Providing quality patient care in the back of a moving ambulance isn’t only challenging, it’s dangerous and can lead to significant injury in a vehicle crash. A sudden stop, swerve or minor fender bender can result in serious injury to unrestrained passengers. Over the last decade, there’s been a growing body of knowledge that suggests ambulance crashes are recurring events in our industry. Research and data collection on EMS injuries and vehicle accidents have forced our industry to recognize that we have a safety problem.
There are several interrelated factors that affect ambulance safety. The design of the ambulance-how it’s constructed and maintained-is at the top of the list. Only recently have some ambulance builders started to develop effective solutions to these construction issues and adopt modern safety designs.
As industry standards change, so will the ambulances we purchase. New static and dynamic testing requirements will force some builders to improve the crashworthiness of their products.
Building EMS transport vehicles and fire trucks is part of my job and I don’t take those responsibilities lightly. People’s lives may depend on what ambulance we buy and how we design it. Education is a key ingredient to building a safe product that meets the needs of our caregivers.
I’ve spent more than 20 years researching construction methods and becoming educated on ambulance standards and design. My research has taken me to U.S. ambulance factories where I’ve photographed different production styles, and I’ve traveled overseas to see firsthand how ambulances are manufactured abroad.
In this article, I share 10 key areas that can enhance safety and improve the longevity of your next ambulance. I also highlight construction methods that you’ll want to discuss with your ambulance builder as you design your next rig. Lastly, I compare EMS vehicle construction in the U.S. and Europe. I encourage you to use these focus areas as discussion points to improve ambulance safety at your department.
When it comes to ambulance construction, the ambulance industry has had little national oversight and few safety standards during the past 40 years. The patient compartment, or “box,” isn’t subject to standard automotive safety regulations and has minimal structural crash safety features.
The Federal KKK-A-1822F (KKK) standard, originally written for the purchase of federal ambulances, was the industry’s only standard and has seen many revisions.1 Although there are general references to ambulance construction, safety wasn’t the basis for this document. The KKK standard has since been replaced by two new standards: the Commission on Accreditation of Ambulance Services (CAAS) Ground Vehicle Standard (GVS) v1.0 and the National Fire Protection Agency (NFPA) 1917.2,3
The objective of both new standards is to improve safety through new design guidelines, performance standards and testing requirements. Important items addressed in the standards include: occupant seating and restraint, seat belt warning systems, cot and equipment retention, tire pressure monitoring, carbon monoxide monitoring, payload requirements and static and dynamic patient compartment integrity testing.
Your first steps toward building a safer ambulance are to read and adopt the new safety standards. This may seem simple, but some consumers don’t follow safety standards. Why? Because “change wouldn’t be popular,” or because of “our history and tradition,” or because “that’s the way we’ve always done things.” The new standards are based on sound research, data and safety testing. These guidelines are a collaborative effort to improve ambulance safety. Educate yourself on the new standards and adopt their recommendations into your ambulance design.
It’s important to note that the new ground vehicle standards now encompass remounts. Remounted boxes will be required to incorporate important safety aspects, such as stretcher mounts. For more on remounts, see “Rethinking remounts: Developing a national standard for ambulance remounts,” by Laura Aguirre, in the August issue.
A thoughtful, well-planned design will avoid costly construction and design
mistakes that stay around for the life of vehicle. Photo courtesy Wayne Zygowicz
Put a lot of extra time, effort and thought into your design up front. Carefully design your ambulance on paper, keeping crew comfort and safety as top priorities. Develop a detailed set of drawings and specifications that lay out the plan. A committee made up of EMTs and paramedics who will use the vehicle regularly should ensure the design is functional, user-friendly and safe. A thoughtful, well-planned design will avoid costly construction mistakes that stay around for the life of vehicle.
The patient compartment should be laid out in exact detail. Seat location should allow for easy access to the patient, equipment and vehicle controls without providers having to constantly remove the seat belt. Kneeling in the aisle to start an IV because the seat was installed in a bad location is the result of poor design specifications and may lead to injury.
All heavy equipment (e.g., monitors, oxygen cylinders, mechanical CPR devices, computers, medical kits, etc.) should be restrained or kept in a secure cabinet.
NFPA 1917 recommends that all equipment weighing more than three pounds be mounted in a bracket that can withstand up to 10 Gs of force.3 An unrestrained cardiac monitor can become a deadly missile during a quick deceleration or an abrupt lane change. If you’ve seen pictures of the patient compartment after a rollover, you wonder how anyone could survive being tossed around in a metal box with heavy objects flying around.
Take your time in the design phase. Do your homework and have your selected manufacturer develop a solid set of drawings and specifications. Gather a lot of input and carefully review the drawings and specifications with your ambulance manufacturer before construction begins. Any changes you make after you sign on the dotted line become costly change orders.
If you’re interested in a safer and more ergonomically designed ambulance, carefully review the Ambulance Patient Compartment Human Factor Design Guidebook, published by the Department of Homeland Security.4 New research indicates that we need to change the patient compartment layout to improve safety. The guidebook will help you develop a safer and more efficient patient compartment that’s right for your service and the type of work you need to do in it.
Chassis & Suspension Selection
The chassis and suspension are extremely important to the overall safety of your vehicle. An undersized, overloaded ambulance chassis moving down the road with lights and siren is an accident waiting to happen.
Gross vehicle weight rating (GVWR) is the maximum operating weight (i.e., mass) of a vehicle specified by the manufacturer. GVWR includes the vehicle’s chassis, body, engine, engine fluids, fuel, accessories, driver, passengers and cargo. Driving any vehicle over its GVWR leads to increased brake wear and makes stopping the vehicle problematic and dangerous, especially at higher speeds.
The type of work your agency does will dictate your chassis options. Available payload changes with each size chassis. For example, a light chassis (GVWR 8,000-10,000 lbs.) may work well for an ambulance service that carries no firefighting gear and may not need external storage.
A light chassis will be easily overloaded if you add the firefighting equipment used by many departments: bunker gear, SCBAs, forcible entry tools, thermal imagers, extrication equipment, water/ice rescue suits, wildland gear, mass casualty incident bags, fire extinguishers, hand tools, etc.
Inventory all equipment and supplies you typically carry and carefully estimate the total weight. Always weigh your ambulance as it leaves the factory and again when it’s fully loaded with the crew inside.
To add a margin of safety, select a chassis that exceeds your estimated payload. If you don’t do this, you may find that your chassis exceeds the recommended GVWR.
Some manufacturers build ambulance boxes with rounded corners,
using extrusions to connect the walls and the roof.
Photo courtesy Wayne Zygowicz
Most consumers don’t understand that all ambulances aren’t created equal. Unless you visit ambulance factories to see how each company builds their bodies, you’d assume that a wall is just a wall. But there are actually structural variations hidden behind the finished walls, ceiling and floor. When purchasing an ambulance, you should learn what the structural components are made of and how they’re assembled and held together.
Some manufacturers build their ambulance box with rounded corners using extrusions to connect the walls to each other and to the roof. An extrusion is a hollow piece of rounded molding that acts like a frame. Other builders use formed parts that create an integrated module using no extrusions. Solid body construction has square edges at the corners and the roof line.
Wall and roof construction also varies between builders. Some manufacturers utilize spot welds, glues and double-sided tape to build walls while other builders incorporate fully welded seams.
The interior cabinetry can vary from wood to metal to aluminum, and even plastic inserts. Even insulation can differ. One builder may spray in an expanding foam insulation while another might use common household-type insulation that’s glued to the walls.
The real integrity and strength of the ambulance body lies behind the finished walls. It’s obvious when you see some ambulance boxes being constructed that they’re built stronger than others. Educate yourself, ask the builder about their construction techniques, visit factories and network with other users before you make a purchase. Most ambulance manufacturers will gladly provide you with satisfied customers you can speak with.
Ambulance insulation can vary; one builder may use spray-in
foam insulation while another uses common household
insulation. Photo courtesy Wayne Zygowicz
Some ambulance manufacturers use spot welds,
glues and double-sided tape to build walls; other builders
incorporate welded seams. Photo courtesy Wayne Zygowicz
There have been vast improvements in seating
safety and range of movement.
Photo A.J. Heightman
People spend a lot of time sitting in ambulances, so choose seating wisely. They have to be functional, comfortable and safe. They also have to clean up easily after bad calls.
The industry has seen significant safety improvements in ambulance seats. Manufacturers are focusing on building products that meet the Society of Automotive Engineers (SAE) standards. Two SAE standards are SAE J2917: Occupant Restraint and Equipment Mounting Integrity-Frontal Impact System-Level Ambulance Patient Compartment; and J3026: Ambulance Patient Compartment Seating Integrity and Occupant Restraint.
NFPA 1917 requires dynamic seat testing to improve occupant safety and crash survivability.3 The standards also address seat belts, head clearance, patient access, child restraints and seat belt warning systems. Purchase seats that meet these safety standards.
One subject not covered in the new standards is seat direction. Have you ever wondered why there are no side-facing seats in U.S. automobiles? Many may feel that the old side-facing bench seat has worked well for 30 years, but it’s an unsafe riding position in the event of a crash, even with a seat belt on.
One recent study stresses that forward- or rear-facing seats provide better protection in the event of an accident or evasive maneuver than side-facing seats.4
I attended the RETTmobil (German for “mobile rescue”) conference in Fulda, Germany, where 300 international vendors were exhibiting their EMS products. I noticed a similar theme in every European ambulance: There was no side-facing seating. Why are we still riding sideways in U.S. ambulances? Is it our history and tradition? Is it the original, outdated KKK specifications?
It’s a challenge to design ambulance seats and restraint systems that provide the necessary crash protection and still allow responders to access the patient, medical equipment and supplies in an unrestrained manner. The new European designs, which offer comfortable, more compact and adjustable seats are slowly being adopted by EMS services in the U.S.5
With the rising cost of workers’ compensation injury claims, having a
power stretcher or lift gate system will help reduce back injuries and
possibly extend the careers of the crew members. Photo courtesy Mac’s Lift Gate
Cot Lifting Systems
With the rising cost of workers’ compensation injury claims, having an electric stretcher, hydraulic cot lifting system or lift gate system will help reduce back injuries and possibly extend the careers of crew members. At first glance, a lifting system may seem pricey, but they’re a great return on the initial investment. Operationally, cot lifting systems also make perfect sense with the increasing number of obese patients that EMS crews are called upon to transport.
A cot lifting system may be a mechanical or hydraulic device that lifts the cot into the patient compartment without requiring the crew to physically lift it into the ambulance. The currently available systems include independent power cots, loading ramps, lift gates and power loaders.
An advantage of using a ramp or lift gate system is that it can accommodate a variety of cots, along with other types of equipment, such as incubators and balloon pumps.
One such system, Mac’s Lift Gate, sets up in less than 60 seconds and the standard lift gate can carry up to 750 lbs. A bariatric version can lift up to 1,300 lbs. These lifts can be installed on a new unit or retrofitted on an older unit.
The location of emergency lights and the color scheme
around your vehicle should be carefully designed for
maximum effectiveness. Photo courtesy Wayne Zygowicz
Driving emergency vehicles is a risky task, especially in a densely populated urban environment or busy highway system. Crew safety depends on other motorists seeing, hearing and identifying your ambulance early enough to move out of your way. When installed correctly, properly positioned emergency lighting and audible warning devices can enhance crew safety.
Emergency lighting, scene lighting, loading lights and ground lighting increase the visibility of your ambulance and improve safety both day and night. The location of emergency lights and their color scheme should also be carefully designed for maximum effectiveness.
Lighting packages that meet the new standards focus on warning zones, signaling modes (“calling for the right of way” or “blocking the right of way”), flash rates and patterns, lighting zones and power requirements.
Bright scene lights and loading lights significantly improve provider safety. Chassis-mounted LED ground lights can also add a greater margin of safety for anyone entering and exiting the ambulance and help you see items placed or left on the ground.
Audible warning devices are essential when responding to emergent calls. To be effective, your siren must overpower the surrounding environmental noises and penetrate the soundproofing insulation found in modern vehicles. A siren should have ample power, produce a wide spectrum of frequencies and have multiple signaling modes. Several new siren types emit low-frequency sound waves that penetrate and shake solid materials. These are very effective in urban environments with heavy vehicle and pedestrian traffic.
Research what’s on the market, consult with vendors and other users and buy a siren package that will be the most effective for the environment you work in. For more on ambulance warning systems, refer to the Ambulance Innovations section of the October 2016 issue.6
New standards for vehicle visibility recommend retroreflective
striping that forms a downward-sloping chevron pattern and
covers at least 50% of rear-facing surfaces.
Photo courtesy Wayne Zygowicz
Apparatus visibility and recognition are key safety components. The ability of motorists and pedestrians to recognize an approaching ambulance or to see the vehicle when parked is dependent on a number of interrelated factors: vehicle size, color scheme, conspicuity markings, marker lights, active emergency warning systems, motorist distractions and environmental conditions. Studies suggest that increasing the vehicle’s visibility using retroreflective materials can improve safety in traffic and when parked along the roadway.7,8
Crew safety depends on other motorists quickly identifying your approaching ambulance in any environmental condition: day and night, rain, snow or low light conditions. New standards recommend increasing retroreflective striping by 25% on the front and 50% on each side.3
The rear of the vehicle should be equipped with retroreflective striping that forms a downward-sloping chevron pattern and covers 50% of rear-facing surfaces. For maximum visibility, red with alternating fluorescent yellow or yellow-green stripes are the recommended colors.
Although this guideline is gradually being applied in the U.S., European ambulances have met these standards for years. The use of high-visibility color schemes on ambulances and bright reflective safety clothing are commonplace outside the U.S.
Training & Procedures
Ambulance safety doesn’t just happen; it requires a thoughtfully planned strategy. The fundamental goal is to reduce accidents and injuries through training and re-education.
Driving an emergency vehicle is dangerous and the physical dynamics are complex. All providers, regardless of their age, experience or maturity, should be trained on operating an emergency vehicle.
A well-designed training program should include classroom time, behind-the-wheel training and testing. Drivers should have an annual refresher training and baseline medical exam to verify their ability to physically operate an ambulance.
Establishing standard operating procedures (SOPs) for emergency vehicles is a must. SOPs provide direction and outline expectations on how these very expensive mobile emergency rooms should be driven and maintained.
Although vehicle monitoring, warning and report-generating systems are effective, it still takes SOPs to establish and maintain operational compliance. Written guidelines should include: intersection approach, maximum response speeds, driver responsivities, backing guidelines, warning device usage and vehicle limitations.
Each accident and near miss should be fully investigated by a safety committee to establish the root cause and determine what corrective action is needed to avoid future injuries or damages.
Modern ambulances are high-tech machines; a comprehensive maintenance plan is essential to the safety of the occupants. Treat vehicle maintenance as if the life of your crews and patients depend on it-because it may!
Having a proactive maintenance plan can prevent emergency run breakdowns, prolong the life of the vehicle, avoid costly repairs and reduce costly vehicle downtime.
Your builder should provide a local, reputable warranty service location for their products. Some manufacturers contract with a local dealership trained in ambulance repair to perform warranty service. It’s a must that repairs be performed quickly and correctly the first time.
Make sure the dealership has emergency vehicle technicians, compatible replacement parts, proper facilities and the appropriate equipment to complete the job. Locate a local towing service that can safely handle an ambulance when the truck isn’t operable.
If Not Now, When?
Real dangers exist in our current practices. Often, we choose to ignore them and think that it won’t ever happen to us. The consequences of ignoring these dangers are predictable and, likely, preventable. It’s time to focus on all aspects of the ambulance environment and embrace the changes necessary to advance safety in our industry.
We must continue to raise awareness of the inherent dangers of our job and put our history and tradition aside to improve safety. Our loss of life is a quiet epidemic and the personal toll on families is enormous. The costs of addressing safety issues are small in comparison to the huge burden we’ll carry if we maintain the status quo.
The efforts to improve ambulance design and safety have started, but there’s a lot of work ahead of us. Multidisciplinary teams of healthcare professionals, safety engineers, regulatory bodies and ambulance manufacturers have begun to provide our industry with the research and data we need to be informed consumers.
The real question is, will our culture allow us to change or will it be a barrier to our progress? Let’s improve safety for our EMS providers and our patients. Safer practices save lives, time and money.
1. Federal specifications for the star-of-life ambulance. (Aug. 1, 2007.) U.S. General Services Administration. Retrieved June 1, 2017,
2. Commission on Accreditation of Ambulance Services. (March 28, 2016.) Ground vehicle standards for ambulances. Ground Vehicle Standard. Retrieved June 10, 2017, from www.groundvehiclestandard.org/wp-content/uploads/ 2016/03/
3. NFPA 1917: Standard for automotive ambulances. (2016.) National Fire Protection Agency. Retrieved June 11, 2017, from www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=1917.
4. Ambulance patient compartment human factors design guidebook. (February 2015.) United States Department of Homeland Security. Retrieved May 15, 2017, from www.naemt.org/docs/default-source/ems-health-and-safety-documents/health-
5. Hildwine F. Take a seat: New ambulance seating improves safety, size & functionality. JEMS. 2016;41(10)38-42.
6. Zygowicz WM. Lights and sirens: Improving the safety of the sights & sounds of EMS. JEMS. 2016;41(10):30-36.
7. Emergency vehicle safety initiative. (February 2014.) United States Fire Administration. Retrieved Jun. 10, 2017, from www.usfa.fema.gov/downloads/pdf/publications/fa_336.pdf.
8. Emergency vehicle visibility and conspicuity study. (August 2009.) United States Fire Administration. Retrieved Jun. 10, 2017, from www.usfa.fema.gov/downloads/pdf/publications/fa_323.pdf.