Safety Practices Must be Enforced for EMS Providers

The prehospital environment poses unique risks to providers, including multiple distractions like radios, pagers and cell phones while providing care in unsecured locations. EMS providers suffer work-related fatalities more than two times more frequently than the national average, and the transportation-related injury rate is five times greater.1-3 As a result, the National EMS Advisory Council has called for a “culture of safety” where safety is a fundamental and integral component of the work environment.4 This has led to national and state-specific safety operations guidelines detailing EMS practices, including the use of seatbelts in the patient care compartment (PCC), utilizing carbon monoxide detectors to avoid entering hazardous environments, encouraging seat belt use and limiting the use of mobile devices while driving or riding in the front compartment of an ambulance.5,6

Distracted Driving

Studies of cell phone use and motor vehicle operation have been performed in simulated and observational situations.7,8 Up to 30% of drivers have read or sent text or e-mail messages while driving at least once in the past 30 days.8 This distracted driving interferes with lane maintenance and speed maintenance even with ideal road conditions.7 Texting while driving can be the equivalent of having a blood alcohol level between 0.07 g/dL and 0.10 g/dL, resulting in similar delays in reaction times and inability to maintain target vehicle speeds.9,10

Given the increased challenges of operating a motor vehicle in the prehospital setting, Pennsylvania has developed protocols to help limit provider distractions while operating an emergency vehicle. These protocols recognize the safety hazard caused by distracted driving and specify that providers “should not view pagers, cell phone screens, text messages, or mobile data terminals or enter data into GPS devices while an EMS vehicle is in motion.”11 Currently, if a provider is found to be in violation of this protocol, disciplinary action is reserved at the local, and possibly the regional, level of EMS direction.

Despite the push for limiting distractions while driving, however, distracted driving was believed to cause 13,846 motor vehicle collisions and 11 fatalities in Pennsylvania alone in 2010.1 Out of concern for EMS staff, patients and the general public, we sought to determine if these state protocols and innovations in safety technology are utilized and adhered to by EMS personnel.

Identifying the Problem

We performed a survey of EMS providers from the northwest region of Pennsylvania at the 2012 EMS Provider’s Safety Conference in Summit Township, Pa. This EMS region encompasses seven counties that include over 3,300 EMS providers who respond to over 110,000 EMS calls annually.

We were allowed to establish a survey booth at their conference and distribute a safety survey consisting of 21 predetermined questions. All employees who worked clinically for the agency and attended the conference were considered eligible; that included EMS providers of varying certifications (EMT-B, EMT-P and prehospital RNs). The survey included details on provider demographics, information relating to provider-specific vehicle safety practices (seat belt use, cell phone use, etc.) and EMS-specific safety practices implemented through Pennsylvania state protocol July 2011 (usage of safety vests, carbon monoxide detector use, etc.).5 Five questions had possible responses of Never, Always, Less than 50% of the time, and Greater than 50% of the time. Eleven questions were strictly Yes or No responses. All data was collected anonymously. This was approved by our hospital’s Institutional Review Board.

EMS safety practices
Fifty-seven of the 67 (85%) enrolled EMS providers in the region who registered for the course participated in our study. The majority of respondents (65%) were male and many (42%) had over 15 years of experience in EMS. (See Table 1.) Survey results were further divided into two categories: EMS-specific safety practices and provider-specific vehicle safety practices. (See Table 2 and Table 3, respectively, below.)


EMS safety practices
Many factors have been identified by these surveys as barriers to seat belt use in the PCC including: inhibited patient care, restricted movement, inconvenience or lack of efficacy.12 Failure to wear a seatbelt in the PCC has resulted not only in the death of EMS workers in the PCC but also can turn EMS providers into projectiles, injuring or killing those in the front seat.3,13 The National Institute for Occupational Safety and Health identified 27 EMS worker fatalities in ambulance crashes reported in the National Highway Traffic Safety Administration’s Fatality Analysis Reporting System for 1991-2000.13The majority of respondents always use a seatbelt when not in the PCC, 87% while driving and 96% when the front passenger. Only 9% of providers always wear a seat belt while in the PCC with a patient.

EMS safety practices

Despite national campaigns to limit the use of mobile devices, 26% of respondents admit to having used a mobile device while driving an emergency vehicle and 53% of those admit to still using a mobile device despite knowing the safety recommendations.

Providers consistently reported adhering to many EMS specific safety practices. The majority (95%) of respondents had completed an emergency vehicle operator’s course (EVOC). Many (70%) always wear an American National Standards Institute (ANSI) II/III safety reflective vest on highway-related calls. Only 35% of respondents use a driver feedback system in their emergency vehicle, but 90% of those respondents felt it helped them adhere to safe driving habits.

Making It Safer

Our data indicates that many EMS providers adhere to specific, established EMS safety practices. However, general public safety recommendations such as routine use of seat belts and refraining from cell phone/pager use while driving are still not consistently adhered to in the prehospital setting. Utilization of education and protocols may help encourage compliance with individual safety policies. Onboard event recorders, along with formal feedback from management, have resulted in a positive changes in driving behavior.14

A Culture of Safety

Previous work has demonstrated the importance of workplace safety cultures and healthcare outcomes. In the prehospital setting, improved individual EMS worker perceptions of workplace safety culture can improve patient and provider outcomes.15

EMS providers who perceive a culture of safety in their workplace have greater adherence to safe work practices, and those who receive frequent safety-related feedback and training have the greatest adherence to safe workplace behaviors.16 Improving the frequency of safety-related feedback and training may help to bridge the gap in safety metrics such as cell phone use and seat belt use while in the PCC.


1. Maguire BJ. Transportation-related injuries and fatalities among emergency medical technicians and paramedics. Prehosp Disast Med. 2011;26(5):346-352.

2. Maguire BJ, Hunting KL, Smith GS, et al. Occupational fatalities in emergency medical services: A hidden crisis. Ann Emerg Med. 2002;40(6):625-632.

3. Centers for Disease Control and Prevention. Ambulance crash related injuries among emergency medical services workers-United States, 1991-2002. MMWR Morb Mortal Wkly Rep. 2003;52(8):154-156.

4. Reinert A, Wingrove G. (February 2010.) Rural responder: Learning from our mistakes. Michigan Center for Rural Health. Retrieved June 28, 2014, from

5. Pennsylvania Department of Health. (March 1, 2011.) Pennsylvania Statewide BLS Protocols 2011. Retrieved Jan. 1, 2014, from

6. McCallion T. Ambulance safety first: Experts convene to discuss personal & patient safety issues. JEMS. 2007;32(6):44-47.

7. McKeever JD, Schultheis MT, Padmanaban V, et al. Driver performance while texting: Even a little is too much. Traffic Inj Prev. 2013;14(2):132-137.

8. Centers for Disease Control and Prevention. Mobile device use while driving–United States and seven European countries, 2011. MMWR Morb Mortal Wkly Rep. 2013;62(10):177-182.

9. Leung S, Croft RJ, Jackson ML, et al. A comparison of the effect of mobile phone use and alcohol consumption on driving simulation performance. Traffic Inj Prev. 2012;13(6):566-574.

10. Alcohol and the driver. JAMA. 1986;256(1):37.

11. Pennsylvania Department of Health. (n.d.) Pennsylvania statewide basic life support protocols. Retrieved Nov. 5, 2015, from Health/Emergency Medical Services/EMS Statewide Protocol/Documents/Statewide_BLS_Protocols-2015 final.pdf.

12. Larmon B, LeGassick TF, Schriger DL. Differential front and back seat safety belt use by prehospital care providers. Am J Emerg Med. 1993;11(6):595-599.

13. Mayrose J, Jehle D, Hayes M, et al. Influence of the unbelted rear-seat passenger on driver mortality: “The backseat bullet.” Acad Emerg Med. 2005;12(2):130-134.

14. Myers LA, Russi CS, Will MD, et al. Effect of an onboard event recorder and a formal review process on ambulance driving behaviour. Emerg Med J. 2012;29(2):133-135.

15. Weaver MD, Wang HE, Fairbanks RJ, et al. The association between EMS workplace safety culture and safety outcomes. Prehosp Emerg Care. 2012;16(1):43-52.

16. Eliseo LJ, Murray KA, White LF, et al. EMS providers’ perceptions of safety climate and adherence to safe work practices. Prehosp Emerg Care. 2012;16(1):53-58.

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Caroline Colleran, DO, PHP, FAAEM, FACEP, is the medical director for prehospital services at Saint Vincent Hospital in Erie, Pa. She started in EMS in 1996 and has remained active. She's also the assistant regional medical director for EMMCO West Region in Pennsylvania.

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