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On Sept. 25, 2012, the new National Fire Protection Agency (NFPA) 1917 Standard for Automotive Ambulances was released. It applies to new ambulances contracted for purchase on or after Jan. 1, 2013. The standard is expected to replace the Federal KKK-A-1822 Ambulance Purchasing Guide (commonly referred to as the KKK) that’s anticipated to expire in October 2013. Although most applaud the effort, not everyone is convinced the new standard is the best model.
The National Association of State EMS Officials (NASEMSO) gathered industry representatives for a two-day session during its 2012 annual meeting in Boise, Idaho, to discuss possible options. According to NASEMSO Executive Director Dia Gainor, the move was necessary so the organization could advise state EMS officials on the best course of action regarding the regulation of ambulance standards.
“This isn’t anti-NFPA. This is a regulatory dilemma that the states need help solving,” she says. But first, NASEMSO members needed to better understand the specific differences between the options.
To corral the technical expertise needed, they invited a 19-member, multi-disciplinary group that included EMS regulator community members, several national associations representing ambulance purchasers and users, and representatives of the Ambulance Manufacturers Division of the National Truck Equipment Association. The group also included National EMS Management Association (NEMSMA) member Aarron Reinert, who served on the NFPA 1917 TechnicalCommittee, occupying one of several user seats.” (For a full roster of the NFPA 1917 Technical Committee, go here.) NFPA Emergency Services Specialist and Staff Liaison Ken Holland also attended, along with Kenneth Willette, the division manager of the NFPA’s Public Fire Protection Division.
The NASEMSO-led group reviewed a compilation document that compared the draft NFPA 1917, KKK and American Society for Testing Materials (ASTM) standards. To assist in the evaluation, NASEMSO also invited three organizations with international expertise—American Medical Response, Falck and Ferno—to discuss their experiences.
“That was really the first time … that we [had the opportunity to] understand the commonalities and, more importantly, the differences, between these specifications,” Gainor says. Using a 14-page grid that provided a side-by-side comparison of specific points of the three options, the group began to discuss the issues. Unfortunately, says Gainor, they only had time to focus on the two most challenging concerns. The first was the draft NFPA standard requiring the use of a governor to limit the speed on all ambulances to 77 miles per hour (mph). Neither of the other standards specifies top vehicle speed.
The NFPA Technical Committee, in its published reports, states that the intent of the rule is the safety of the crew and civilians. Gainor and others point out that, in rural states, the legally posted speed limit is as high as 80 or 85 mph. “Driving 77 mph would actually create a safety issue,” she says. In addition, some ambulance manufacturers will have to install the device as an after-market part, creating potential liability and warranty concerns.
The second issue involves a requirement that the purchaser of a new ambulance adhere to every stipulation in the NFPA 1917 standards. If they aren’t compliant, then the manufacturer must present a “Statement of Exceptions” for the purchasers to sign. It states that the ambulance delivered is not in full compliance, and shall not be placed in emergency service until the ambulance has been modified, as necessary, to accomplish full compliance with the standard.
Again, the group expressed concerns about the potential liability for the EMS agency that doesn’t need or want to further modify the vehicle. The concern is that a state inspector could refer to the document to charge the EMS agency with fraud in legal proceedings after a crash.
According to the NFPA process, any member of the public can submit a temporary interim amendment (TIA) that will modify the identified portions of the standard in the published edition of the NFPA 1917, while in between revision cycles. The process requires at least two Technical Committee members to endorse the TIA before it’s processed by the committee. Gainor says the group consensus is that, with those two standards removed, the new NFPA 1917 is “at least feasible to consider. Without it, it would not be adopted by most states,” she says.
The group planned to meet again in November.
A technical committee of 33 representatives from ambulance manufacturers, providers, regulators and researchers first met in June 2009. Chaired by David H. Fischler, retired fire commissioner of the Suffolk County (N.Y.) Department of Fire Rescue and Emergency Services, the group drafted specifications and took public input, according to the standards process established by the NFPA.
The tedious process included reviewing approximately 1,700 separate proposals from the public on the initial draft of the document. “It was well-distributed and commented on to begin with,” Fischler says.
The volunteer consensus process works extremely well, according to Holland. It’s the same process used for all of the NFPA standards. The technical committee prepares a draft, receives public input, meets again to address the submitted public input and issues the next draft. A public comment period is offered, followed by a final meeting of the committee to hammer out the third and final version.
Fischler commends the members of the committee for their hard work and professionalism. “The group of people on the committee worked extremely well together. It went exceptionally well,” he says.
In early 2012, NASEMSO began an investigation into state regulations regarding standards for ambulance design. They found that 42 states and all of the U.S. territories had rules specifying the design of ambulances. Of those states, 30 incorporate the KKK guide in whole or in part. Once the KKK specifications are retired, those rules must be modified. “That’s 60% of our membership who now have a rule-making dilemma,” says Gainor.
As an advisory group, she notes, it’s important for NASEMSO to help state EMS directors understand the differences, so they may assist states in submitting detailed justifications and rationale about the rule changes. These include the effect on the regulated community and fiscal impact, such as the cost and workload for the state and cost implications for the regulated community. State EMS directors must be knowledgeable enough on the subject to testify about the rule change. “It could be career-killing if they can’t speak to the background information on the apparent choices and reasons for selection when the state makes a decision,” Gainor says.
With the 2013 deadline looming, NASEMSO sees four options for state regulators:
1. Adopt the ASTM International F2020-02a standards, which were last revised in 2009;
2. Adopt international standards, such as those published by the European Committee for Standardization (CEN);
3. Adopt a state-specific version of the KKK specifications; and/or
4. Adopt the new NFPA 1917 standards.
Holland says states can choose whether they want to implement NFPA 1917 in its entirety or in portions. However, even if a state adopts portions of the standard, agencies that purchase ambulances will still be required to sign the “Statement of Exceptions.” There’s a final option, according to Gainor. “If the GSA were to keep the triple K specs in place for a longer period of time, the states wouldn’t be facing an urgency issue to adapt rules,” she says.
Opposition to NFPA 1917
The American Ambulance Association has issued a position statement indicating that it doesn’t support the new standards. The letter, available on the NASEMSO website states that “many of the new requirements may be inappropriate or unsuitable for ambulances … [and] will appreciably raise the cost of vehicles produced under this standard…” The group also expressed concern regarding an increase in liability for ambulance manufacturers. The AAA leadership supports for the NASEMSO effort to develop model state requirements that would delay implementation of the NFPA standards until further research, currently underway, is completed.
A letter to NASEMSO from the Ambulance Manufacturers Division (AMD), dated May 4, 2012, expresses concern for ambulance manufacturers who face a lack of consistency among the states in ambulance design and construction requirements. They advocate for uniform requirements that would establish consistency across the country, enabling manufacturers to minimize product customization and provide economies of scale that will ultimately benefit customers.
“Given this, AMD supports a ‘model law’ effort to provide states with the necessary legislative tools to provide such a uniform requirement for ambulance construction,” the letter states.
Support for NFPA 1917
The new NFPA standard also has its supporters. In an e-mail to the EMS section of the International Association of Fire Chiefs, Gary Ludwig, section chair and deputy chief of the Memphis (Tenn.) Fire Department, states that the standards are the first specifically written to safeguard EMS providers. “Even the federal KKK specification, which many states have adopted and many specifications are based upon, does not prioritize safety, and it’s designed to be a buying spec written for the purchase of federal ambulances,” he writes. He dismisses opponents to the NFPA 1917 within the EMS profession saying, “the completion of this document is a great step in improving safety and making sure everyone goes home.”
Typically, an NFPA standard is reviewed after five years. However, the NFPA Technical Committee decided to revise it as soon as it was published to allow for input from research currently underway by the National Institute for Occupational Safety and Health, the Department of Human Services and the National Institute of Standards and Technology. Fischler will again lead the charge. He says a majority of the committee will return for the revision cycle, which will begin next year. The NFPA 1917 can be viewed here.