Sunday, December 8, 2013
David R. McGowan, ASHM
If a proposal by the National Highway Traffic Safety Administration (NHTSA) is successful, by 2014, all new vehicles sold in the U.S. will be required to have event data recorders (“black boxes”) installed. In fact, a recent report by the New York Times estimated that this technology is already standard on 96 percent of all new cars and light duty trucks.1 In passenger vehicles, the event recorders will capture specific data to assist law enforcement in their investigation to determine culpability in crashes. Fourteen states now allow access to the data via warrant.
The data contained in these recorders will eventually find its way to safety researchers to assist in designing safer vehicles. It’s unknown how or when the data will go beyond technical research and into other “legitimate” interested parties—it’s not a matter of if, but when.
Black boxes aren’t new technology; the aviation industry began using a first-generation device in the 1940s. In 1965, all commercial airliners were required to have a voice and data recorder installed on all their aircraft. These flight recorders assisted in the investigation of air crashes and provided invaluable information that has shaped the safety standards in commercial aviation. It’s no coincidence that travel by air today is the safest mode of transportation by distance traveled.
As EMS emerges from the days of Cadillac ambulances, it’s becoming obvious that in spite of the advances in equipment, training, leadership and clinical oversight, EMS staff, their patients and the public are still at a risk. Ambulance crashes are the number one cause for provider deaths and injuries and the resulting financial burden is nearing $750 million annually.2,3 Unlike our colleagues in the aviation industry, however, we don’t have enough data to pinpoint all the contributing factors of ambulance crashes.
Catching Up with the Clinical Side
Without data, and the means to collect, interpret, recommend and report it, improvements will be slow or non-existent. EMS is a dynamic industry and the strides it has made to date to improve patient care and outcomes could not have happened without robust and accurate data. Electronic capture of this information and its communication to data sources is seamless and relatively effortless today.
In the U.S., organizations such as NEMSIS and CARES provide clinicians and leaders with accurate and concise data to help improve their efficiencies and clinical outcomes. With regard to patient safety, several organizations now allow for anonymous event reporting and data analysis that can be used to develop policies and training programs that will prevent unsafe patient events industry wide. E.V.E.N.T (EMS Voluntary Event Notification Tool) is an excellent example.
Unfortunately, ambulance crash data has not evolved at the same pace as clinical and operational metrics. Crash data in the U.S. is largely collected by state government agencies and forwarded either by request or mandated to federal agencies for their review.
Each state is unique in the data it captures; some don’t even have a vehicle classification for ambulances. On the federal level, one of the most widely respected organizations is NHTSA. Within the organization there are several other groups that receive and analyze crash data: the National Automotive Sampling System, Special Crash Investigators State Data System, Crash Outcome Data Evaluation System and the Fatal Accident Reporting System.
Beyond the scope of data that each of these organizations collects and analyzes is another subset of data that is not retrieved. Ambulance providers now have a powerful tool to collect data and change unsafe driver behavior. Just like the event data recorders found in aircraft and passenger vehicles, EMS and fire organizations now can install safety devices that are engineered to be deployed in emergency vehicles. Such devices are similar to the black boxes found in aircraft; they record vital vehicle operation inputs such as speed, g-forces, engine RPM, seatbelt usage and the operation of a backup spotter, lights, sirens, turn signals and brakes. There are two advanced capability “black box” systems available to EMS operations today: Ferno’s Acetech system and ZOLL’s RescueNet Road Safety System.
The data from these devices are constantly downloaded, reviewed and interpreted by trained individuals. The data that is collected not only measures vehicle, but driver performance as well. The system provides an instant audible alert to the driver if unsafe driving parameters are closing in or exceeded, which effectively changes behavior. These parameters are user-defined, which allows for flexibility determining the scope and location of the provider.
The systems use an algorithm to score individual drivers to determine if they are compliant with agency driving policies. It measures miles driven and then calculates the number of violations (speed, high g-forces, seatbelt not fastened and no spotter for reverse operation) and provides the driver with a score between 1 and 10 (the higher number being less unsafe). Service operators will determine a minimum number that all drivers must meet.
Having this data available has other far-reaching benefits. If the ambulance is involved in a crash, the data from the vehicle can be used to factually dispute false claims by other parties. The same is true when speeding complaints or semaphore violations are received from the public. The data will confirm or refute the claim.
When evaluating and selecting a vehicle safety question, consider the following factors:
• Focus on safety of first responders. Vehicle safety technologies must monitor key safety parameters—including backup spotters, lights and sirens, seatbelts, turn signals and driver identification—to proactively stop factors leading to aggressive and unsafe driving.
• Reliability. Many vehicle safety products are primarily focused on large fleet applications such as commercial vehicles and mass transit. Is the vehicle safety technology proven to withstand the rigors of EMS? How long has the technology been successfully used in accident investigations and litigation? Are customers willing to vouch for the system’s performance and financial impact?
• Designed to grow as EMS evolves. Will the technology expand in functionality as the EMS agency grows (e.g., wireless communication and software application technologies)? How committed is the technology vendor to the emergency response industry? When features are added to the system, how disruptive is this upgrade to the EMS operation?
• Emphasis on safety training. A committed technology vendor will act as a partner to help guide and instill safety practices throughout an organization—not as an afterthought. What services are offered to ensure that the vehicle safety system is used to its full potential? What guidance is offered to customers to implement best practices?
• Implementation and support. How seasoned is the team that will install, train staff and support the vehicle safety system? Were past customers satisfied with the implementation process?
Reporting & Sharing
As of today there is no voluntary reporting of ambulance crash or driver safety data to any organization. Service operators do not want to allow this information to fall into the wrong hands because it could have deleterious effects on the organization. Withholding this information, however, will only delay the progress of achieving a much safer medical transportation mode.
Our colleagues in the aviation industry have this figured out, and its success is well documented. The Aviation Safety Reporting System (ASRS) is a confidential, voluntary and non-punitive organization that allows submissions from all aviation sources. Where EMS has E.V.E.N.T., their submissions do not include ambulance crash information to the degree that can be impactful.
A relatively new organization in EMS that is taking strong strides to mirror that of ASRS is the Emergency Medical Error Reduction Group (EMERG). EMERG’s mission is to facilitate a cultural shift within EMS to embrace a fully integrated, rapid and continuous improvement effort that reduces the occurrence and impact of accidents and preventable errors on providers, patients and the populations served. As a U.S. federally certified patient safety organization, EMERG may be the right destination for our ambulance crash and event recorder data.
Other Response Technologies
Another device that has successfully improved vehicle safety controls the signal lights at an intersection. Developed more than 35 years ago by 3M in St. Paul, Minn., Opticom (or Emergency Vehicle Pre-emption) has a proven record of reducing intersection crashes for emergency vehicles. This signal priority control system eliminates right-of-way conflicts at intersections. As emergency vehicles approach the intersection, an emitter on the vehicle sends a signal to the traffic control processor. The processor then changes the intersection signals to stop all traffic with the exception of the direction the emergency vehicle is traveling. If another emergency vehicle approaches the intersection from another direction, a white signal light located on top of the signal stanchion will flash or remain on, indicating which vehicle has priority in the intersection. This system now uses GPS technology to trigger the system where line of sight to the intersection is hindered.
In addition, data derived from GPS systems has improved efficiency and safety for EMS and fire organizations. Intelligent dispatch systems that track fleets by GPS are constantly collecting data: vehicle speeds by location, day of the week and time of day.
By “learning” this information, dispatch systems can provide preferred routes to a given call that otherwise would be congested with heavy traffic or numerous intersections. In predictive dispatch systems, the data can enhance dynamic vehicle deployment by placing ambulances in positions that historically have the highest call volume by time of day and day of week.
Getting an ambulance closer to a call not only reduces response times, it enhances efficiency and reduces fuel consumption. From a safety aspect, an ambulance that does not have to travel a great distance and avoids heavy traffic is less likely to be involved in a potential crash.
Data drives EMS leaders to make informed decisions, relying on facts rather than conjecture. The data gleamed from the above technology, when combined with PCR, dispatch, billing and scheduling data, provide agencies the essential information to evaluate performance and make improvements if warranted.
As this data become more readily available, EMS services have an obligation to share it with non-profit EMS improvement organizations, who in turn can benchmark performance and identify best practices.
With much talk about pay-for-performance as a reimbursement model for EMS in the future, how an EMS system performs and its percentile ranking in key areas will be critical to its revenue stream. Aside from clinical performance, a key metric that should not be overlooked is patient injuries due to an ambulance crash. Vehicle event data will be a significant driver of these rankings.
1. Trop J. (July 21, 2013) A black box for car crashes. New York Times. Accessed Oct. 22, 2013 from www.nytimes.com/2013/07/22/business/black-boxes-in-cars-a-question-of-privacy.html?_r=0.
2. Grant CC, Merrifield B. (September 2011) Analysis of Ambulance Crash Data: Final Report. The Fire Protection Research Foundation. Accessed Oct. 22, 2013 from www.nfpa.org/~/media/files/research/research%20foundation/rfambulancecrash.ash.
3. National Highway Traffic Safety Administration. (n.d.) The economic burden of traffic crashes on employers: costs by state and industry and by alcohol and restraint use. Publication DOT HS 809 682. Accessed Oct. 22, 2013, from http://www.nhtsa.gov/people/injury/airbags/economicburden.