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EMS is one of the most dangerous jobs in the country with an injury rate about three times the national average for all occupations (Prehosp Disaster Med. 2013 Aug;28(4):376-82. doi: 10.1017/S1049023X13003555. Epub 2013 May 9).

Ambulances can be big, dangerous boxes; occasionally operated by drivers with limited experience. Ambulances weigh much more than an automobile, are more difficult to maneuver, and when responding to an emergency may operate with special privileges regarding motor vehicle laws.

Historically, while the driver’s compartment of an ambulance has been designed by automotive engineers, the patient compartment was the domain of buyers and manufacturers. In the absence state regulations referencing safety testing and standards, configuration decisions were based upon convenience and storage instead of safety.

Ambulances by design and EMS by culture have encouraged providers to be unsecured during patient transport. In the event of a sudden stop, turn, or crash, people and objects unsecured during transport become airborne and pose a threat to themselves, the patient, and others in the vehicle.

Ambulances are custom built to the buyer’s specifications, which means that everything from the number of warning lights to the position of cabinets and type of seats can be different in each ambulance.

The General Services Administration (GSA) was the government agency responsible for establishing federal standards for ambulances in 1974 and has maintained them ever since.

Ground Vehicle Standards (GVS) is a project of the Commission on Accreditation of Ambulance Services (CAAS). CAAS is an American National Standards Institute (ANSI) accredited standard development agency that specializes in ground ambulance EMS standards. GVS standards were developed by a predominately EMS centric group.

NFPA is also an ANSI accredited standard development agency with experience in developing a variety of codes and standards with a focus on responder safety. NFPA 1917: Standard for Automotive Ambulances is an ANSI accredited standard that was developed by the Technical Committee using a broad group of interested parties.

Every state has a lead agency responsible for Emergency Medical Services. In most, but not all, states, the lead EMS agency has the authority to establish the requirements for personnel, service, and vehicle licensing.

In some states licensing requirements are in the law, which can only be changed by legislative action. In other states, the requirements may be established through regulations and rules promulgated by the EMS agency or a governing board. While the latter may be more responsive in terms of contemporary changes, legislative review may also be required before adoption.

That depends on a number of factors and can range into several thousand dollars. However, by talking with the manufacturer and using their ambulance design resources, it is possible to reduce the cost by careful selection of other customized options.

The first step is to plan well in advance; like a couple of years. The process should include talking with the state EMS office about current requirements and any changes in the works. Next is reviewing the current ambulance standards and other resources that are available regarding contemporary safety.

Yes. Many manufacturers have worksheets that provide this information. Check with the local sales representatives for details.

Child restraints are not directly mentioned in J3026, GVS, or NFPA because they are covered by FMVSS 213, which is a federal standard that others cannot supersede. This means if a manufacturer is offering an integrated seat, the seat must be tested to both the SAE J3026 (adult) and FMVSS 213 (child) restraint requirements.

Regulations are a means of establishing a foundation for public trust. The majority of people calling 9-1-1 for an ambulance will only do so once in their life. It is an unplanned event where a caller reaches out for help with an expectation that those who respond are appropriately educated and equipped to assist in a safe and efficient manner. There has been considerable research conducted within the past decade that has resulted in standards that make the ambulance environment safer. Regulations should be reviewed and revised to maintain contemporary standards.

Yes. There are standards that apply to all vehicles and all compartments, such as safety restraints. Other standards apply based upon vehicles with a Gross Vehicle Weight Rating (GVWR) of more than 10,000#, which includes both Type I and Type III ambulances. Type II (van) ambulances have a GVW of between 9,201 -10,000. There is an additional classification of a Type 1 AD (Additional Duty) ambulance, which applies to vehicles with a GVWR of more than 14,001#.

No. Vehicles with a GVWR of greater than 10,000 pounds (except for school buses) are not required to be crash tested.

No. These we were removed in with revision KKK-A-1822F in 2007.

Maybe. It depends on the specific standard and the vehicle itself. Check with your sales representative or ambulance manufacturer for details.

In most states, it’s the state EMS office. Some state EMS offices have regulatory boards with rulemaking authority; others may involve the state legislature.

The current K-Specs, NFPA, and GVS standards are for new ambulances. However, remounts have been the topic of much discussion and may be included in future revisions.

This places an added responsibility on the purchaser to know the regulations in neighboring states/territories into which they may respond and/or transport.

It will also be important to have an understanding of the concurrent standards and to work with a manufacturer who adheres to an accredited ambulance standard.

Please contact your state EMS office for licensing details.

Across the country, EMS protocols are under review and undergoing changes with regard to treating patients at the scene and providers being seated and safely restrained during transport. For example, performing CPR in a moving ambulance was once the general practice. However, in many states cardiac arrest patients are now being treated at the scene – and the results suggest that this has both a better outcome for the patient and reduces the likelihood of a provider being injured during transport.

By rethinking about what a patient needs and how to provide it. For example, once upon a time, the conventional wisdom was the best way to care for a cardiac arrest was to load the patient quickly and perform one handed CPR while holding onto the ceiling rail. Today, we know that cardiac arrest survival rates are improved with high performance CPR provided at the scene. Similarly, ambulances can be configured to allow an EMS provider access to a patient and also have access to supplies and essential equipment (monitor, suction, and radio) while safely seated; facing forward, and restrained.

CPR seats and bench seats were standard configurations for decades, but crash tests by NIOSH demonstrates that both are unsafe to the provider.

Ambulances are now available with a configuration that enables an EMS provider to care for the patient, communicate with the hospital, and reach essential supplies and equipment while safely seated and restrained.

The manners in which cots/litters are secured in a vehicle have changed from the traditional antler mount to a track mount. Many ambulances also have power assisted cots that may help reduce back injuries to EMS providers.

The “Star of Life” is a certification mark that was issued in 1977 to the National Highway Traffic Safety Administration. It is to be used on emergency medical care vehicles to certify that they meet Federal standards; by emergency medical care personnel to certify, based on their training and affiliation with qualified emergency medical care system, that they are authorized to provide emergency medical care; on road maps and highway signs to indicate the location of or access to qualified emergency medical care service; and such other EMS-related uses that the Administrator of NHTSA may authorize. Any other use is prohibited.

Star of Life Background, Specifications, and Criteria

Yes. NHTSA has published the Safe Transportation of Children in Ground Ambulances, which is available for download at: www.ems.gov

The NASEMSO Safe Transportation of Children ad hoc committee has published the Safe Transport of Children by EMS: Interim Guidance and has additional information available from their website.

Changing ambulance design and manufacturing is an important step, but in many respects a greater challenge exists with improving the awareness and changing the attitude of EMS administrators, medical directors and providers.

In 2013, the American College of Emergency Physicians (ACEP) under a cooperative agreement with several federal partners developed a National EMS Culture of Safety Strategy document.

In addition, there are a growing number of articles about behavioral factors that affect EMS provider and patient safety, such as:

Teammate familiarity and risk of injury in emergency medical services. (Emerg Med J. 2015 Nov 27. pii: emermed-2015-204964. doi: 10.1136/emermed-2015-204964)

The association between weekly work hours, crew familiarity, and occupational injury and illness in emergency medical services workers. (Am J Ind Med. 2015 Dec;58(12):1270-7. doi: 10.1002/ajim.22510. Epub 2015 Aug 25)