KENTUCKY EMS FOR CHILDREN VOLUNTARY EMS PEDIATRIC RECOGNITION PROGRAM … Voluntary EMS... · 2017-06-22 · KENTUCKY EMS FOR CHILDREN VOLUNTARY EMS PEDIATRIC RECOGNITION PROGRAM

KENTUCKY EMS FOR CHILDREN

VOLUNTARY EMS PEDIATRIC RECOGNITION

PROGRAM HANDBOOK

“This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S.

Department of Health and Human Services (HHS) under grant number H33MC08042 EMSC Partnership

Grants for $130,000.00 annually. This information or content and conclusions are those of the author and

should not be construed as the official position or policy of, nor should any endorsements be inferred by

HRSA, HHS or the U.S. Government.”

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April 1, 2017

Dear EMS Agency Administrator:

It is our pleasure to introduce a voluntary statewide initiative sponsored by the Kentucky EMS for Children

(KYEMSC) program. This program honors EMS agencies who meet established criteria, beyond regulatory

requirements, and which are designed to improve the agency’s capabilities to deliver care to pediatric

patients. Again, participation in this program is voluntary.

This is an excellent opportunity for your agency to receive recognition within your community and from

local media outlets for going “above and beyond.” It is important to note that your decision to

participate in this recognition program will not affect your licensure by the Kentucky Board of EMS

(KBEMS).

If your organization is interested in participating in this program, please review this manual. An application

is available in KEMSIS under your organization profile. Organizations who successfully complete the

application process will receive a certificate for display and decals, which may be affixed to EMS vehicles,

to recognize its accomplishment and commitment to Kentucky’s youth. The KYEMSC Advisory

Committee will review this program annually. Any changes to the program criteria will be shared with

participating organizations in advance so that they will have an opportunity to work on the developments

and maintain their program status.

Should you have any questions, please do not hesitate to contact me at 859-256-3583 or

[email protected]

Regards,

Morgan Scaggs, AA, NRP

KY EMS for Children Project Director

Kentucky Board of Emergency Medical Services

118 James Court, Suite 50

Lexington, KY 40505

P: (859) 256-3583

C: (502) 330-9007

F: (859) 256-3128

kbems.kctcs.edu

mailto:[email protected]

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TABLE OF CONTENTS

Contents

TABLE OF CONTENTS ...................................................................................................... 3

Introduction ........................................................................................................................... 4

Frequently Asked Questions.................................................................................................. 5

Program Criteria for Initial Recognition ............................................................................... 6

Compliance with KY EMS Statutes and Regulations ................................................ 6

KYEMSC EMS Agency Assessments........................................................................ 6

Pediatric Emergency Care Coordinator ...................................................................... 6

Pediatric Education and Skill Competency ................................................................ 7

Pediatric Continuing Education ........................................................................................................... 8

Pediatric Skills Competency Evaluation Plan ...................................................................................... 8

Community Outreach Programs ................................................................................. 8

Pediatric Equipment Standards ................................................................................... 9

Summary of Recognition Requirements ..................................................................... 9

Special Note Regarding the Safe Transport of Pediatric Patients .............................. 9

Application and Review Process ............................................................................................. 10

Application for Enrollment ................................................................................................. 12

Attestation and Compliance Reporting Form ..................................................................... 13

Appendix A ......................................................................................................................... 14

Instructions for Documentation Upload ................................................................... 14

Appendix B .......................................................................................................................... 16

Compliance with Pediatric Equipment Recommendations ....................................... 16

Appendix C ......................................................................................................................... 23

Safe Transport Documents........................................................................................ 23

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Introduction

This document has been prepared by the Kentucky Emergency Medical Services for Children (KYEMSC)

Program, to assist the leadership of licensed EMS agencies within the Commonwealth that desire to apply

for recognition through the KYEMSC Voluntary EMS Pediatric Recognition Program. EMS agencies

currently licensed within the Commonwealth of Kentucky are eligible to participate. Currently, this

program only applies to ground transport services. This overview manual will describe the steps

necessary to apply for, and maintain, recognition status.

This document is subject to review and revision; therefore, the applicant is encouraged to review a current

copy and confer with KYEMSC to secure additional assistance. The most recent version of this overview

document is posted on the KYEMSC website.

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S.

Department of Health and Human Services (HHS) under grant #H33MC08042, EMS for Children State

Partnership, for $130,000 annually (no supporting funding provided). This information or content and

conclusions are those of the author and should not be construed as the official position or policy of, nor

should any endorsements be inferred by HRSA, HHS or the U.S. Government.

http://kbems.kctcs.edu/EMSC.aspx

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Frequently Asked Questions

Q. Is participation in this program mandatory? Does the Kentucky Board of EMS plan

to mandate future participation? A. No, participation in this program is voluntary.

Q. What are the benefits to participating? A. Not only will participation improve the capability of your organization to treat pediatric

emergencies, but it will also allow you to present your achievement to your local media outlets,

elected officials, and the members of your community.

Q. Is there a fee to participate in this recognition program? A. No. There is no cost to an organization to participate in the program beyond the cost to meet

the requirements of the program, which we hope are minimal.

Q. My pulse-ox does not have pediatric probes but it seems to work on children, does this

count? A. Yes, the terminology used on the required equipment list is based on federally developed lists.

EMS agencies will comply with the KYEMSC Voluntary EMS Pediatric Recognition Program as

long as its pulse-oximeter is pediatric CAPABLE, even if it does not have a specific pediatric

probe. Managers should obtain documentation from their pulse-ox manufacturer validating the

unit’s ability to obtain accurate readings on pediatric patients.

Q. What is meant by “small, medium, and large” extremity splints? A. The terminology used on the required equipment list is based on federally developed lists. EMS

agencies will comply with the KYEMSC Voluntary EMS Pediatric Recognition Program as long as

it carries, on all units, a variety of splint sizes that would be appropriate for use on pediatric patients.

Typically, SAM splits (or equivalent) and a variety pack of padded board splints will serve this

purpose.

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Program Criteria for Initial Recognition

The KYEMSC Voluntary EMS Pediatric Recognition Program is a single-level system to recognize agencies

who have demonstrated a commitment to excellence in pediatric emergency care. Agencies must meet all

requirements stated below to be eligible for participation in the program.

Compliance with KY EMS Statutes and Regulations

All interested agencies must be compliant with all applicable KBEMS statutes and regulations.

Access to quality data and effective data management play an important role in improving the performance

of a health care organization. Collecting, analyzing, and interpreting data allows health care professionals

to identify where systems are falling short, to make corrective adjustments, and to track outcomes. Uniform

data collection is a first step toward quality improvement (QI) in pediatric emergency medical and trauma

care.

Compliance with the 202 KAR 7:540 data collection regulation is of particular importance and agencies

must be submitting data in the latest version of NEMSIS. An agency with a deficiency or disciplinary action

related to data submission is still eligible to apply provided they are under a plan of correction and not

delinquent on any elements of the plan. Compliance will be verified through consultation with the KBEMS

Data Administrator.

Deficiencies or disciplinary action related to other regulatory requirements or complaints may preclude or

delay program participation depending on the circumstances and will be evaluated on a case-by-case basis.

KYEMSC EMS Agency Assessments

KYEMSC is required by the terms of our grant to complete data collection on our performance measures.

This process typically includes surveying EMS agencies in the state approximately once every three years

to determine progress with the performance measures. Agencies participating in this program are required

to complete performance measure assessments as requested by KYEMSC. A review of previous assessment

data and a signed statement from the agency director will be utilized for verification of this requirement.

Pediatric Emergency Care Coordinator

Participating agencies are required to have a designated Pediatric Emergency Care Coordinator (PECC)

and list the individual fulfilling this role on the application. Notification to KYEMSC is required for any

PECC personnel changes and contact information must be kept up to date.

The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains”1 recommends that

EMS agencies and emergency departments (EDs) appoint a pediatric emergency care coordinator to provide

pediatric leadership for the organization. This individual need not be dedicated solely to this role and could

be personnel already in place with a special interest in children who assumes this role as part of their existing

duties.

Gausche-Hill et al.2 in a national study of EDs found that the presence of a physician or nurse pediatric

emergency care coordinator was associated with an ED being more prepared to care for children. EDs with

1 Institute of Medicine Committee on the Future of Emergency Care in the U. S. Health System (2007). Emergency care for children: growing pains.

2 Gausche-Hill, M., Ely, M., Schmuhl, P., Telford, R., Remick, K. E., Edgerton, E. A., & Olson, L. M. (2015). A national assessment of pediatric readiness of emergency departments. JAMA Pediatrics, 169(6), 527–534.

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a coordinator were more likely to report having important policies in place and a quality improvement plan

that addressed the needs of children than EDs that reported not having a coordinator.

The IOM report further states that pediatric coordinators are necessary to advocate for improved

competencies and the availability of resources for pediatric patients. The presence of an individual who

coordinates pediatric emergency care at EMS agencies may result in ensuring that the agency and its

providers are more prepared to care for ill and injured children.

The Pediatric Emergency Care Coordinator (PECC) should be a member of the EMS agency and be familiar

with the day-to-day operations and needs at the agency. However, some states or territories may use a

variety of models to coordinate pediatric emergency care at the county or regional levels. If there is a

designated individual who coordinates pediatric activities for a county or region, that individual could serve

as the PECC for one or more individual EMS agencies within the county or region.

Some of the roles that the individual who coordinates pediatric emergency care might oversee at an EMS

agency include:

• Ensuring that the pediatric perspective is included in the development of EMS protocols.

• Ensuring that fellow providers follow pediatric clinical-practice guidelines.

• Promoting pediatric continuing-education opportunities.

• Overseeing pediatric-process improvement.

• Ensuring the availability of pediatric medications, equipment, and supplies.

• Promoting agency participation in pediatric-prevention programs.

• Promoting agency participation in pediatric-research efforts.

• Liaises with the emergency department pediatric emergency care coordinator.

• Promoting family-centered care at the agency.

Pediatric Education and Skill Competency

The Institute of Medicine (IOM) report “Emergency Care for Children: Growing Pains”3, states that because

EMS providers rarely treat seriously ill or injured pediatric patients, providers may be unable to maintain

the necessary skill level to care for these patients. For example, Lammers et al.4 reported that paramedics

manage an adult respiratory patient once every 20 days compared to once every 625 days for teens, once

every 958 days for children, and once every 1,087 days for infants. As a result, skills needed to care for

pediatric patients may deteriorate. Another study by Su et al.5 found that EMS provider knowledge rose

sharply after a pediatric resuscitation course, but when providers were retested six months later their

knowledge was back to baseline. Continuing education helps ensure that pre-hospital providers are ready

to take care of pediatric patients and improves both the quality and effectiveness of pediatric emergency

care. Pediatric specific courses, such as Pediatric Advanced Life Support (PALS) and Pediatric Education

for Prehospital Professionals (PEPP), are vitally important for maintaining skills and are considered an

effective remedy for skill atrophy. These courses are typically required only every two years. More frequent

practice of skills using different methods of skill ascertainment are necessary for EMS providers to ensure

their readiness to care for pediatric patients when faced with these infrequent encounters.

3 Institute of Medicine Committee on the Future of Emergency Care in the U. S. Health System (2006). Emergency care for children: growing pains. 4 Lammers, R. L., Byrwa, M. J., Fales, W. D., & Hale, R. A. (2009). Simulation-based assessment of paramedic pediatric resuscitation skills. Prehospital

Emergency Care, 13(3), 345–356. 5 Su, E., Schmidt, T. A., Mann, N. C., & Zechnich, A. D. (2000). A randomized controlled trial to assess decay in acquired knowledge among paramedics

completing a pediatric resuscitation course. Academic Emergency Medicine, 7(7), 779-786.

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Demonstrating skills using EMS equipment is best done in the field

on actual patients, but in the case of pediatric patients, this can be

difficult given how infrequently EMS providers see seriously ill or

injured children. Other methods for assessing skills include

simulation, case scenarios and skill stations. In the absence of

pediatric patient encounters in the field, there is no definitive evidence

that shows that one method is more effective than another is for

demonstrating clinical skills. However, Miller’s Model of Clinical

Competence6 posits via the skills complexity triangle that

performance assessment can be demonstrated by a combination of task

training, integrated skills training, and integrated team performance.

In the EMS environment, this can be translated to task training at skill

stations, integrated skills training during case scenarios, and integrated

team performance while treating patients in the field.

Pediatric Continuing Education

To achieve recognition program, an EMS agency shall require ALS providers to receive a minimum of

four (4) hours of continuing education on pediatric-specific subject matter on an annual basis, and BLS

providers to receive a minimum of two (2) hours of continuing education on pediatric-specific subject

matter on an annual basis. Any hours that meet KBEMS standards for continuing education credit and are

pediatric focused will be accepted.

Verification will be completed in the form of a statement signed by the EMS agency’s administrator and

maintenance of training records demonstrating 90% compliance. You will find instructions for submitting

documentation for verification in Appendix A.

Pediatric Skills Competency Evaluation Plan

To achieve recognition program, an EMS agency shall develop and submit a written plan to evaluate

pediatric skill competency for all staff a minimum of once per year. It is highly recommended that skill

competency evaluations be completed twice annually using a variety of methods.

Verification will be completed in the form of a statement signed by the EMS agency’s administrator and

submission of the written plan for initial recognition. In subsequent years, documentation will include

submission of the written plan and maintenance of training records demonstrating 90% compliance. You

will find instructions for submitting documentation for verification in Appendix A.

Community Outreach Programs

Beyond simply providing high quality and safe clinical care to children, EMS agencies demonstrating

excellence in pediatric care also share a responsibility to provide education, injury prevention initiatives,

and outreach within their community. There are many potential audiences (children, parents,

schoolteachers, etc.) for this outreach and it can be accomplished in multiple ways.

To achieve recognition, an EMS agency shall regularly participate in community outreach initiatives. There

must be least one (1) outreach offered annually, but there is no specific way that this must be accomplished

as long as a benefit to children can be demonstrated. You will find instructions for submitting

documentation for verification in Appendix A.

6 Miller, G. E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9), S63-7.

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Some examples include:

1. Hosting a community safety day at the EMS station;

2. Hosting a community CPR class, including child/infant curriculum components;

3. Providing a presentation to local elementary school students on EMS;

4. Conducting injury prevention presentations or campaigns such as:

• bicycle, ATV, or hunting safety

• water safety awareness, drowning prevention

• child passenger safety check point events

5. Collaborating with your local schools to educate and improve awareness of EMS topics including, but

not limited to, compression-only CPR, the Thomas J. Burch Safe Infant Act, and 9-1-1 usage.

Pediatric Equipment Standards

Pre-hospital providers must have the appropriate pediatric equipment and supplies to care for ill and injured

children in order to achieve optimal pediatric outcomes. The Joint Policy Statement “Equipment for Ground

Ambulances”7 is the metric used to determine a state’s compliance with the Federal EMSC performance

objectives.

Appendix B includes the national recommendations for equipment on ground ambulances and a list of

specific items not currently required under KY regulations. To obtain recognition through this program,

agencies must demonstrate compliance with the national recommendations. Agencies must attest that they

carry all of the nationally recommended equipment.

Verification of any equipment items not included in KY regulations may occur either through an in-person

or virtual site visit by KYEMSC representatives.

Summary of Recognition Requirements Compliance with KBEMS Statutes and Regulations

o including data submission requirements

Participation in KYEMSC assessments

Designated Pediatric Emergency Care Coordinator

Annual Pediatric Education (4 hrs. for ALS, 2 hrs. for BLS)

Pediatric Competency Skill Evaluations

Community Outreach

Pediatric Equipment per national recommendations

Special Note Regarding the Safe Transport of Pediatric Patients

The safe transport of pediatric patients remains an area of significant challenge for EMS providers. It is

strongly recommended that EMS agencies have policies that include prohibiting the transport of

unrestrained pediatric patients and provisions for securing all equipment during transport. Furthermore,

agencies should seek compliance with both the Safe Transport of Children by EMS: Interim Guidance

(2017 NASEMSO) and the Working Group Best-Practice Recommendations for the Safe Transport of

Children in Ground Ambulances (2012 NHTSA). Both documents can be found in Appendix C.

7 American Academy of Pediatrics, American College of Emergency Physicians, American College of Surgeons Committee on Trauma, Emergency Medical

Services for Children, Emergency Nurses Association, National Association of EMS Physicians, National Association of State EMS Officials. (2014) Equipment for Ground Ambulances. Pediatrics, 134(3), e919: DOI: 10.1542/peds.2014-1698.

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Future program revisions will likely include specific requirements regarding the safe transport of pediatric

patients.

Application and Review Process

The application for enrollment in the recognition program is available under your agency’s KEMSIS

account. You can use the following pages to gather needed information prior to completing the application

online.

You may submit your application through KEMSIS at any time and we will review it as soon as feasible.

Regardless of date of initial recognition, renewal submissions will be due for all agencies at the same time.

Recognition certificates and decals will be marked with the year recognition is awarded. Renewal

submissions will be due by March 15 each year for review by the EMSC Advisory Committee in April.

KYEMSC will release an updated list of recognized agencies to the press/public each year in May on EMSC

for Children Day during EMS Week.

1. KYEMS for Children Program Review Applications will be checked for completeness and accuracy. The EMS agency’s licensure status and

status of “good standing” will be verified through KBEMS. The applying agency will be contacted by

the EMS for Children Project Director via e-mail or phone to arrange an in-person or virtual site visit as

needed to verify program compliance. The agency will also be contacted if the application is incomplete

or is in need of correction or clarification.

2. Award of Recognition

Upon successful submission of completed verification documentation, the EMS for Children Program

will send a recognition certificate and decal(s) to the applicant. While placement of the vehicle

recognition decal is strongly encouraged, it is not required. Successful applicants, by virtue of applying

for recognition, authorize their organization name and general information to be posted in program

documents and on the EMS for Children website. EMS agencies are also encouraged to promote their

recognition under this program through a public relations event, press release, etc. The EMS for

Children Program has a generic press release available for use. EMS agencies seeking assistance with

public relations events should contact the EMS for Children Project Director.

3. Renewal of Recognition In order to “renew” program recognition, the agency must update their application in KEMSIS between

January 1 and March 15. This includes submission of documentation to verify pediatric continuing

education and skill competency completion, along with community outreach events for the previous year

and a summary of plans for the coming year.

4. Appeal Process for Denied Applications EMS Agencies may appeal a decision to deny recognition by submitting a written request to have their

application or status re-evaluated. Appeal letters should be submitted to the Project Director for further

review by the EMS for Children Advisory Committee. A written response to the appeal will be returned

to the EMS agency within 90 days of its receipt.

5. Suspension or Revocation

Recognition through this program may be suspended or revoked if the EMS agency: a. Willfully or repeatedly violated any provision of these guidelines;

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b. Willfully or repeatedly acted in a manner inconsistent with preserving the health and safety

of patients, the public, or providers;

c. Provided falsified information in order to gain recognition;

d. Failed to maintain the standards of this Voluntary EMS Pediatric Recognition Program as

identified in the guidance; or

e. In the event that an organization no longer maintains recognition status, decals must be removed

from all EMS vehicles and disposed of or returned to the KY EMS for Children Program.

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Application for Enrollment KYEMSC Voluntary EMS Pediatric Recognition Program

Please use the following forms to gather information needed to complete the application in your Agency

KEMSIS account.

EMS Agency Information

Name: *Prepopulated*

Address: *Prepopulated*

Agency License #: *Prepopulated*

EMS Agency Director


EMS Agency Medical Director


Designated Pediatric Emergency Care Coordinator

Name:

KEMSIS #:

Phone Number:

Email Address:

Indicate preferred color of vehicle decals:

󠆛 Pink󠆛 󠆛 Silver

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Attestation and Compliance Reporting Form KYEMSC Voluntary EMS Pediatric Recognition Program

To be completed by an EMS Agency Administrator (e.g., chief operating officer, administrator, director, president, etc.).

This form will be electronically signed during the application submission in KEMSIS and this copy is provided for

informational purposes only.

By signing this verification form, I attest that my EMS Agency:

Is currently compliant with all applicable KBEMS statutes and regulations.

Shall participate in national EMS assessments, administered by KYEMSC and the National EMS for

Children Data Analysis Research Center (NEDARC) to maintain program participation and recognition.

Has designated an individual to serve as the Pediatric Emergency Care Coordinator (PECC) as noted in the

program guidelines, included their name and contact information on the application, and shall notify

KYEMSC of any personnel changes related to this position.

Maintains, on all EMS vehicles, all pediatric equipment mandated by Kentucky licensure standards and all

of the optional equipment as required by the KYEMSC Voluntary EMS Pediatric Recognition Program and

agree that our equipment, specific to this form, is subject to audit and inspection by KYEMSC and KBEMS

representatives, including during a KBEMS licensing inspection.

Requires ALS providers to obtain a minimum of four (4) hours of continuing education on pediatric-

specific subject matters on an annual basis, and BLS providers to obtain a minimum of two (2) hours of

continuing education on pediatric-specific subject matters on an annual basis. (All courses must meet

KBEMS standards for continuing education credit.) That we maintain documentation of completion of the

required education hours such as course completion certificates or continuing education reports for

providers at our EMS agency and will make these records available for review upon request.

Has a written plan to evaluate pediatric skill competency for all staff a minimum of once per year, using a

variety of methods and maintains documentation of these evaluations that will be made available for review

upon request.

Regularly participates in at least one community outreach event annually which focuses on pediatric

education, injury prevention initiatives, and/or outreach within our community. We will maintain records

of our participation in these events and provide notice, whenever possible, to the KYEMSC Program of

upcoming community outreach events.

Print Name:

Title:

Signature: Date:

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Appendix A

Instructions for Documentation Upload

To demonstrate compliance with program criteria, you will upload documentation within the KEMSIS

application. You will need to gather the appropriate information and create a single Word or PDF

document to upload for each section.

This program will track education, skills competency evaluations, and outreach events by the calendar

year. Example: An agency submits an initial application to the program in May of 2017, including plans

for the remainder of 2017, and will receive “2017” recognition. In early 2018, this agency submits for

renewal. At that time, they will report on the previous year’s activities (2017) and submit new plans for the

coming/current year of 2018. Upon successful review of the application, the agency would then receive

“2018” recognition.

Specific guidance for each section:

Pediatric Education, Plan, Summary, and/or Records

For Initial Recognition:

Submit a written plan for how your agency will sponsor, provide, or require pediatric specific education

for your personnel in the coming/current year. (Minimum of 4 hours of for ALS providers and 2 hours for

BLS providers) The plan should detail how you will ensure completion of the minimum requirements by

90% of certified or licensed staff each year.

For Renewal of Recognition:

Submit a written summary of how your agency complied with the education requirements for the previous

calendar year and any plans for the coming/current calendar year. This summary should include:

the number of certified/licensed personnel on your roster

the title, date, and length of pediatric topics or courses provided to personnel

the percentage of those personnel who met the minimum requirement

copies of rosters and/or other training records DO NOT need to be included but must be available

for review upon request

Pediatric Skill Competency Evaluation Plan and Records


Submit a written plan for how your agency will evaluate pediatric skill competency of your providers in

the coming/current year. This process must require the physical demonstration of correct use of pediatric-

specific equipment.

Methods used can include task training in skill stations, integrated skills training during case scenarios,

and integrated team performance while treating patients in the field.

At least 90% of certified/licensed personnel must be evaluated annually. Biannual evaluations are

recommended. It is not required that all personnel or skills be evaluated in a single session. Each

individual should be evaluated on each skill at least once per calendar year to count in the 90%

completion.

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Suggested Skills/Equipment Evaluations (based on equipment carried by agency):

pediatric safe transport devices

airway management: OPA, NPA, BVM, laryngoscopy, ET tubes, LMA, King airway, i-gel, etc.

intravenous and intraosseous line insertion and use

immobilization devices

medication administration (i.e. transferring epinephrine to a 1 ml syringe for an infant in cardiac

arrest)

use of an age/weight/length-based reference (i.e. Broselow tape, Handtevy System)


Submit a written summary of how your agency complied with the skills competency evaluation

requirements for the previous calendar year and any plans for the coming/current calendar year. This

summary should include:

the number of certified/licensed personnel on your roster

dates, skills evaluated, and methods used

the percentage of those personnel who met the minimum requirement

copies of rosters and/or other training records DO NOT need to be included but must be available

for review upon request

Community Outreach Events


Submit a written plan for how your agency will meet the requirement for at least one community outreach

event that is pediatric focused in the coming/current year. Your agency may be the event sponsor or you

may participate in an event sponsored by another community partner.

For planned events, list the following as applicable:

the date (exact or approximate)

sponsor

location

name or type of event

specific program or activities that are pediatric related

recognized or anticipated benefits to children in your community


Submit a written summary of how your agency complied with the pediatric outreach requirement for the

previous calendar year and any plans for the coming/current calendar year. The summary for completed

events can include copies or links to media coverage, flyers, pictures, or other available documentation.

Follow the same guidelines for planned events as listed above under initial recognition.

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Appendix B

Compliance with Pediatric Equipment Recommendations

National Recommendations Current KY Regulations Compliance

Pulse oximeter with pediatric and

adult probes

Not addressed All ambulances must comply

with the recommendation.

Thermal absorbent blanket and

head covering, aluminum foil

roll, or appropriate heat-

reflective material (enough to

cover a newborn infant)

Not addressed specifically. May

be included in the requirement

for Two (2) sterile obstetrical

kits.

All ambulances must comply

with the recommendation. Items

may be included in a

commercially prepared kit or

available separately.

Access to pediatric and adult

patient care protocols throughout

the call.

All agencies shall maintain

evidence in the form of a letter

that medical protocols have been

reviewed and approved by the

board.

All ambulances must comply


Electronic or hard copy is

acceptable.

A length-based resuscitation tape

OR a reference material that

provides appropriate guidance for

pediatric drug dosing and

equipment sizing based on length

OR weight.

Not required for BLS

ambulances.

For ALS: Pediatric drug dosage

tape or equivalent that provides

easy reference for pediatric and

infant treatment and drug

dosages.

All ground ambulances, BLS and

ALS, must carry reference

materials as noted in the

recommendation.

ET Tubes

2.5, 3.0, 3.5, 4.0, 4.5, 5.0,

and 5.5 mm cuffed and/or

uncuffed, and

6.0, 6.5, 7.0, 7.5, and 8.0 mm

cuffed, other sizes optional

Endotracheal tubes in the

following sizes:

2.5, 3.0, 3.5, 4.0, 4.5, 5.0,

and 5.5 cuffed or uncuffed;

and

6.0, 7.0, and 8.0 cuffed

All ALS ambulances must

comply with the

recommendation.

Nebulizer



Long large-bore needles or

angiocatheters (should be at least

3.25” in length for needle chest

decompression in large patients)



Availability of necessary age/size

appropriate restraint systems for

all passengers and patients

transported in ground

ambulances.

Not addressed Strong recommendation for

compliance with the Safe Transport

of Children by EMS: Interim

Guidance (2017 NASEMSO) and

the Working Group Best-Practice

Recommendations for the Safe

Transport of Children in Ground

Ambulances (2012 NHTSA).

The full equipment guideline follows or you can access it at the following link:

http://pediatrics.aappublications.org/content/134/3/e919

http://pediatrics.aappublications.org/content/134/3/e919

JOINT POLICY STATEMENT

EQUIPMENT FOR GROUND AMBULANCES

American Academy of PediatricsAmerican College of Emergency Physicians

American College of Surgeons Committee on TraumaEmergency Medical Services for Children

Emergency Nurses AssociationNational Association of EMS Physicians

National Association of State EMS Officials

Four decades ago, the Committee on Trauma of theAmerican College of Surgeons (ACS) developed alist of standardized equipment for ambulances. In1988, the American College of Emergency Physicians(ACEP) published a similar list. The two organiza-tions collaborated on a joint document published in2000, and the National Association of EMS Physi-cians (NAEMSP) participated in the 2005 revision. The2005 revision included resources needed on emergencyground ambulances for appropriate homeland secu-rity. All three organizations adhere to the principle thatemergency medical services (EMS) providers at all lev-els must have the appropriate equipment and suppliesto optimize out-of-hospital delivery of care. The docu-ment was written to serve as a standard for the equip-ment needs of emergency ground ambulance servicesboth in the United States and Canada.

EMS providers care for patients of all ages whohave a wide variety of medical and traumatic condi-tions. The 2009 revision included updated pediatricrecommendations developed by members of the Fed-eral Emergency Medical Services for Children (EMSC)Stakeholder Group and endorsed by the AmericanAcademy of Pediatrics (AAP). The EMSC program hasdeveloped several performance measures for the pro-gram’s state partnership grantees. One of the perfor-mance measures evaluates the availability of essen-tial pediatric equipment and supplies for basic life

Declaration of Interest: Organizations participating in this joint pol-icy statement, and their representatives to the working group thatdrafted it, report no conflicts of interest.

doi: 10.3109/10903127.2013.851312

support (BLS) and advanced life support (ALS) pa-tient care units. This document is used as the standardfor this performance measure. The National Associa-tion of State EMS Officials and the Emergency NursesAssociation have participated in the latest revisionprocess. The recommendations in this documentspecifically pertain to ALS and BLS emergency groundambulance services in the United States.

For purposes of this document, the following defini-tions have been used: a neonate is 0–28 days old, aninfant is 29 days to 1 year old, and a child is >1 yearthrough 11 years old with delineation into the follow-ing developmental stages:

Toddlers (1–3 years old)Preschoolers (3–5 years old)Middle childhood (6–11 years old)Adolescents (12–18 years old)

These standard definitions are age based. Length-based systems have been developed to more accuratelyestimate the weight of children and predict appropri-ate equipment sizes, medication doses, and guidelinesfor fluid volume administration.

PRINCIPLES OF OUT-OF-HOSPITAL CARE

The goal of out-of-hospital care is to minimize fur-ther systemic injury and manage life-threatening con-ditions through a series of well-defined and appropri-ate interventions and to embrace principles that ensurepatient safety. High-quality, consistent emergency caredemands continuous quality improvement and is di-rectly dependent on the effective monitoring, integra-tion, and evaluation of all components of the patient’scare.

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2 PREHOSPITAL EMERGENCY CARE OCTOBER/DECEMBER 2013 EARLY ONLINE

Integral to this process is medical oversight of out-of-hospital care by using preexisting patient care pro-tocols (indirect medical oversight), which are evidencebased when possible, or by medical control via voiceand/or video communication (direct medical over-sight). The protocols that guide patient care shouldbe established collaboratively by medical directors forground ambulance services, adult and pediatric emer-gency medicine physicians, adult and pediatric traumasurgeons, and appropriately trained basic and ad-vanced emergency medical personnel. Current recom-mendations of the Institute of Medicine (IOM) encour-age each EMS agency to have a pediatric coordinatorto specifically coordinate the capability of the serviceto care for non-adult patients.

EQUIPMENT AND SUPPLIES

The current guidelines provide a recommendedcore list of supplies and equipment that shouldbe stocked on ground ambulances to provide theaccepted standards of patient care. Equipment re-quirements will vary, depending on the certifica-tion or licensure levels of the providers (as definedby the National EMS Scope of Practice Model 2007www.ems.gov/education/EMSScope.pdf), local med-ical direction and jurisdiction, population densities,geographic and economic conditions of the region, andother factors.

The National EMS Scope of Practice Model de-fines and describes four certification or licensurelevels of EMS provider: emergency medical respon-der (EMR), emergency medical technician (EMT), ad-vanced EMT (AEMT), and paramedic. Each level rep-resents a unique role, set of skills, and knowledge base.The National EMS Scope of Practice Model establishesa framework that ultimately determines the range ofskills and roles that an individual possessing a stateEMS license is authorized to do in a given EMS system.Individual state EMS rules or regulations that limitprovider scope of practice may impact the need foravailability of certain pieces of equipment.

The current equipment list is derived from a num-ber of sources, which may be found in the referencelist at the end of the document. The use of a propri-etary name that is inextricably linked with its productshould not be construed as an endorsement.

The following list is divided into equipment for ba-sic life support (BLS) and advanced life support (ALS)emergency ground ambulances. ALS ambulances musthave all of the equipment on the required BLS list aswell as equipment on the required ALS list. This listrepresents a consensus of recommendations for equip-ment and supplies that will facilitate patient care in theout-of-hospital setting.

REQUIRED EQUIPMENT FOR BLS EMERGENCY

GROUND AMBULANCES

A. Ventilation and Airway Equipment1. Portable and fixed suction apparatus with a

regulator, per federal specifications• Wide-bore tubing, rigid pharyngeal curved

suction tip; tonsil and flexible suctioncatheters, 6F–16F, are commercially available(have one between 6F and 10F and one be-tween 12F and 16F)

2. Portable oxygen apparatus, capable of meteredflow with adequate tubing

3. Portable and fixed oxygen supply equipment• Variable flowmeter

4. Oxygen administration equipment• Adequate-length tubing; transparent mask

(adult and child sizes), both non-rebreathingand valveless; nasal cannulas (adult, child)

5. Bag-valve mask (manual resuscitator)• Hand-operated, self-expanding bag; adult

(>1000 mL) and child (450–750 mL) sizes,with oxygen reservoir/accumulator, valve(clear, operable in cold weather), and mask(adult, child, infant, and neonate sizes)

6. Airways• Nasopharyngeal (16F–34F; adult and child

sizes)• Oropharyngeal (sizes 0–5; adult, child, and

infant sizes)7. Pulse oximeter with pediatric and adult probes8. Saline drops and bulb suction for infants

B. Monitoring and DefibrillationBLS ground ambulances should be equipped withan automated external defibrillator (AED) unlessstaffed by advanced life support personnel whoare carrying a monitor/defibrillator. The AEDshould have pediatric capabilities, includingchild-sized pads and cables OR dose attenuatorwith adult pads.

C. Immobilization Devices1. Cervical collars

• Rigid for children ages 2 years or older; childand adult sizes (small, medium, large, andother available sizes) OR pediatric and adultadjustable cervical collars

2. Head immobilization device (not sandbags)• Firm padding or commercial device

3. Upper and lower extremity immobilizationdevices• Joint-above and joint-below fracture (sizes

appropriate for adults and children) rigidsupport, constructed with appropriate mate-rial (cardboard, metal, pneumatic, vacuum,wood, or plastic)

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EQUIPMENT FOR AMBULANCES 3

4. Impervious backboards (long, short; radiolu-cent preferred) and extrication device• Short extrication/immobilization device

(e.g., KED)• Long transport (head-to-feet length) with

at least 3 appropriate restraint straps (chinstrap alone should not be used for head im-mobilization) and with padding for childrenand handholds for moving patients

D. Bandages/Hemorrhage Control

1. Commercially packaged or sterile burn sheets2. Bandages

• Triangular bandages3. Dressings

• Sterile dressings, including gauze sponges ofsuitable size

• Abdominal dressing4. Gauze rolls

• Various sizes5. Occlusive dressing or equivalent6. Adhesive tape

• Various sizes (including 1′′ and 2′′) hypoal-lergenic

• Various sizes (including 1′′ and 2′′) adhesive7. Arterial tourniquet (commercial preferred)

E. Communication

Two-way communication device between groundambulance, dispatch, medical control, andreceiving facility

F. Obstetrical Kit (commercially packaged areavailable)

1. Kit (separate sterile kit)• Towels, 4′′ × 4′′ dressing, umbilical tape,

sterile scissors or other cutting utensil, bulbsuction, clamps for cord, sterile gloves,blanket

2. Thermal absorbent blanket and head cover,aluminum foil roll, or appropriate heat-reflective material (enough to cover newborninfant)

G. Miscellaneous

1. Access to pediatric and adult patient careprotocols

2. A length-based resuscitation tape OR a refer-ence material that provides appropriate guid-ance for pediatric drug dosing and equipmentsizing based on length OR age

3. Sphygmomanometer (pediatric and adultregular size and large cuffs)

4. Adult stethoscope5. Thermometer with low-temperature

capability6. Heavy bandage or paramedic scissors for cut-

ting clothing, belts, and boots

7. Cold packs8. Sterile saline solution for irrigation9. Two functional flashlights

10. Blankets11. Sheets (at least one change per cot)12. Pillows13. Towels14. Triage tags15. Emesis bags or basins16. Urinal17. Wheeled cot18. Stair chair or carry chair19. Patient care charts/forms or electronic

capability20. Lubricating jelly (water soluble)

H. Infection Control∗1. Eye protection (full peripheral glasses or gog-

gles, face shield)2. Face protection (e.g., surgical masks per appli-

cable local or state guidance)3. Gloves, nonsterile4. Fluid-resistant overalls or gowns5. Waterless hand cleanser, commercial antimi-

crobial (towelette, spray, or liquid)6. Disinfectant solution for cleaning equipment7. Standard sharps containers, fixed and portable8. Biohazard trash bags (color coded or with

biohazard emblem to distinguish from othertrash)

9. Respiratory protection (e.g., N95 or N100mask—per applicable local or state guidance)

∗Latex-free equipment should be available

I. Injury-prevention Equipment

1. Availability of necessary age/size-appropriaterestraint systems for all passengers and pa-tients transported in ground ambulances. Forchildren, this should be according to the Na-tional Highway Traffic Administration’s doc-ument: Safe Transport of Children in Emer-gency Ground Ambulances (www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf)

2. Fire extinguisher3. Department of Transportation Emergency Re-

sponse Guide4. Reflective safety wear for each crewmember

(must meet American National Standard forHigh Visibility Public Safety Vests if workingwithin the right of way of any federal-aidhighway. Visit www.reflectivevest.com/federalhighwayruling.html for moreinformation)

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REQUIRED EQUIPMENT: ADVANCED LIFE

SUPPORT (ALS) EMERGENCY GROUND

AMBULANCES

For paramedic services, include all of the requiredequipment listed above, plus the following additionalequipment and supplies. For advanced EMT services(and other non-paramedic advanced levels), includeall of the equipment from the above list and selectedequipment and supplies from the following list, basedon scope of practice, local need, and consideration ofout-of-hospital characteristics and budget.

A. Airway and Ventilation Equipment

1. Laryngoscope handle with extra batteries andbulbs

2. Laryngoscope blades, sizes:a. 0–4, straight (Miller), andb. 2–4, curved

3. Endotracheal tubes (if ALS service scope ofpractice includes tracheal intubation), sizes:

a. 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, and 5.5 mm cuffedand/or uncuffed, and

b. 6.0, 6.5, 7.0, 7.5, and 8.0 mm cuffed (1 each),other sizes optional

4. 10-mL non-Luer Lock syringes5. Stylettes for endotracheal tubes, adult and

pediatric6. Magill forceps, adult and pediatric7. End-tidal CO2 detection capability (adult and

pediatric)8. Rescue airway device, such as the ETDLA

(esophageal–tracheal double-lumen airway),laryngeal tube, disposable supraglottic airway,or laryngeal mask airway (as approved by lo-cal medical direction)

B. Vascular Access

1. Isotonic crystalloid solutions2. Antiseptic solution (alcohol wipes and

povidone–iodine wipes preferred)3. Intravenous fluid bag pole or roof hook4. Intravenous catheters, 14G–24G5. Intraosseous needles or devices appropriate

for children and adults6. Latex-free tourniquet7. Syringes of various sizes8. Needles, various sizes (including suitable

sizes for intramuscular injections)9. Intravenous administration sets (microdrip

and macrodrip)10. Intravenous arm boards, adult and pediatric

C. Cardiac

1. Portable, battery-operated monitor/defibri-llator

• With tape write-out/recorder, defibrillatorpads, quick-look paddles or electrode, orhands-free patches, electrocardiogram leads,adult and pediatric chest attachment elec-trodes, adult and pediatric paddles

2. Transcutaneous cardiac pacemaker, includingpediatric pads and cables• Either stand-alone unit or integrated into

monitor/defibrillatorD. Other Advanced Equipment

1. Nebulizer2. Glucometer or blood glucose measuring de-

vice with reagent strips3. Long large-bore needles or angiocatheters

(should be at least 3.25” in length for needlechest decompression in large adults)

E. MedicationsDrug dosing in children should use processesminimizing the need for calculations, preferably alength-based system. In general, medications mayinclude:1. Cardiovascular medication, such as 1:10,000

epinephrine, atropine, antidysrhythmics (e.g.,adenosine and amiodarone), calcium channelblockers, beta-blockers, nitroglycerin tablets,aspirin, vasopressor for infusion

2. Cardiopulmonary/respiratory medications,such as albuterol (or other inhaled betaagonist) and ipratropium bromide, 1:1000epinephrine, furosemide

3. 50% dextrose solution (and sterile diluent or25% dextrose solution for pediatrics)

4. Analgesics, narcotic and nonnarcotic5. Anti-epileptic medications, such as diazepam

or midazolam6. Sodium bicarbonate, magnesium sulfate,

glucagon, naloxone hydrochloride, calciumchloride

7. Bacteriostatic water and sodium chloride forinjection

8. Additional medications, as per local medicaldirector

OPTIONAL EQUIPMENT

The equipment in this section is not mandated orrequired. Use should be based on local needs andresources.

A. Optional Equipment for BLS Ground Ambu-lances1. Glucometer or blood glucose test strips (per

state protocol and/or local medical controlapproval)

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EQUIPMENT FOR AMBULANCES 5

2. Infant oxygen mask3. Infant self-inflating resuscitation bag4. Airways

a. Nasopharyngeal (12F, 14F)b. Oropharyngeal (size 00)

5. CPAP/BiPAP capability6. Neonatal blood pressure cuff7. Infant blood pressure cuff8. Pediatric stethoscope9. Infant cervical immobilization device

10. Pediatric backboard and extremity splints11. Femur traction device (adult and child sizes)12. Pelvic immobilization device13. Elastic wraps14. Ocular irrigation device15. Hot packs16. Warming blanket17. Cooling device18. Soft patient restraints19. Folding stretcher20. Bedpan21. Topical hemostatic agent/bandage22. Appropriate CBRNE PPE (chemical, biologi-

cal, radiological, nuclear, explosive personalprotective equipment), including respiratoryand body protection; protective helmet/jackets or coats/pants/boots

23. Applicable chemical antidote auto-injectors(at a minimum for crew members’ protection;additional for victim treatment based on localor regional protocol; appropriate for adultsand children)

B. Optional Equipment for ALS Emergency GroundAmbulances

1. Respirator, volume-cycled, on/off operation,100% oxygen, 40–50 psi pressure (child/infantcapabilities)

2. Blood sample tubes, adult and pediatric3. Automatic blood pressure device4. Nasogastric tubes, pediatric feeding tube sizes

5F and 8F, sump tube sizes 8F–16F5. Size 1 curved laryngoscope blade6. Gum elastic bougies7. Needle cricothyrotomy capability and/or

cricothyrotomy capability (surgical cricothy-rotomy can be performed in older children inwhom the cricothyroid membrane is easilypalpable, usually by puberty)

8. Rescue airway devices for children9. Atomizers for administration of intranasal

medications

OPTIONAL MEDICATIONS

A. Optional Medications for BLS Emergency Ambu-lances

1. Albuterol2. Epi-pen3. Oral glucose4. Nitroglycerin (sublingual tablet or paste)5. Aspirin

B. Optional Medications for ALS EmergencyGround Ambulances1. Intubation adjuncts, including neuromuscular

blockers

INTERFACILITY TRANSPORT

Additional equipment may be needed by ALS andBLS out-of-hospital care providers who transport pa-tients between facilities. Transfers may be made toa lower or higher level of care, depending on thespecific need. Specialty transport teams, includingpediatric and neonatal teams, may include other per-sonnel, such as respiratory therapists, nurses, andphysicians. Training and equipment needs may be dif-ferent depending on the skills needed during transportof these patients. There are excellent resources avail-able that provide detailed lists of equipment neededfor interfacility transfer, such as Guidelines for Air andGround Transport of Neonatal and Pediatric Patientsfrom the AAP and The Interfacility Transfer Toolkit forthe Pediatric Patient from the EMSC, ENA, and the So-ciety of Trauma Nurses.

Any ground ambulance that, either by formal agree-ment or by circumstance, may be called into serviceduring a disaster or mass casualty incident to treatand/or transport any patient from the scene to the hos-pital or to transfer between facilities any patient otherthan those within their designated specialty popula-tion should carry, at a minimum, all equipment, adultand pediatric, listed under “Required Equipment forAll Emergency Ground Ambulances.”

EXTRICATION EQUIPMENT

In many cases, optimal patient care mandates appro-priate and safe extrication or rescue from the patient’ssituation or environment. It is critical that EMS person-nel possess or have immediate access to the expertise,tools, and equipment necessary to safely remove pa-tients from entrapment or hazardous environments. Itis beyond the scope of this document to describe theextent of these. Local circumstances and regulationsmay affect both the expertise and tools that are main-tained on an individual ground ambulance, and on anyother rescue vehicle that may be needed to accompanyan ambulance to an EMS scene. The tools and equip-ment carried on an individual ground ambulance needto be thoughtfully determined by local features of theEMS system with explicit plans to deploy the neededresources when extrication or rescue is required.

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American Academy of Pediatrics. Section on Cardiology and Car-diac Surgery. Policy statement: pediatric sudden cardiac arrest.Pediatrics. 2012;129(4):e1094–102.

American Academy of Orthopedic Surgeons (AAOS). Weaponsof Mass Casualties and Terrorism Response Handbook.Sudbury, MA: Jones & Bartlett; 2006.

American Academy of Pediatrics Section on Transport Medicine. In:Woodward GA, Insoff RM, Kleinman ME (eds.): Guidelines forAir and Ground Transport of Neonatal and Pediatric Patients,3rd edition. American Academy of Pediatrics, Elk Grove Vil-lage, IL, 2006.

American College of Surgeons; Committee on Trauma; AmericanCollege of Emergency Physicians; National Association of EMSPhysicians; Pediatric Equipment Guidelines Committee; Amer-ican Academy of Pediatrics. Equipment for ambulances. BullAm Coll Surg. 2009;94(7):23–9; Pediatrics. 2009;124(1):e166–71.

American College of Surgeons Committee on Trauma; Amer-ican College of Emergency Physicians; National Associa-tion of EMS Physicians; Pediatric Equipment GuidelinesCommittee—Emergency Medical Services for Children Part-nership for Children Stakeholder Group; American Academyof Pediatrics. Equipment for ambulances. Out-of-hosp EmergCare. 2009;13(3):364–9.

American College of Surgeons Committee on Trauma; Amer-ican College of Emergency Physicians; National Associa-tion of EMS Physicians; Pediatric Equipment GuidelinesCommittee—Emergency Medical Services for Children Part-nership for Children Stakeholder Group; American Academyof Pediatrics. Equipment for Ambulances. Irving, TX: Amer-ican College of Emergency Physicians; 2009. Availableat: www.acep.org/clinical—practice-management/equipment-for-ambulances

Berg MD, Schexnayder SM, Chameides L, et al. Pediatric Basic LifeSupport, Part 13: 2010 American Heart Association guidelinesfor cardiopulmonary resuscitation and emergency cardiovascu-lar care. Circulation. 2010;122(18 Suppl 3):S862–75.

Bledsoe B, Barnes D. Traction splint: an EMS relic? JEMS.2004;29(8):64–9.

Brown MA, Daya MR, Worley JA. Experience with chitosan dress-ings in a civilian EMS system. J Emerg Med. 2009;37(1):1–7.

Daugherty MC, Mehlman CT, Moody S, LeMaster T, Falcone RA Jr.Significant rate of misuse of the hare traction splint for childrenwith femoral shaft fractures. J Emerg Nurs. 2013;39:97–103.dx.doi.org/10.1016/j.jen.2012.10.008

Doyle GS, Taillac PP. Tourniquets: a review of current use with pro-posals for expanded out-of-hospital use. Prehosp Emerg Care.2008;12(2):241–56.

Federal Highway Administration. Worker Visibility. DOT CFR-634.2and 634.3.

Federal Highway Administration. Use of High-Visibility Ap-parel When Working on Federal-Aid Highways. Available at:www.reflectivevest.com/federalhighwayruling.html

Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pedi-atric endotracheal intubation on survival and neurological out-come. JAMA. 2000;283(6):783–90.

Granville-Chapman J, Jacobs N, Midwinter MJ. Out-of-hospital haemostatic dressings: a systematic review. Injury.2011;42(5):447–59.

Kattwinkel J, Perlman JM, Aziz K, et al. Neonatal Resuscitation, Part15: 2010 American Heart Association guidelines for cardiopul-monary resuscitation and emergency cardiac care. Circulation.2010;122(18 Suppl 3):S909–19.

Kragh JF, Walters TJ, Baer DG, et al. Practical use of emergencytourniquets to stop bleeding in major limb trauma. J Trauma.2008;64: S38–50.

Kwan I, Bunn F. Effects of out-of-hospital spinal immobilization: asystematic review of randomized trials on healthy subjects. Pre-hosp Disaster Med. 2005;20(1):47–53.

Institute of Medicine, Board on Health Care Services. Future ofEmergency Care in the United States Health Care System.Washington, DC: National Academies Press; 2007.

Lecky F, Bryden D, Little R, Tong N, Moulton C. Emergency intuba-tion for acutely ill and injured patients. Cochrane Database SystRev. 2008;(2):CD001429.

Leonard JC, Kuppermann N, Olsen C, et al. Factors associated withcervical spine injury in children after blunt trauma. Ann EmergMed. 2011;58(2):145–55.

National Highway Traffic Safety Administration: www.nhtsa.govChild Restraint Re-use After Minor Crashes. www.nhtsa.dot.gov/

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National Highway Traffic Safety Administration. Best Practice Rec-ommendations for Safe Transportation of Children in Emer-gency Ground Ambulances. September 2012.

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23

Appendix C

Safe Transport Documents

The complete documents follow this page or you can access them at the links provided.

Safe Transport of Children by EMS: Interim Guidance (2017 NASEMSO)

https://www.nasemso.org/Committees/STC/documents/Safe-Transport-of-Children-by-EMS-

InterimGuidance-08Mar2017-FINAL.pdf

Working Group Best-Practice Recommendations for the Safe Transport of Children in Ground

Ambulances (2012 NHTSA) https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf

https://www.nasemso.org/Committees/STC/documents/Safe-Transport-of-Children-by-EMS-InterimGuidance-08Mar2017-FINAL.pdf

https://www.nasemso.org/Committees/STC/documents/Safe-Transport-of-Children-by-EMS-InterimGuidance-08Mar2017-FINAL.pdf

https://www.nhtsa.gov/staticfiles/nti/pdf/811677.pdf

Safe Transport of Children by EMS: Interim Guidance

March 8, 2017

Establishing guidelines for safely transporting children in ambulances has been an endeavor

undertaken by various individuals and organizations in recent years. Despite these efforts, this

multi-faceted problem has not been easy to solve. While there have been resources developed,

such as the Working Group Best-Practice Recommendations for the Safe Transportation of

Children in Emergency Ground Ambulances (NHTSA 2012), there remain unanswered

questions, primarily due to the lack of ambulance crash testing research specific to children.

The National Association of EMS State Officials (NASEMSO) is committed to advocating for

the creation of evidence-based standards for safely transporting children by ambulance. Such

standards would ensure a safer environment for the patients who rely on the EMS provider to act

on their behalf. Developing standards will require large investments of both time and funding to

conduct the required crash testing. If research were started today, it would require at least three

years and hundreds of thousands of dollars to complete.

While NASEMSO collaborates with other organizations to bring these standards to reality, it

recognizes the gap between that goal and the reality of the decisions that EMS providers face

today will continue to be an issue of concern. The purpose of this interim guidance is to reduce

that gap as much and as soon as possible, until evidence can be collected, analyzed, and used to

develop standards specifically for children. Ultimately, pediatric restraint devices should be

tested by the manufacturer to meet a new, yet-to-be developed standard.

NASEMSO recommends that this new standard include a pass/fail injury criteria comparable to

that identified in FMVSS-213, which applies to child restraints in passenger vehicles. All testing

should use the ambulance-specific crash pulses described in SAE J3044, SAE J2956, and SAE

J2917 respectively. Litters used in testing should meet the SAE J3027 Integrity, Retention and

Patient Restraint Specifications. Manufacturers should indicate to prospective purchasers

whether their device(s) have met these requirements for the weight range indicated for the

device.

It is the position of NASEMSO that:

1) Evidence-based standards for safely transporting children in ambulances should be

developed and published by nationally recognized standards development organizations,

such as the Society for Automotive Engineers (SAE);

2) Safe ambulance transport should be considered as a standard of care for the EMS system

equivalent to maintaining an open airway, adequate ventilation and the maintenance of

cardiovascular circulation; and

3) There are immediate actions that can be taken to improve pediatric safety in ambulances

including, but not limited to:

a. All EMS agencies that transport children should develop specific policies and

procedures that address, at minimum the following elements:

i. Methods, training (initial and continual), and equipment to secure children

during transport in a way that reduces both forward motion and possible

http://standards.sae.org/j3044_201406/




Safe Transport of Children by EMS: Interim Guidance March 8, 2017

ejection. The primary focus should be to secure the torso, and provide

support for the head, neck, and spine of the child, as indicated by the

patient’s condition;1

ii. Considerations for the varied situations that a child who needs transport to

a hospital or other point of care may present to the EMS professional.

These include, but may not be limited to a child who is:

o uninjured/not ill,

o ill/injured, but requiring no intensive interventions or

monitoring,

o requiring intensive interventions or monitoring,

o requiring spinal immobilization or supine transport, and

o multiple patients;2

iii. Prohibits children from being transported unrestrained, e.g. held in arms or

lap;3

iv. Provision for securing all equipment during a transport where a child is an

occupant of the vehicle, with mounting systems tested in accordance with

the requirements of SAE J3043;

v. Only use child restraint devices in the position for which they are designed

and tested; and

b. EMS agencies should have appropriately-sized child restraint system(s) readily

available on all ambulances that may transport children. Additionally, personnel

should be initially and recurrently evaluated and trained on the correct use of

those restraint systems;

i. The device(s) should cover, at minimum, a weight range of between five

(5) and 99 pounds (2.3 - 45 kg), ideally supporting the safest transport

possible for all persons of any age or size;

ii. Only the manufacturer’s recommendations for the weight/size of the

patient should be considered when selecting the appropriate device for the

specific child being transported; and

c. State EMS officials should act to put interim steps in place while evidence-based

standards are developed and implemented, including, but not limited to:

i. Encourage and support EMS transport agencies to implement cost

effective solutions to mitigate risk while transporting children in

ambulances; and

ii. Work with other state EMS officials to create uniform approaches and

policy language, including, but not limited to a network of information

relating to ambulance crash-related injuries; and

4) NASEMSO does not recommend or endorse any particular product.

1Working Group Best-Practice Recommendations for the Safe Transport of Children in Emergency Ground

Ambulances, page 12. 2 Ibid, pages 12-15. 3 The Do’s and Don’ts of Transporting Children in an Ambulance (December 1999).



https://one.nhtsa.gov/people/injury/ems/Archive/New%20Folder/childam.html

Safe Transport of Children by EMS: Interim Guidance March 8, 2017

Members of the NASEMSO Safe Transport of Children Ad Hoc Committee

NASEMSO Members

Stephanie Busch, Vermont EMSC Program

Katherine Hert, Alabama EMSC Program

Eric Hicken, New Jersey EMSC Program

Brandon Kelley, Wyoming EMSC Program

Kjelsey Polzin, Minnesota EMSC Program

Carolina Roberts-Santana, Rhode Island EMSC

Program

Katherine Schafer, New Mexico EMSC Program

Tom Winkler, Pennsylvania EMSC Program

Cyndy Wright-Johnson, Maryland EMSC

Program

Steve McCoy, Director, Florida Office of EMS

Paul Phillips, Kentucky Board of EMS

Mary Hedges, NASEMSO Program Manager

Other

Katrina Altenhofen, Paramedic, Washington

County EMS, Iowa

Dr. Marilyn Bull, Riley Hospital for Children at

Indiana University

Amy Haughn, Association of Air Medical

Services (AAMS) Children Special Interest

Group (KIDS SIG)

Matthew Maltese, Ph.D., University of

Pennsylvania, Children’s Hospital of

Philadelphia

Teresa Merk, AAMS Critical Care Ground

Special Interest Group (CCG SIG)

Brian Moore, MD, University of New Mexico

Manish I. Shah, MD, Baylor College of

Medicine, Texas Children’s Hospital

Elena Sierra, AAMS Membership Manager

Dan Sjoquist, AMD Seat and Restraint

Committee Chair

Sailesh Tangirala, AMD and SAE Committee

member

Federal Partners

Dave Bryson, National Highway Traffic Safety

Administration, Office of EMS

John McDonald, General Services

Administration

Theresa Morrison-Quinata, Health Resources

Service Administration

James Green, National Institute of Occupational

Safety and Health

Alexander “Sandy" Sinclair, National Highway

Traffic Safety Administration

DOT HS 811 677 September 2012

Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances

DISCLAIMER

This publication is distributed by the U.S. Department of Transportation, National Highway Traffic Safety Administration, in the interest of information exchange. The opinions, findings, and conclusions expressed in this publication are those of the authors and not necessarily those of the Department of Transportation or the National Highway Traffic Safety Administration. The United States Government assumes no liability for its contents or use thereof. If trade names, manufacturers’ names, or specific products are mentioned, it is because they are considered essential to the object of the publication and should not be construed as an endorsement. The United States Government does not endorse products or manufacturers.


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Table of Contents

Glossary of Terms ..........................................................................................................................................2 1.0 Background.....................................................................................................................................................4 2.0 A Description of the Problem .........................................................................................................................6 3.0 Previous Guidance Regarding the Safe Transportation of Children in Emergency Ground Ambulances .....8 4.0 A “Non-Technical” Definition of a “Child” .................................................................................................10 5.0 Operational Safety Issues Related to the Safe Transportation of Children in Emergency Ground

Ambulances ..................................................................................................................................................11 6.0 The Goal of the Recommendations .............................................................................................................12 7.0 The Recommendations ................................................................................................................................13

Situation 1— For a child who is uninjured/not ill ................................................................................................15 Situation 2—For a child who is ill and/or injured and whose condition does not require continuous and/or intensive medical monitoring and/or interventions ..............................................................................................16 Situation 3—For a child whose condition requires continuous and/or intensive medical monitoring and/or interventions .........................................................................................................................................................17 Situation 4—For a child whose condition requires spinal immobilization and/or lying flat ...............................18 Situation 5—For a child or children requiring transport as part of a multiple patient transport (newborn with mother, multiple children, etc.) ............................................................................................................................19

8.0 Limitations of the Recommendations ...........................................................................................................20 9.0 Additional Considerations ...........................................................................................................................21 9.1 Considerations for Governmental and Other Entities ...................................................................................21 9.2 Considerations for Manufacturers ................................................................................................................22 Appendix A: Literature Review Findings ................................................................................................................23 Appendix B: Agenda and List of Participants at July 2009 Meeting of the Working Group ...................................35 Appendix C: General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport ..38 Appendix D: Recommendations for Using Convertible Child Safety Seat, Car Bed, and Securing Child on Cot in Emergency Ground Ambulances ..............................................................................................................40 Appendix E: Recommended Best Practices for Child Restraint System Use...........................................................43 PLEASE NOTE: These recommendations, which were developed by an Expert Working Group convened in a contract overseen by the National Highway Traffic Safety Administration do not necessarily reflect the policies, recommendations or opinions of NHTSA or its employees, vendors, or contractors. The membership of the working group is provided on page 5 of this report.


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Glossary of Terms

Term Definition bench beat Also known as the squad bench, this is the multi-person side

facing seat alongside the cot mounting area in the rear of a ground ambulance.

call-taker The person responsible for answering a 911 call for response to an emergency situation and request for an immediate response, which may include a medical emergency and the need for emergency medical services.

captain’s chair Also known as the EMS provider’s seat, this is the passenger location that (typically an EMS professional) faces the rear exit of the emergency ground ambulance that is typically located immediately behind the driver’s seat. From this location, the person is physically able to see the patients being transported.

child restraint system (CRS) A CRS is any device (except a passenger system lap seat belt or lap/shoulder seat belt), designed for use in a motor vehicle to restrain, seat, or position a child.

cot A temporary bed used in emergency ground ambulances for the purposes of transporting patients via ambulance to a medical facility for treatment. Also commonly referred to as a stretcher or gurney. A wheeled cot (elevating) or wheeled cot-bench (non-elevating) may be referred to as a litter.

cot restraints

A restraining device that is designed for use on a cot in an ambulance to restrain or position a child in a sitting position. Cot restraints may be devices that are permanently mounted (integrated) or can be secured to a cot in an ambulance.

emergency ambulance or emergency ground ambulance or ground ambulance

An emergency ambulance, emergency ground ambulance, or ground ambulance is a vehicle designed for the transportation of sick or injured people to, from, or between places of medical treatment.

emergency medical services (EMS)

Emergency medical services are the responses and activities dedicated to providing out-of-hospital medical care and/or transportation to definitive medical care, to patients with illnesses and injuries that the patient, or the medical practitioner, believes constitutes a medical emergency. At the community level, EMS may also be referred to as but not limited to: first aid squad, emergency squad, rescue squad, ambulance squad, ambulance service, ambulance corps, or life squad.

EMS provider seat Also known as the captain’s chair (see definition above).

EVOC The Emergency Vehicle Operators Curriculum (EVOC) is the national standard curriculum developed by NHTSA and the U.S. Office of Personnel Management for training personnel in the safe operation of emergency ground ambulances.


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Term Definition FARS The Fatality Analysis Reporting System is NHTSA’s annual

census of data collected on all fatal motor vehicle traffic crashes occurring in the United States and the injuries, people, and vehicles involved in these crashes.

five-point cot restraint system A system for restraining a patient to the cot of a ground ambulance, consisting of three horizontal restraints across the patient’s torso (chest, waist, and knees) and two vertical shoulder restraints across each of the patient’s shoulders.

FMVSS No. 208 Federal Motor Vehicle Safety Standard No.208 is the standard for occupant crash protection. FMVSS No. 208 specifies the performance requirements for active and passive restraints (seat belts) using anthropomorphic test dummies seated in the front outboard seats of passenger cars and of certain multi-purpose passenger vehicles, trucks, and buses. The purpose of FMVSS No. 208 is to reduce the number of fatalities and the severity of injuries to occupants involved in crashes.

FMVSS No. 213 Federal Motor Vehicle Safety Standard No. 213 is the standard for child restraint. FMVSS No. 213 specifies requirements for child restraint systems used in motor vehicles and aircraft. The purpose of FMVSS No. 213 is to reduce the number of children killed or injured in motor vehicle crashes and in aircraft.

HRSA The U. S. Department of Health and Human Services’ Health Resources and Services Administration is the primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.

NEMSIS Established in 2001, the National Emergency Medical Services Information System is a project to create a national EMS database that contains standardized data elements from local and State EMS agencies from the entire United States

securement The act or process of fastening a child restraint system or other safety device or piece of equipment to ensure the safety of the child being transported in the system or device or equipment so as not to allow movement or subject the child to unsafe or inappropriate conditions while being transported.

stretcher Also referred to as a cot (see definition above). squad bench Also known as the bench seat (see definition above).


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1.0 Background The National Highway Traffic Safety Administration of the U.S. Department of Transportation initiated a project in September 2008 titled “Solutions to Safely Transport Children in Emergency Vehicles.” The major objectives of this project were to:

1. Build consensus in the development of a uniform set of recommendations to safely and appropriately transport children (injured, ill, or uninjured) from the scene of a crash or other incident in an ambulance;

2. To foster the creation of best practice recommendations after reviewing the practices currently being used to transport children in ambulances; and

3. To provide consistent national recommendations that will be embraced by local, State and national emergency medical services organizations, enabling them to reduce the frequency of emergency transport of ill, injured or uninjured children who may be transported in an unsafe or inappropriate manner.

To achieve these major objectives, a working group was formed; the working group was comprised of members with experience, background, and extensive knowledge in the current practices of the emergency transportation of children in ground ambulances. The expert members of the working group were drawn from those organizations and entities involved in the health care of children and the emergency transportation of children and others in ground ambulances. It should be noted that throughout the remainder of this document, references to ambulances are limited to ground ambulances, unless otherwise stated. Also, based upon the deliberations of the working group, it was decided to use the terms “child” or “children” versus “youth” to the extent practical throughout the remainder of this document, to represent all children, starting at birth. The panel of experts comprising the working group and the organizations represented are shown in the following table.


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General support for the project was also provided by the International Association of Fire Chiefs. Members from NHTSA, the sponsors for the project, along with partners from other Federal agencies, also participated in the activities and deliberations of the working group. The working group members from Federal agencies are shown in the following table:

Operational support for the project was provided under NHTSA contract DTNH22-08-C00085 by Maryn Consulting, Inc. A first step to achieving the project’s major objectives was to complete a review of the literature of current practices for the emergency transportation of child passengers in ground ambulances. The emphasis of the literature review included research in professional journals and elsewhere that described an ideal or model uniform approach to transport children safely in ambulances, as well as articles and

Working Group Members from Children’s Health, Medical, and Emergency Organizations

Michael Aries International Association of Firefighters Katrina Altenhofen, MPH, PS, EMSC Program Manager

National Association of State EMS Officials

Marilyn J. Bull, M.D., FAAP American Academy of Pediatrics James M. Callahan, M.D., FAAP, FACEP

American College of Emergency Physicians (ACEP)

Andrew L. Garrett, M.D., MPH National Association of Emergency Medical Service Physicians (NAEMSP)

Ken Knipper National Volunteer Fire Council Tommy Loyacono, MPA, NREMT-P National Association of Emergency Medical

Technicians John Russell, M.D., FAAP American Ambulance Association Joseph L. Wright, M.D., MPH, FAAP

National Emergency Medical Services for Children’s Resource Center (EMSC NRC)

Cynthia Wright-Johnson, R.N., MSN Emergency Nurses Association (ENA)

Working Group Members from Federal Agencies Alexander (Sandy) Sinclair NHTSA Headquarters, Traffic Injury Control,

Research and Program Development, Office of Occupant Protection

David Bryson NHTSA HQ, TIC, Research and Program Development, Emergency Medical Services

Thelma Kuska, R.N., BSN, CEN, FAEN

NHTSA Region 5

Eileen Holloran

Health Resources and Services Administration, U. S. Department of Health and Human Services

Dan Kavanaugh Health Resources and Services Administration, U. S. Department of Health and Human Services


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publications that documented unsafe or incorrect practices. The expectation was that the findings from the literature review would serve as a point of reference for consensus building efforts towards the development of the recommendations for the safe transportation of children. Maryn Consulting, Inc. conducted the literature review, reviewing several hundred pages of information related to ambulance safety issues and the emergency transportation of children in ground ambulances. Relevant sources addressing various aspects of the transportation of children in ground ambulances (statistical information, existing guidelines, current practices and outcomes, safety research, etc.) were examined in depth and analyzed. The expert members of the working group were asked to review and provide comment on the literature review before it was finalized. Key findings from the literature review served as the foundation for the deliberations and activities of the working group. The literature review addressed the following major topics:

·

·

·

·

·

Background: An overview of statistical findings and data sources specific to ambulance transportation issues and child transportation in ground ambulances and media coverage of the issue of child transportation in ground ambulances. Ambulance Safety Issues: An overview of ambulance safety issues in general, with references to research and publications regarding this topic. Child Transport in Ambulances: Existing Guidelines: An overview of the current published guidelines regarding the safe transportation of children in ground ambulances at the national and State levels, as well as those promulgated by relevant practitioner associations. Child Transport in Ambulances: Current Practices and Outcomes: A description of current trends in the transportation of children in ambulances and questions identified by practitioners regarding this topic. Child Transport in Ambulances: Safety Research: An overview of engineering and safety research findings regarding safe and unsafe methods of transporting children in ground ambulances.

The literature review, completed in May 2009, is included in its entirety as Appendix A. The second step to achieving the major objectives of the project was the convening of the working group of experts. A series of teleconferences and a meeting were held, aimed at discussing issues of critical importance related to the major goals of the project, leading to the development of the recommendations contained in this report. Maryn Consulting, Inc. convened monthly teleconferences of the working group members in 2009 and 2010; deliberations were recorded. In addition to holding the monthly teleconferences, the working group was brought together for a one day meeting in Washington, DC, on July 22, 2009. The agenda for the July 22, 2009 meeting and a list of the participants are listed in Appendix B.

2.0 A Description of the Problem Describing and defining the problem of the unsafe and inappropriate methods of transporting children (injured, ill, or uninjured) from the scene of a crash or other incident in a ground ambulance is somewhat challenging, due to limited data involving such crashes. Also, existing protocols do not currently provide detailed guidance to EMS and child passenger safety professionals in the United States on how


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best to safely transport children in ground ambulances from the scene of a traffic crash or medical emergency to a hospital or other facility. In describing the problem, it should be noted that this project focused on developing recommendations for safely transporting children in ground ambulances by defining the project scope to address those situations for which the most evidenced-based information is available. As such, the issues of neonatal intensive care transportation and the unique circumstances that may present when transporting children with special health care needs in ground ambulances, while critically important, were considered outside of the purview of this effort and are not specifically addressed in the recommendations presented in this report. For the same reasons, while the inter-facility transportation of children in ground ambulances is not specifically addressed in the recommendations provided in this report, it is recognized that many of these recommendations would also apply to those patients. Data sources regarding ambulance crashes involving child ambulance occupants in the United States, as well as abroad, are limited. There is no single national EMS dataset in the United States that can be analyzed to better understand the annual number of ambulance trips, the number that involve children, the frequency of ambulance crashes, the victims or types of injuries associated with such crashes, or the possible causes of such crashes and the injuries involved. While efforts are underway to enhance the National EMS Information System (NEMSIS) to better inform EMS related policy, protocols, and practices, detailed data on crashes and other incidents involving ambulances are not easily extracted from existing EMS data collection systems.1 While a number of States, local communities, and private sector EMS providers capture some of this information, this data is often not readily available or easily accessible on a national level. Estimates suggest that ground EMS responds to approximately 30 million emergency calls each year.1 Approximately 6.2 million patient transport ambulance trips occur annually,2 of which approximately 10 percent of those patients are children.3 Insurance companies report that approximately 10,000 ambulance crashes result in injury or death each year.4 Estimates suggest that up to 1,000 ambulance crashes involve pediatric patients each year.5 Some information regarding ambulance crashes can be gleaned from analyses of data available from NHTSA’s Fatality Analysis Reporting System (FARS). However, it should be noted that the FARS data do not capture crash information unless that crash results in a fatality. A research article published in 2006 examining the specific issue of ambulance crashes using FARS data from 1987 to 1997 reported that 339 ambulance crashes were recorded and that resulted in 405 fatalities and 838 injuries. These fatalities and injuries include those involving ambulance drivers and passengers, as well as other vehicle drivers and passengers, in addition to pedestrians and bicyclists.6 1 Levick, N. R. (2007). Emergency Medical Services: A Transportation Safety Emergency. Paper presented at American Society of Safety Engineers’ Professional Development Conference, June 24-27, 2007; Orlando, FL. Available at www.objectivesafety.net/2007ASSE628Levick.pdf. 2 Levick, N. R. (2002). New Frontiers in optimizing ambulance transport safety and crashworthiness. The Paramedic; 4:36-39. 3 Winters, G., & Brazelton, T. (2003). Safe Transport of Children. EMS Professionals. July-August 2003:13-21. 4 American Ambulance Association. Position Paper: Safe Driving Statement, May 6, 2002. McLean, VA: Author. Available at www.the-aaa.org/about/positionpapers/afaedriving.html. 5 Winters & Brazelton. 6 Kahn, C. A. (2006). EMS, First Responders and Crash Injury. Topics in Emergency Medicine; 28(1)68–74.

http://www.the-aaa.org/about/positionpapers/afaedriving.html


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An examination of 2010 FARS data indicates that two fatal crashes involving ambulances involved children (under age 18) who were riding in ambulances. However, in both cases the fatalities occurred in vehicles other than the ambulances. A 3-year-old female riding in the rear compartment of one of the ambulances involved in a fatal crash was uninjured and a 16-year-old male riding in the rear compartment of an ambulance involved in another fatal crash had only minor injuries. Although recent crash data in the United States does not indicate that children are being killed or injured in ambulance crashes as patients or passengers, a review of local and national media coverage of ambulance crashes suggests that children of all ages may not be properly restrained while riding in ambulances and can potentially be injured if involved in a crash. Children riding in ambulances may be patients or passengers accompanying a parent or caregiver; they may be receiving transportation from the scene of a crash, a medical emergency, or involved in an inter-facility transport.7 Meanwhile, accepted national protocols for EMS and child passenger safety professionals in the United States for how best to safely transport children in ground ambulances from the scenes of traffic crashes or medical emergencies to hospitals or other facilities is very limited. There are unanswered questions regarding the placement and restraint of injured, ill, or uninjured children among EMS and child passenger safety professionals. The limited amount of national standards and protocols regarding the transportation of children in ground ambulances complicates the work of EMS professionals and may result in the improper and unsafe restraint of highly vulnerable child passengers. As a result, EMS agencies, advocates, and academicians have turned to NHTSA for leadership, which led to this effort.

3.0 Previous Guidance Regarding the Safe Transportation of Children in Emergency Ground Ambulances

The issue of variation in emergency child transport guidelines was first identified in a 1998 study that reported the results of a survey examining State requirements regarding the use of child restraint systems for children in ground ambulances.8 The study revealed that 35 States did not require patients of any age to be restrained in ground ambulances. Of those States that require the use of child restraint systems, requirements varied between those that require the child to be restrained on a cot, or restrained in a child restraint system, or restrained using both. Following the publication of the 1998 study, NHTSA and the HRSA Emergency Medical Services for Children program (EMS-C) convened a national consensus committee to review EMS child transportation safety practices. This group of representatives from EMS national organizations, Federal agencies, and transportation safety engineers developed a document titled The Dos and Don’ts of Transporting Children in an Ambulance (December 1999). The Dos and Don’ts document provides general guidance for EMS practitioners in the field regarding how to most safely transport children in a ground ambulance. With respect to the safe transportation of children, The Dos and Don’ts document included the following recommendations: 7 NHTSA: Solutions to Safely Transport Children in Emergency Ground Ambulances; Literature Review Findings; May 28, 2009; Completed under NHTSA Contract: DTNH22-08-C00085 with Maryn Consulting, Inc. Sources for the articles obtained from LexisNexis search conducted in October 2008 include the Associated Press (1999, 2003, and 2008); Financial Times (2008), Press Association (1992 and 1995). 8 Seidel, J. S., & Greenlaw, J. (1998). Use of restraints in ambulances: a state survey. Pediatric Emergency Care; 14(3):221-3.


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·

·

·

·

·

·

·

Do tightly secure all monitoring devices and other equipment. Do ensure available restraint systems are used by EMTs and other occupants, including the patient. Do transport children who are not patients, properly restrained, in an alternate passenger vehicle whenever possible. Do not leave monitoring devices and other equipment unsecured in moving EMS vehicles. Do not allow parents, caregivers, EMTs or other passengers to be unrestrained during transport. Do not have the child/infant held in the parent, caregiver, or EMT’s arms or lap during transport. Do not allow emergency vehicles to be operated by persons who have not completed the DOT NHTSA Emergency Vehicle Operating Course (EVOC), National Standard Curriculum, or its equivalent.

Since the publication of the Dos and Don’ts document, States, localities, and private EMS providers across the country have developed their own guidelines, some of which are more detailed than the Dos and Don’ts document. There remains, however, limited uniformity; EMS practitioners continue to struggle with unanswered questions. For example, a State EMS requirement to restrain all child passengers may result in the placement of a child in a child restraint system strapped to a side-facing bench in the rear compartment of an ambulance, rather than in the captain’s chair of the ambulance. The use of a child restraint system in such a fashion is prohibited by all child restraint system manufacturers. In addition, safety researchers conclude it “is not recommended, because this usage applies the severity of a frontal impact to the less protected side-facing child.”9 In this example, more specific guidance regarding the safest placement of the child is required. Use of child restraints involved in a crash: Please note that NHTSA recommends that child restraints should be replaced following a moderate or severe crash in order to ensure a continued high level of crash protection for child passengers. In addition, NHTSA recommends the re-use of a child safety seat that has been involved in a “minor” crash. A “minor” crash should meet ALL the following criteria:

a. The vehicle was able to be driven away from the crash site; b. The vehicle door nearest the safety seat was undamaged; c. There were no injuries to any of the vehicle occupants; d. The air bags (if present) did not deploy; AND e. There is no visible damage to the safety seat.

Source: www.nhtsa.gov/people/injury/childps/childrestraints/reuse/restraintreuse.htm

9 Bull, M. J., Weber, K. B., Talty, J., & Manary, M. A. (2001). Crash Protection for Children in Ambulances. In: 45th Annual Proceedings of the Association of the Advancement of Automotive Medicine (AAAM). Des Plaines, IL: AAA:353-367.


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4.0 A “Non-Technical” Definition of a “Child” Defining a “child,” in order to address the safe transportation of children in emergency ground ambulances and to provide an accurate framework for developing recommendations is also a challenge. In the course of reviewing existing data, professional articles, and official protocols, as well as media coverage, it was learned that the definition of a “child” is not always consistent or consistently addressed. In many cases, a focus on very young children can be inferred from the context of the article or protocol, but a uniform definition of child has not been developed for the purposes of emergency ground ambulance transport. At its July 2009 meeting in Washington, DC, the expert members of the working group discussed options for defining a child for the purposes of this project by considering the following questions:

·

·

Should age and/or stature be considered in developing our recommendations? Should we use previously established age categories?

The working group decided to use the terms child or children to represent all children, starting at birth. Next, the working group considered several possible options for defining a child, including: by age; by child restraint system requirements; or by height/weight. The working group considered the pros and cons of each option, what might be most useful to EMS professionals in the field, and what definition would be needed to ensure that all children would be safely transported. Among the options considered were NHTSA’s current car seat recommendations for children10 for the appropriate child restraint system to be used, based upon the child’s age. The prevailing view of the expert panel members of the working group was that the realities of delivering EMS in the field necessitates having an algorithm for safely transporting all occupants of a ground ambulance, regardless of age and by injury severity. The working group members continued their deliberations by considering the following question:

· How is a "child" or a "pediatric patient" in the EMS setting defined with regard to operations? Examples include: choosing the appropriate type of therapy or determining if a specialized child restraint system must be used to transport a child safely by EMS.

There is a range of options here, and little consensus. The various definitions of a child or pediatric patient are inconsistent. The term "child" may be used to denote all non-adult patients, OR it may be used to represent all non-adult, non-adolescent patients, OR it may be used to represent all non-adult, non-adolescent, non-neonatal, and non-infants.

·

·

·

·

Even the "non-adult" descriptor lacks consensus and is variable depending on the setting; it could be those under 17, 18, or 21 years old. Weight or length are commonly used to "proxy" for age in the field by EMS professionals to determine (e.g., using a measurement tape) if a patient is pediatric versus adult. EMS and medical personnel are not always accurate at estimating age, height, and weight. Parents and caregivers are also not always accurate at estimating age, height, and weight.

10 For details on NHTSA’s guidance for parents and caregivers on selecting and installing the proper child restraint for children, visit www.nhtsa.dot.gov and click on Child Safety.

http://www.nhtsa.dot.gov/


11

To provide appropriate care, some EMS professionals prefer to use a very simple standard in the field: if you think your patient is a child/pediatric patient, then treat and restrain the patient accordingly. This approach eliminates one additional factor or issue of concern for EMS personnel and allows them to focus on the real perils of the child patient in EMS, including safe transportation, safe use of medications and provision of therapy. While this is a “non-technical” definition, the consensus of the working group was to adopt this definition. This definition is practical and could be easily adopted and implemented by EMS professionals and the working group recommends using it in the implementation of the recommendations contained in this report. EMS professionals, their agencies and others involved in the transportation of children in ambulances are urged to consider the use of a method or technique to more accurately define the weight and height of a child, if available, in order to determine the safest method of transportation. In this regard, EMS professionals, their agencies and others may consider using a length/weight-based measurement tool or other appropriate measurement device for pediatric equipment sizing to estimate height and weight.

5.0 Operational Safety Issues Related to the Safe Transportation of Children in Emergency Ground Ambulances

As stated in the Background of this report, the major goal of the working group was to develop a uniform set of recommendations to safely and appropriately transport children (injured, ill, or uninjured) from the scene of a crash or other emergency incident in a ground ambulance. As such, the working group was committed to developing recommendations that cover every aspect of an EMS ground ambulance response and the full coordination of response elements from the call-taker to the receiving medical facility. With the foregoing in mind, the first principle to be followed to ensure the safe transportation of children in emergency ground ambulances is to make everything as safe as possible. It is important to note that safety for transporting a child in an ambulance starts with general operational policy and procedures that enhance ambulance safety for all occupants, regardless of age. These include:

·

·

·

·

·

·

·

·

·

seat belt and restraint use for ALL ambulance occupants all of the time; securement of movable equipment; maintaining and cleaning neonatal and child restraint seats and equipment per manufacturer’s instructions; following current pediatric standards of care for injured children; driver screening and selection (including background checks as provided for by the State’s EMS personnel policy); training that includes hands-on emergency ground ambulance operation instruction; monitoring of driving practices through use of technology and other means; use of principles of emergency medical dispatching to determine resource and response modalities; and methods to reduce the unnecessary use of emergency lights and sirens (when transporting patients) when appropriate.

While the recommendations that follow may not mention these operational policy and procedures specifically, it is anticipated that EMS professionals and their organizations will implement operational policies and procedures that address these factors to the maximum extent possible.


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To support the recommendations that follow, and within the limitations as stated, guidelines for the gathering of statistics and design engineering standards for the chassis, patient module, treatment equipment, and the testing and maintenance of those ideals will be required. It is important to note, however, that the project effort leading to the development of the recommendations contained in this report did not include a determination on these issues or others that may be related, e.g., evaluating the efficacy of one child restraint system compared to another; conducting field tests of transport solutions or equipment; evaluating the crashworthiness of EMS ground ambulances; and assessing ambulance design.

6.0 The Goal of the Recommendations The ultimate goals of the recommendations contained in this report are to: Prevent forward motion/ejection, secure the torso, and protect the head, neck, and spine of all children transported in emergency ground ambulances. By ensuring that this goal is met in all scenarios involving the transportation of children in emergency ground ambulances from the scene of a traffic crash or medical emergency, the working group panel of experts believes that the safety of such transportation will be improved.


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7.0 The Recommendations The recommendations for the safe transportation of children via emergency ground ambulances from the scene of a traffic crash or medical emergency are presented as follows to address five situations:

Situation 1 For a child who is uninjured/not ill

Situation 2 For a child who is ill and/or injured and whose condition does not require continuous and/or intensive medical monitoring and/or interventions

Situation 3 For a child whose condition requires continuous and/or intensive medical monitoring and/or interventions

Situation 4 For a child whose condition requires spinal immobilization and/or lying flat

Situation 5 For a child or children who require transport as part of a multiple patient

transport (newborn with mother, multiple children, etc.)

On occasion, one of the above situations may present the circumstance where an uninjured child or children may need to be transported from the scene of an emergency in order to ensure appropriate adult supervision to the uninjured child or children, and/or to provide for family continuity. The working group recommends that all EMS systems use this document and its recommendations and “pre-plan,” i.e., plan in advance for those situations events where infants and children may be on the scene - as primary patients or not - so such events can be successfully mitigated. Pre-planning for such events must also involve other public health, public safety and other partners to be most successful. Some situations EMS systems and their partners need to pre-plan for are:

1. Injured or ill parents, guardians or caregivers who need to be transported to definitive care, with uninjured and well infants and/or children on the scene.

2. Events involving multiple patients who need to be transported. This may include a mother in labor or a parent/guardian and one or more newborns.

Addressing and planning for these situations in advance will better prepare EMS personnel and their agencies and other public safety personnel, patients, family members and the general public. Regardless of what type of vehicle is used in these situations, an age/size-appropriate child restraint system that complies with FMVSS No. 213 must always be used. Generally speaking, when the number of patients exceeds the ability to provide adequate care with existing EMS personnel and emergency ground ambulances, or to secure child patients as described in the following recommendations, EMS personnel need to request additional transportation resources that can respond in a timely manner.


14

“The Ideal” is the ultimate goal for safely and appropriately transporting children in emergency ground ambulances, and is presented in bold as the first recommendation for transporting a child in each of the five situations. “If the Ideal is not Practical or Achievable” is also provided in each of the five situations—this recommendation provides guidance to EMS professionals for the safe transportation of children if the Ideal cannot be achieved. For the situation involving the transportation of a child who is uninjured and/or not ill, a third recommendation for safely transporting the child, “If Resources are Limited,” is also presented. Further, in addition to the guidance provided in the following recommendations, it is the consensus of the working group that it is not appropriate to transport children, even in a child restraint system, on the multi-occupant squad bench located in the rear of ground ambulances. Appendix C, General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport, provides guidance to EMS providers for identifying equipment that may be used to meet the requirements of each of the recommendations. EMS providers are encouraged to check with equipment manufacturers for detailed information on the proper use and installation, results of crash testing, and possible limitations of any equipment that is obtained for the purposes of fulfilling the recommendations for the safe transportation of children in emergency ground ambulances. Transportation of children in convertible child restraint systems or on car beds on an ambulance cot may be appropriate in some circumstances. Instructions for selection of equipment for this purpose and the installation are provided in Appendix D.


15

Situation 1

For a child who is uninjured/not ill 11 (accompanying an injured or ill patient) Consult manufacturers’ guidelines to determine optimal orientation for the child restraint (i.e., rear-

facing or forward-facing) depending on the age and size of the child.

The Ideal Transport the child in a vehicle other than an emergency ground ambulance using a size-appropriate child restraint system12 that complies with FMVSS No. 213. Consult child restraint manufacturers’ guidelines to determine optimal orientation for the child restraint (i.e., rear-facing or forward-facing) depending on the age and size of the child.

If the Ideal Is Not Practical or Achievable

1. Transport the child in a size-appropriate child restraint system that complies with FMVSS No. 213 appropriately installed in the front passenger seat (with air bags in the “off” position, if an on/off switch is available) of the emergency ground ambulance (If EMS providers have turned off the air bag while transporting a child in the front seat of a vehicle with an on/off switch, they should reactivate the air bag after the child has been transported to the medical facility and the child restraint system has been removed from the front passenger seat); or

2. Transport the child in the forward-facing EMS provider’s seat /captain’s chair, which is currently rare in the industry) in a size-appropriate child restraint system that complies with FMVSS No. 213; or

3. Transport the child in the rear-facing EMS provider’s seat/captain’s chair in a size-appropriate child restraint system that complies with FMVSS No. 213. This system can be a convertible or combination seat using a forward-facing belt path). Do not use a rear-facing only seat in the rear-facing EMS provider’s seat.13 You may also use an integrated child restraint system certified by the manufacturer to meet the injury criteria of FMVSS No. 213; or

4. If necessary, transport the ill or injured patient in the original emergency ground ambulance and leave the non-ill, non-injured child under appropriate adult supervision on scene. Transport the non-ill, non-injured child in a size-appropriate child restraint system that complies with FMVSS No. 213 to a hospital, residence or other location, in another appropriate vehicle.

11 Please consult Appendix C, General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport, for guidance on how to select equipment that may be used to meet the requirements of each of the recommendations. EMS providers are encouraged to check with equipment manufacturers for detailed information on the proper use and installation, results of crash testing, and possible limitations of any equipment that may be considered for use to fulfill the recommendations for the safe transportation of children in emergency ground ambulances. 12 NHTSA’s Ease of Use Ratings for child restraint systems is a five-star ratings system that allows parents and caregivers to evaluate how easy certain CRS features are to use before purchasing a seat for their personal use in transporting a child. While the testing requirements and regulations do not include emergency ground ambulances, EMS agencies and providers may wish to review the Ease of Use Ratings materials available at www.nhtsa.gov when selecting CRS systems for use in emergency ground ambulances. 13 Please note that a rear-facing-only child restraint system cannot be installed on a rear-facing EMS provider’s seat as it does not have a forward-facing belt path and is engineered to face rearward on a forward-facing seat. As such, a rear-facing-only seat will not safely secure a child in a rear-facing EMS provider’s seat.

http://www.nhtsa.gov/


16

Situation 2 For a child who is ill and/or injured and whose condition does not require continuous

and/or intensive medical monitoring and/or interventions 14 The Ideal Transport the child in a size-appropriate child restraint system

that complies with the injury criteria of FMVSS No. 213—secured appropriately on cot.


1. Transport in the forward-facing EMS provider’s seat/ captain’s chair, which is currently rare in the industry, in a size-appropriate child restraint system that complies with FMVSS No. 213. Consult child restraint manufacturers’ guidelines to determine optimal orientation for the child restraint (i.e., rear-facing or forward-facing), depending on the age and size of the child.

2. Transport the child in the rear-facing EMS provider’s seat/ captain’s chair in a size-appropriate child restraint system that complies with FMVSS No. 213. This system can be a convertible or combination seat using a forward- facing belt path. Do not use a rear-facing-only seat in the rear-facing EMS provider’s seat.15 You may also use an integrated child restraint system certified by the manufacturer to meet the injury criteria of FMVSS No. 213; or

3. Secure the child to the cot,16 head first, using three horizontal restraints across the child’s torso (chest, waist, and knees) and one vertical restraint across each of the child’s shoulders. The cot should be positioned (subject to the manufacturer’s specifications) to provide for the child’s comfort based upon the child’s injuries and/or illness and to allow for appropriate medical care.

14 Please consult Appendix C, General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport, for guidance on how to select equipment that may be used to meet the requirements of each of the recommendations. EMS providers are encouraged to check with equipment manufacturers for detailed information on the proper use and installation, results of crash testing, and possible limitations of any equipment that may be considered for use to fulfill the recommendations for the safe transportation of children in emergency ground ambulances. 15 Please note that a rear-facing-only child restraint system cannot be installed on a rear-facing EMS provider’s seat as it does not have a forward-facing belt path and is engineered to face rearward on a forward-facing seat. As such, a rear-facing-only seat will not safely secure a child in a rear-facing EMS provider’s seat. 16 All children transported on a cot shall be restrained to the cot with the 5-point cot restraint system that includes three horizontal restraints across the torso (chest, waist, and knees) and one vertical restraint across each shoulder.


17

Situation 3 For a child whose condition requires continuous and/or intensive medical monitoring and/or

interventions17 The Ideal Transport child in a size-appropriate child restraint system that complies

with the injury criteria of FMVSS No. 213—secured appropriately on cot.


Secure the child to the cot;18 head first, with three horizontal restraints across the torso (chest, waist, and knees) and one vertical restraint across each shoulder. If the child’s condition requires medical interventions, which requires the removal of some restraints, the restraints should be re-secured as quickly as possible as soon as the interventions are completed and it is medically feasible to do so. In the best interest of the child and the EMS personnel, the emergency ground ambulance operator is urged to consider stopping the ambulance during the interventions. If spinal immobilization of the child is required, please follow the recommendation for Situation 4.

17 Please consult Appendix C, General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport, for guidance on how to select equipment that may be used to meet the requirements of each of the recommendations. EMS providers are encouraged to check with equipment manufacturers for detailed information on the proper use and installation, results of crash testing, and possible limitations of any equipment that may be considered for use to fulfill the recommendations for the safe transportation of children in emergency ground ambulances. 18 All children transported on a cot shall be restrained to the cot with the 5-point cot restraint system that includes three horizontal restraints across the torso (chest, waist, and knees) and one vertical restraint across each shoulder.


18

Situation 4

For a child whose condition requires spinal immobilization and/or lying flat19 The Ideal Secure the child to a size-appropriate spineboard and secure the

spineboard to the cot,20 head first, with a tether at the foot (if possible) to prevent forward movement. Secure the spineboard to the cot with three horizontal restraints across the torso (chest, waist, and knees) and a vertical restraint across each shoulder.


Secure the child to a standard spineboard with padding added, as needed, (to make the device fit the child) and secure the spineboard to the cot, head first, with a tether at the foot (if possible) to prevent forward movement. Secure the spineboard to the cot with three horizontal restraints across the torso (chest, waist, and knees) and a vertical restraint across each shoulder.

19 Please consult Appendix C, General Considerations and Selecting Child Restraint Systems for Ground Ambulance Transport, for guidance on how to select equipment that may be used to meet the requirements of each of the recommendations. EMS providers are encouraged to check with equipment manufacturers for detailed information on the proper use and installation, results of crash testing, and possible limitations of any equipment that may be considered for use to fulfill the recommendations for the safe transportation of children in emergency ground ambulances. 20 All children transported on a cot shall be restrained to the cot with the 5-point cot restraint system that includes three horizontal restraints across the torso (chest, waist, and knees) and one vertical restraint across each shoulder.


19

21 The working group recommends that all EMS systems pre-plan for those situations where multiple infants and children may be on the scene - as primary patients or not - so such events can be successfully mitigated. Pre-planning for such events must also involve other public health, public safety and other partners to be most successful. An example of such an event is one that involves multiple patients, i.e., infants and/or children who need to be transported (to include a mother in labor or with one or more newborns). 22 Please note that a rear-facing-only child restraint system cannot be installed on a rear-facing EMS provider’s seat as it does not have a forward-facing belt path and is engineered to face rearward on a forward-facing seat. As such, a rear-facing-only seat will not safely secure a child in a rear-facing EMS provider’s seat.

Situation 5 For a child or children requiring transport as part of a multiple patient transport (newborn with mother, multiple children, etc.).21 Consult child restraint manufacturers’ guidelines to determine optimal orientation for the child restraint (i.e., rear-facing or forward-facing) depending on the age and size of the child.

The Ideal 1. If possible, for multiple patients, transport each as a single

patient according to the guidance shown for Situations 1 through 4.

2. Transport in the forward-facing EMS provider’s seat

/captain’s chair, which is currently rare in the industry) in a size-appropriate child restraint system that complies with FMVSS No. 213.

3. For mother and newborn, transport the newborn in an approved size-appropriate child restraint system that complies with the injury criteria of FMVSS No. 213 in the rear-facing EMS provider seat /captain’s chair) that prevents both lateral and forward movement, leaving the cot for the mother. Use a convertible seat with a forward-facing belt path). Do not use a rear-facing only seat in the rear-facing EMS provider’s seat.22 You may also use an integrated child restraint system certified by the manufacturer to meet the injury criteria of FMVSS No. 213.

PLEASE NOTE: A child passenger, especially a newborn, must never be transported on an adult’s lap. Newborns must always be transported in an appropriate child restraint system. Never allow anyone to hold a newborn during transport.


When available resources prevent meeting the criteria shown for the previous Situations 1 through 4 for all child patients, including mother and newborn, transport using space available in a non-emergency mode, exercising extreme caution and driving at reduced (i.e., below legal maximum) speeds.


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8.0 LIMITATIONS OF THE RECOMMENDATIONS As stated previously, the major goal of this project is “to provide consistent national recommendations that will be embraced by local, State, and national emergency medical services organizations, enabling them to reduce the frequency of emergency transport of ill, injured or uninjured children in an unsafe or inappropriate manner.” The most critical aspects of this goal are consistency, practicality and ultimately safety. As reported in the literature review, an examination of existing guidelines, protocols or standards reveals that while over the years States, localities, associations and EMS providers have developed legislation, guidelines or protocols regarding this issue, standards vary across jurisdictions and often provide limited, or in some cases inappropriate, guidance. It is hoped that the recommendations provided in this report will address the lack of consistent standards or protocols among EMS and child passenger safety professionals in the United States regarding how to most safely transport children in ground ambulances from the scene of a traffic crash or medical emergency to a hospital or other facility. It should be noted that the expectation is that States, localities, associations, and EMS providers will implement these recommendations to improve the safe transportation of children in emergency ground ambulances when responding to calls encountered in the course of day-to-day operations of EMS providers. In addition, it is hoped that EMS providers will be better prepared to safely transport children in emergency ground ambulances when faced with disaster and mass casualty situations. In developing the recommendations and as was noted elsewhere in this report, various issues related to ambulance safety and equipment safety are important for discerning between safe and unsafe methods of transporting children in emergency ground ambulances. However, it is outside the purview of this project to conduct the vast amount of engineering research, crash testing, and field work that would be required to evaluate and determine the effectiveness of ambulance vehicles and child restraint and medical equipment currently available and in use for the purposes of transporting children in emergency ground ambulances. As such, it is important to note the limitations of the recommendations presented in this report. The deliberations that led to the development of these recommendations did not include efforts to:

• Evaluate the efficacy of one child restraint system over another; • Address the unique transportation challenges of children with special health care needs; • Address the special transportation requirements of neonates and children with complex medical

problems; • Identify specific strategies that may be also be needed at the local, State, and national levels to

safely transport children in emergency situations involving disasters and mass casualties; • Conduct any field tests of solutions or equipment; • Evaluate the crashworthiness of emergency ground ambulances; or • Assess ambulance design.

If additional ground ambulances may be needed based upon preliminary information, request additional ground ambulances to help with transport as soon as possible.


21

Nevertheless, it is hoped that the detailed protocols provided by the recommendations presented in this report will help enhance the safety of children transported in emergency ground ambulances in the U. S.

9.0 ADDITIONAL CONSIDERATIONS The intent of the recommendations presented in this report is to improve the safe transport of children in emergency ground ambulances. In the course of the deliberations of the working group that led to the recommendations, a number of important issues outside of the purview of this effort were identified. While these issues do not preclude improving the safe transportation of children in emergency ground ambulances, the working group believes it is important their notation be made for further study by the appropriate governmental, medical, professional, or other entities. These additional considerations are presented below: 9.1 Considerations for Governmental and Other Entities 1. Expedite efforts to enhance the NEMSIS to collect detailed data on crashes involving emergency

ground ambulances and their passengers of all ages and make these data available at the State and national level.

2. Encourage State EMS agencies to share data with the State Highway Safety Offices and NEMSIS

by collaborating on modifications to or an exemption from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to facilitate the development of NEMSIS.

3. Conduct further study to identify strategies for use at the local, State, and national level that may be

needed to safely transport children when faced with disaster and mass casualty incidents. 4. Conduct further study to develop recommendations for the safe transportation of children in

situations involving inter-facility transport.

5. Examine real world data to evaluate crash protection of restrained occupants in emergency ground ambulances.

6. Examine real world data to evaluate the structural stability and restraint of cots and other transport devices (including incubators) used for transporting children in emergency ground ambulances.

7. Determine the need for developing standards for child restraint systems and cot restraints that meet

the unique medical needs during the transportation of term and pre-term neonates (neonatal transports).

8. Determine the need for developing standards for child restraint systems and cot restraints that meet

the medical needs of children with special health care and/or complex medical problems.

9. Examine real world data to evaluate crashworthiness of ground ambulances.


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9.2 Considerations for Manufacturers

1. Develop child restraint systems that meet or exceed the injury criteria for FMVSS No. 213 to accommodate child patients of various heights and weights (or lengths including newborn/infant patients) for use on cots in ground ambulances.

2. Develop an integrated cot restraint system that, when tested with child dummies in a dynamic

sled test environment simulating a 30 mph ambulance frontal crash, results in dummy injury metrics that are equal to or lower than those specified in FMVSS No. 213

3. Develop products and provide instructions that improve correct and easier use of devices designed for ambulance use.

4. Determine the need to develop crash-tested child restraint systems for use in the rear- or forward-facing EMS provider’s seat of ground ambulances.

5. Ensure all EMS personnel seats meet or exceed all applicable FMVSS requirements and can

accommodate convertible or rear-facing-only child restraint systems (and adult passenger with three-point belt).

6. Develop improved crashworthy methods of seating for all occupants in the rear of the emergency

ground ambulance compartment.


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Appendix A Solutions to Safely Transport Children in Emergency Ground

Ambulances

Literature Review Findings

May 28, 2009 Contract: DTNH22-08-C00085


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Executive Summary In September 2008 the National Highway Traffic Safety Administration initiated a project titled “Solutions to Safely Transport Children in Emergency Vehicles.” The objectives of this project are:

1. To initiate consensus building in the development of recommendations to safely and appropriately transport children (injured, ill, or uninjured) from the scene of a crash or other incident in a ground ambulance. Draft recommendations will be created after reviewing relevant research and the practices that are currently being used to transport children in ambulances.

2. To provide recommendations that will be embraced by local, State and national EMS

organizations, enabling them to reduce the frequency of inappropriate emergency transportation of ill, injured or uninjured children.

A first step to achieving these objectives is the completion of a literature review of current practices for the emergency transportation of child passengers in ground ambulances. Emphasis includes research in professional journals and elsewhere that describes an ideal or model uniform approach to transport children safely in ambulances, as well as articles and publications that document unsafe or incorrect practices. It should be noted that throughout the remainder of this document, references to ambulances are limited to ground ambulances, unless otherwise noted. The objective of this report is to provide representatives from the NHTSA with a summary of findings from the literature review. This document is designed to provide NHTSA representatives with an overview of the published research conducted to date regarding the safe transportation of children in emergency vehicles, primarily ambulances. This Literature Review Findings report will serve as a point of reference for consensus building efforts going forward. During the course of the literature review, researchers from Maryn Consulting, Inc. reviewed several hundred pages of information related to ambulance safety issues and the transport of children in ambulances. Relevant sources were then organized by topic (statistical information, existing guidelines, current practices and outcomes, safety research, etc.). Once organized, researchers examined these sources in depth and recorded information relevant to this study. Finally, researchers analyzed this information and extracted key findings for inclusion in this Literature Review Findings document. To aid in the review of this document Maryn has organized the summary findings by topic. Below is a list of the topics covered in this document: Background: This section provides an overview of statistical findings and data sources specific to ambulance transport issues and child transport in ambulances. This section also references media coverage of the issue of child transport in ambulances. Ambulance Safety Issues: This section provides an overview of ambulance safety issues in general, with references to research and publications regarding this topic. Child Transport in Ambulances: Existing Guidelines: This section provides an overview of the current published guidelines regarding the safe transport of children in ground ambulances at the national and State levels, as well as those promulgated by relevant practitioner associations.


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Child Transport in Ambulances: Current Practices and Outcomes: This section describes current trends in the transport of children in ambulances, and describes questions identified by practitioners regarding this topic. Child Transport in Ambulances: Safety Research: This section provides an overview of engineering and safety research findings regarding safe and unsafe methods of transporting children in ground ambulances. Background Data sources regarding ambulance crashes involving child ambulance occupants in the United States, as well as abroad, are limited. In the United States there is no single, national EMS dataset that can be analyzed to better understand the annual number of ambulance trips, those that involve children, the frequency of ambulance crashes, the victims or types of injuries associated with such crashes, or the causes of such crashes. At this time efforts are underway to develop NEMSIS to capture some of this data so as to better inform EMS related policy, protocols and practices.1 Many States and private sector EMS providers also capture some of this information. However, these data are often not readily available or easily accessible. Estimates suggest that ground EMS responds to approximately 30 million emergency calls each year.2 Approximately 6.2 million patient transport ambulance trips occur annually,3 of which approximately 10 percent of those patients are children.4 Insurance companies report that approximately 10,000 ambulance crashes result in injury or death each year.5 Estimates suggest that up to 1,000 ambulance crashes involve pediatric patients each year.4 Occupational safety data indicate that “the transportation-related mortality rate for EMS personnel (per 100,000 workers) is 9.6, a rate that eclipses the national average (2.0) and exceeds that of police (6.1) and firefighters (5.7).”6 Some information regarding ambulance crashes can be learned from analyses of NHTSA’s Fatality Analysis Reporting System data. However, it should be noted that this data does not capture crash information unless that crash results in a fatality. A research article published in 2006 examining the specific issue of ambulance crashes used FARS data reported between 1987 and 1997 to find that 339 ambulance crashes resulted in 405 fatalities and 838 injures. These fatalities and injuries include those involving ambulance drivers and passengers, as well as other vehicle drivers and passengers, in addition to pedestrians and bicyclists.6 An examination of 2007 FARS data indicates that three fatal ambulance crashes reported that year involved children present in the ambulances. In one case the child was not injured; in two cases the children suffered minor injuries.7 Because FARS data does not include all ambulance crashes, it is estimated that the number of children injured in ambulance crashes that do not result in fatalities is significantly higher than numbers reflected in FARS (see above). Additional analysis of the FARS data indicates that in 2007 there were 29 fatal ambulance crashes that involved 82 people, including ambulance drivers and passengers, as well as other vehicle drivers and passengers, in addition to pedestrians and bicyclists. Data suggest that during that year 34 people in the rear compartments of ambulances were involved in these fatal accidents. 7


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A review of local and national media coverage of ambulance crashes involving injuries to children suggests such crashes are dangerous. Articles in newspapers across the world, as well as televised news coverage at the local level, suggest ambulance crashes involve children of all ages and can result in injuries ranging from minor to fatal. Injured children may be patients or passengers accompanying a caregiver; they may be receiving transport from the scene of a crash, a medical emergency, or involved in an inter-facility transport. Presently, there are no accepted protocols among EMS and child passenger safety professionals in the United States for how best to safely transport children in ground ambulances from the scene of a traffic

crash or medical emergency to a hospital or other facility. There are unanswered questions regarding the placement and restraint of injured, ill, or uninjured children among EMS and CPS professionals. The absence of consistent protocols regarding the transportation of children in ground ambulances complicates the work of EMS professionals and may result in the improper restraint of highly vulnerable child passengers. EMS agencies, advocates and academicians have turned to NHTSA for leadership. Lastly, it should be noted that when reviewing existing data, professional articles, and protocols, as well as media coverage of this issue, the definition of a “child” is not always consistent, or consistently addressed. In many cases a focus on very young children can be inferred from the context of the article or protocol, but a uniform definition of child has not been developed for the purposes of emergency ambulance transport. Ambulance Safety Issues In 1987, a group of researchers reported on an examination of 102 ambulance crashes in Tennessee in one of the first published efforts to better understand the causes and effects of ambulance crashes on patients, passengers, ambulance

drivers and medical technicians, as well as other vehicle drivers, passengers and pedestrians. Findings indicated that while “wearing a passenger restraint device was highly significant and protective.”8 the use of passenger restraints among patients, technicians and drivers was not common. Additional findings suggested that the risk of an “injury-accident” increased during nighttime and at intersections.8 A more comprehensive study examining the characteristics of fatal ambulance crashes across the country between 1987 and 1997 found that ambulance crashes “occurred more often between noon and 6 [p.m.] ... through an intersection ... and striking another vehicle.” Inside the ambulance, the “most serious and fatal injuries occurred in the rear ... and to improperly restrained occupants.”9 These findings

Figure 1: Ambulance Rear Compartment

Patient Cot

Three

Occupant

Squad

Bench

Drug CabinetStorage

Front

Passenger

Seat

Driver’s

Seat

Captain’s

Chair

Rear Exit

Side Exit

Sto

rage

Ca

bin

ets

Pass

Through

to Front

Cab


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Action Area

and

Equipment

Cabinets

Patient Cot

Three

Occupant

Squad

Bench

Drug Cabinet

Front

Passenger

Seat

Driver’s

Seat

Attendant’s

Seat

Rear Exit

Pass

Through to

Front Cab

Side Exit

Equipment

Cabinent

Fold Down

CPR Seat

Equipment

Cabinet

regarding injuries to ambulance occupants are supported by similar research examining the characteristics of ambulance crashes.10 Subsequent research conducted during the early 2000s examined ambulance crashes, and compared ambulance travel to travel in other motor vehicles. Findings suggest that travel in ambulances is less safe than travel in other motor vehicles for all passengers, including patients. A study conducted in Pennsylvania, comparing motor vehicle crashes involving ambulances and similarly sized vehicles, revealed that “ambulance crashes occur more frequently at intersections and traffic signals and involve more people and more injuries than those of similar sized vehicles.”11 Findings from another study using national data suggest that “relative to police cars and fire trucks, ambulances experienced the highest percentage of fatal crashes where occupants are killed and the highest percentage of crashes where occupants are injured.”10 It should be noted that while ambulance crashes are dangerous for ambulance occupants, data suggest that individuals in other vehicles, pedestrians or bicyclists are significantly more likely to be injured or killed as a result of an ambulance crash than the ambulance occupants themselves.9 From an occupational safety perspective, research suggests that ambulance design may inhibit the use of safety restraints by emergency medical technicians. In order to perform certain clinical tasks, such as administering oxygen or performing CPR, paramedics may require different positioning than that permitted by the use of restraints in either the captain’s chair or a side bench.12 More generally, research suggests that ambulance crashes are the most common cause of work-related fatalities among EMS workers.2 Figures 1 and 2 are diagrams of common rear compartment designs of ambulances.13

Safety standards regarding the EMS transport environment are limited, both in the United States and internationally. In the United States, Federal purchase specifications for ambulances are defined in a document published by the U.S. General Services Administration, Federal Specifications for the Star-of-Life Ambulance.14 These specifications require that ambulances purchased by Federal Government agencies meet applicable Federal Motor Vehicle Safety Standards, specifically those addressing braking requirements, fuel systems, lights, reflective devices, door latches and hinges, as well as emergency medical services provider (EMSP) seating and patient compartment seating. All seating positions, in the front and rear ambulance compartments, must be equipped with seat belts. The ANSI/ASSE Z15.1 fleet management standard, published in March 2006, now applies to EMS fleets. This standard applies to a wide variety of fleet and non-fleet vehicles and requires organizations to have a policy in place pertaining to the use of seat belts, and recommends, but does not require, mandatory seat belts be used on behalf of a business or an organization.15

Figure 2: Ambulance Rear Compartment


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It should be noted that the designs of rear compartments of ambulances vary widely. Figures 1 and 2 depict typical ambulance designs, but many ambulances may vary in the placement of cots, cabinets, and squad benches as well as the type of pass through to the front cab. Child Transport in Ambulances: Guidelines As EMS practitioners encounter a situation requiring the emergency transport of a child in an ambulance, limited guidance is available. In order to identify the best method of restraint, a practitioner must consider the age and stature of the child, if that child is injured or is an accompanying passenger, the medical stability of the patient, and the available locations where the child can be safely restrained inside the ambulance. The wide variation of potential scenarios presents challenges to EMS practitioners. An examination of existing guidelines, protocols or standards reveals that while over the years States, localities, associations and EMS providers have developed legislation, guidelines or protocols regarding this issue, standards vary across jurisdictions and often provide limited, or in some cases inappropriate, guidance. As discussed earlier, there are no widely accepted protocols among EMS and child passenger safety professionals in the United States for how best to safely transport children in ground ambulances from the scene of a traffic crash or medical emergency to a hospital or other facility. This issue of variation in emergency child transport guidelines was first identified in a 1998 publication that reported the results of a survey examining State requirements regarding the use of safety restraints for children in ambulances. The study revealed that 35 States did not require patients of any age to be restrained in ambulances. Of those States requiring the use of child safety restraints, requirements varied between requiring restraint on a gurney, in a child seat, or both. Variation across States in the definition of a “child” ranged from individuals under the age of 4 to individuals under 21. At that time the State agencies responsible for the regulation of ambulance services in each State varied as well. Responsible agencies included State EMS, law enforcement, and public safety agencies, as well as Departments of Transportation and Motor Vehicles. Fourteen States did not regulate EMS services. In some States, multiple agencies were involved in the regulation of ambulance safety.16This study also noted that at that time “the exact method to safely secure infants and smaller children in ambulances has ... not been well conceived.”16 Among other recommendations, the authors suggested that a universal age definition of pediatric patient be established, “a method for safely securing infants and children in ambulances...be developed,” and that “biomechanical research on ambulance safety and crashes...be undertaken.”16 One year after the publication of these State survey findings, the HRSA Emergency Medical Services for Children program and NHTSA convened a national consensus committee to review EMS child transportation safety practices. This group of representatives from EMS national organizations, Federal agencies, and transportation safety engineers developed a document titled The Dos and Don’ts of Transporting Children in an Ambulance, which was published in December 1999. This document provides very general guidance for practitioners in the field regarding how to most safely transport children in an ambulance. In addition to recommendations specific to safe emergency driving, guidance also includes the following recommendations:

·

·

Do tightly secure all monitoring devices and other equipment. Do ensure available restraint systems are used by EMTs and other occupants, including the patient.


29

·

·

·

·

·

Do transport children who are not patients, properly restrained, in an alternate passenger vehicle whenever possible.

Do not leave monitoring devices and other equipment unsecured in moving EMS vehicles.

Do not allow parents, caregivers, EMTs or other passengers to be unrestrained during transport.

Do not have the child/infant held in the parent, caregiver, or EMT’s arms or lap during transport.

Do not allow emergency vehicles to be operated by persons who have not completed the DOT NHTSA Emergency Vehicle Operating Course (EVOC), National Standard Curriculum, or its equivalent.

This document does not define “child” with regards to age or stature. The document also states that through grant funds, researchers are “working to fill critical knowledge gaps and developing standards for pediatric EMS transport safety.”17 However, to date, the federal government has not published more specific guidance. Since the publication of this Dos and Don’ts document, States, localities, and private EMS providers across the country have developed guidelines that include similar information for internal operations. Using safety research published in 2001, some of these guidelines are more detailed than the Dos and Don’ts document (see pp. 7-8). However, there is limited uniformity across these publicly and privately promulgated guidelines. Despite the publication of Dos and Don’ts by the Federal Government, and the development of moderately more detailed guidelines across the country, EMS practitioners continue to struggle with unanswered questions. In many cases, the issue of age or size is not addressed. As discussed above, some of the recommended practices are conflicting, others are impractical, and others may be insufficiently detailed to provide useful guidance. For example, a State EMS requirement to restrain all child passengers may result in the placement of a child in a car seat strapped to a side-facing bench in the rear compartment of an ambulance, rather than the captain’s seat. In addition, safety researchers conclude it “is not recommended, because this usage applies the severity of a frontal impact to the less protected side-facing child.”18 In this example, more specific guidance regarding the placement of a child in a side-facing position is required. It should be noted that more focused research and detailed guidance has been developed for specialized ambulance services providing inter-facility transport of children between hospitals and other care facilities.19 Due to the specific population focus of these vehicles, these ambulances are typically more appropriately equipped for pediatric transport. Lessons derived from this body of work may inform the efforts to better guide EMS practitioners with regards to emergency child transport. Similarly, standards for the transport of pediatric patients in air ambulances may offer guidance regarding safe protocols for child restraint, particularly injured patients. Child Transport in Ambulances: Current Practices and Outcomes Given the limited and sometimes conflicting guidance provided at the Federal, State and local levels, actual emergency child transport practice in ground ambulances varies dramatically. Academic research, as well as well as anecdotal information published in practitioner publications, suggests that there is


30

confusion or ambiguity regarding the safe transport of children in ambulances. Actual practices and protocols are often inconsistent. EMS provider training often omits specific discussions of pediatric emergency transport. In many cases, appropriate equipment may be unavailable, leaving the provider to improvise without clear guidance. In 2000 the results of a study examining the knowledge, opinions, and behaviors of EMS personnel regarding child and provider restraint use in ambulances were published. This study involved surveying EMS providers in a midsized urban area and based its analyses on published safety research that was available at that time, including the Dos and Don’ts document. Findings indicated that large percentages of EMS providers did not correctly indicate the safest method of transporting a 2-year-old child (30%) or correctly securing a child seat to an ambulance cot (40%). This study also indicated that although a significant majority (80%) of EMS providers regularly transports children in car seats, approximately 23 percent of providers reported that they occasionally transport children in adult laps. Additionally, 70 percent of EMS providers reported not using seat belts themselves on the squad bench, with 55 percent indicating that using restraints impairs their ability to provide patient care. Not surprisingly, this study also found that specialized emergency pediatric transport services personnel responses more often correctly identified the safest methods of emergency child transport.20 Findings from the 2000 research publication are supported by similar findings from previous examinations of emergency child transport practices, and anecdotal evidence. The observation of approximately 200 ambulance hospital arrivals involving children under 14 in a midsized urban area in 1999 suggested that children were transported without restraints on the side-bench (squad bench seat), in the captain’s chair, or in an adult’s lap approximately 37 percent of the time. An additional 5 percent were transported without restraints on the ambulance gurney (patient cot).21 Publications for EMS practitioners, including journals and newsletters, also refer to the common practices of allowing stable child patients to travel in the laps of adults, and strapping children to cots using the cot belt systems that are designed for adult patients.4, 22 A lack of clear guidelines and consistent training results in these varied practices. In addition, the dynamic nature of emergency medicine requires that solutions take into consideration numerous potential scenarios. The EMS community has identified the following issues related to emergency pediatric transport that remain unresolved:

·

·

·

·

·

Using a child’s own convertible car seat (that has been involved in a crash) properly restrained in the ambulance or transferring the child to a different car seat or car bed for proper restraint in the ambulance; How to handle child crash victims in car seats that are not convertible models when injuries may be aggravated by transferring them to another method of restraint in the ambulance; Validation of ambulance-specific test procedures for car seats; Using a convertible car seat contrary to manufacturer instructions; and Not all ambulance gurneys have the latest, strongest anchorages to the vehicle floor.22

NHTSA has issued a general position statement regarding the reuse of a child restraint that has been involved in a crash. The NHTSA position is that a child restraint may be reused after involvement in a “minor” crash; one of the criteria in the definition of “minor” is that no vehicle occupants are injured.23 Given that the transport of a child from a crash in an ambulance typically is associated with an injury,


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either to the child or his/her caregiver, the NHTSA position does not directly address the first issue noted above by the EMS community. Despite these identified unresolved emergency child transport questions and the potential for child injury in the rear compartment of an ambulance, a review of legal cases in Westlaw suggests that very few, if any, legal cases involve the improper or lack of restraint of child passengers in the rear compartment of a ground ambulance. Child Transport in Ambulances: Safety Engineering Research Very limited safety engineering research has been conducted to identify the safest methods of transporting children in ambulances. However, the principles of child and patient restraint are useful in developing recommended protocols and practices for child restraint in ground ambulances, as well as guiding safety research and crash testing activities. Existing safety engineering research on this issue focuses on younger children, primarily those 6 and younger. In 2001, Dr. Marilyn Bull, with her colleagues from the Indiana University School of Medicine and the University of Michigan, conducted ambulance crash tests to specifically examine safety outcomes when using convertible car seats, car beds, and harness systems, with 3-year-old, infant and 6-year-old size dummies. The published results are summarized below:

A two-belt attachment with elevated cot backrest was found to be the method with the least performance variability for securing either a convertible child restraint or a car bed. It was concluded that children who weight up to 18 kg, fit in a convertible child restraint, and can tolerate a semi-upright seated position can be restrained in a convertible child restraint secured with two belts to an ambulance cot. Infants who must lie flat can be restrained in a car bed modified for two seat belt paths and secured to a cot. In each case, the cot backrest must be elevated, and the cot and anchor system must be crashworthy. None of the harness configurations tested proved to be satisfactory, but an effective system could be developed by following accepted restraint design principles.18

In addition to discussing the findings of the specific crash tests conducted by this team of researchers, this study also provides an overview of safety issues involved with the use of restraints for children in other locations within the rear ambulance compartment. The authors suggest it may be possible on some occasions to restrain a child or infant in the rear-facing captain’s chair. Some child restraint manufacturers may provide instructions for the installation of a convertible car seat in this seat. Additionally, many of these seats are now equipped with a built-in child restraint that is acceptable for use with an uninjured or less critically injured child (not an infant). However, the authors note, the utilization of the technician seat for a child prohibits the use of that seat for emergency medical personnel. The placement of a child in a car seat strapped onto the side bench in the rear compartment of the ambulance “is not recommended, because this usage applies the severity of a frontal impact to the less protected side-facing child.”18 As discussed above, the use of harnesses on the patient cot for a younger child is not crashworthy. Last, a child held by a properly restrained adult is not an acceptable practice as it leaves the child unrestrained.


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The “Conclusions and Recommendations” section of this study has been widely circulated within the EMS community. States, localities, EMS providers, and practitioner associations have incorporated Dr. Bull’s recommendations into protocols and guidelines for EMS practitioners.24 25 26 However, as Dr. Bull and her colleagues noted in their findings, these tests were completed using a newer cot and anchor system with a “slide-in track to hold the cot firmly to the ambulance floor.”18 This system is often not found in older ambulance models. Crash tests conducted in 1998 found that this older type of cot and fastener “did not provide a secure platform for the child restraint.”18 Therefore, the findings of the 2001 study may not provide the same degree of protection for child transport when older cot and anchor systems are used but may improve safety even in those circumstances in less severe crashes. Also in 2001, colleagues from the Center for Transportation Injury Research and the U.S. Navy’s Naval Air Warfare Center Aircraft Division at Naval Air Station Patuxent River conducted ambulance crash tests that examined more general dynamics inside the rear compartment of an ambulance during a crash. These tests included a 3-year-old size dummy restrained in a convertible car seat strapped to an ambulance cot in the same manner described in the child restraint crash test. Additionally, three adult dummies of varying sizes, and medical equipment typically found inside the rear ambulance compartment, were involved in the crash tests. Results suggest that the restraint method used for the child was effective. However, unrestrained ambulance occupants in the rear compartment hit the restrained child during the crash, presenting the opportunity for significant injury to the child as well as the adult.27 Findings emphasized that patient safety depends upon the use of safety restraints by all ambulance passengers, and the appropriate securing of all equipment in the rear ambulance compartment. Conclusion Although limited research has focused on the specific issue of the emergency transport of children in ambulances, more information has become available since the EMSC and NHTSA’s publication of The Dos and Don’ts of Transporting Children in an Ambulance. Given the lack of a universal definition of “child,” as well as the inconsistent protocols and practices currently used by EMS practitioners, additional guidance, developed by topical experts, would improve the safety of all children transported in ambulances in the United States.


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Endnotes

1 National EMS Information System. The Project Page. Available at: www.nemsis.org.

2 Levick, N. R. (2007). Emergency Medical Services: A Transportation Safety Emergency. Paper presented at the American Society of Safety Engineers Professional Development Conference, June 24-27, 2007, Orlando, Florida. Available at www.objectivesafety.net/2007ASSE628Levick.pdf.

3 Levick, N. R. (2002). New Frontiers in optimizing ambulance transport safety and crashworthiness. The Paramedic, 4:36-39.

4 Winters, G., & Brazelton, T. (2003). Safe Transport of Children. EMS Professionals, July-August 2003, 13-21.

5 American Ambulance Association. (2002). Position Paper: Safe Driving Statement. McLean, VA: Author. Available at www.the-aaa.org/about/positionpapers/safedriving.html.

6 Kahn, C. A. (2006). EMS, First Responders and Crash Injury. Topics in Emergency Medicine, 28(1)68–74.

7 National Highway Traffic Safety Administration. (n.a.). Fatality Analysis Reporting System. Washington, DC: Author. Available at www.nhtsa.gov/FARS.

8 Auerback, P. S., Morris, J. A., Phillips, J. B., Redlinger, S. R., &Vaugn, W. K. (1987). An analysis of

ambulance accidents in Tennessee. Journal of American Medical Association, 258(11):1487-90.

9 Kahn, C. A., Pirallo, R.G., & Kuhn, E. M. (2001). Characteristics of fatal ambulance crashes in the United States: an 11-year retrospective analysis. Prehospital Emergency Care, 5(3)261-9.

10 Becker, L. R., Zaloshnja, E., Levick, N., Li, G., & Miller, T. R. (2003). Relative risk of injury and death

in ambulances and other emergency vehicles. Accident Analysis and Prevention, 35(6):941-8.

11 Ray, A., & Kupas, D. F. (2005). Comparison of Crashes Involving Ambulances With Those of Similar-Sized Vehicles. Prehospital Emergency Care, 9(4):412-415.

12 Ferreira, J., & Hignett, S. (2005). Reviewing ambulance design for clinical efficiency and paramedic

safety. Applied Ergonomics, 36:97-105.

13 National Institute for Occupational Safety and Health. (2004, February 12). Emergency Medical Technician Dies in Ambulance Crash-New York. (FACE Report 2001-12.) Atlanta: Author. Available at www.cdc.gov/niosh/face/In-house/full200112.html.

14 General Services Administration. (2007, August 1). Federal Specifications for the Star-of-Life

Ambulance. KKK-A-1822F. Washington, DC: Author. Available at http://apps.fss.gsa.gov/vehiclestandards/assocDocs.cfm#.

15 ANSI. (2006, March). ANSI Accredited Standards Committee ANSI/ASSE Z15.1-2006 American

Standard: Safe Practices for Motor Vehicle Operations. Des Plaines, IL: Author.

http://www.nemsis.org/

http://www.the-aaa.org/about/positionpapers/safedriving.html

http://www.cdc.gov/niosh/face/In-house/full200112.html

http://apps.fss.gsa.gov/vehiclestandards/assocDocs.cfm


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16 Seidel, J. S., & Greenlaw, J. (1998). Use of restraints in ambulances: A State survey. Pediatric Emergency Care, 14(3):221-3.

17 Health Resources and Services Administration & National Highway Traffic Safety Administration. (1999, December). The Do’s and Don’ts of Transporting Children in an Ambulance. Washington, DC: Authors. Available at https://www.childrensnational.org/files/PDF/EMSC/PubRes/Dos_and_Donts_of_Transporting_Children_by_Ambulance.pdf.

18 Bull, M. J., Weber, K. B., Talty, J., & Manary, M. A. (2001). Crash Protection for Children in

Ambulances. In: 45th Annual Proceedings of the Association of the Advancement of Automotive Medicine, p. 353-367. Des Plaines, IL: AAAM.

19 American Academy of Pediatrics. (2007). Guidelines for Air and Ground Transport of Neonatal and

Pediatric Patients, 3rd Edition. George A. Woodward, Robert M. Insoft, & Monica E. Kleinman, editors. Elk Grove Village, IL: Author.

20 Johnson, T., Lindholm, D., & Dowd, M.D. (2006). Child and Provider Restraints in Ambulances:

Knowledge, Opinions, and Behaviors of Emergency Medical Services Providers. Academy of Emergency Medicine, 13(8):886-892.

21 Levick, N. (2000). Research Reports: Ambulance Passenger Risks. Safe Ride News, 18(4).1. Shoreline,

WA: Safe Ride news Publications.

22 Dewey-Kollen, J. (2003). Protecting Children in Ambulances: Real World Practices. Safe Ride News, 21(1):3. Shoreline, WA: Safe Ride news Publications.

23 National Highway Traffic Safety Administration. (n.a.). Position statement: Child restraint re-use after

minor crashes. Washington, DC: Author. Available at www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/RestraintReUse.htm.

24 Association of Air Medical Services. (2007, October). Improved restraint usage for infant and pediatric

patients in ground ambulances through education and policy development. Alexandria, VA: Author.

25 Idaho Emergency Medical Services for Children. Pediatric Basic Life Support Guideline: Transporting Children in an Ambulance.

26 Georgia Department of Human Resources Division of Public Health. (2006, August 1). Safe

Transportation of Pediatric Patients. RE01A(1): Required Equipment for Licensed Ambulances – Standards for Safe Transport of Pediatric Patients .Atlanta: Author.

27 Levick, N. R., Donnelly, B.R., & Blatt, A. Ambulance crashworthiness and occupant dynamics in

vehicle-to-vehicle crash tests: preliminary report. 17th International Technical Conference on the Safety of Vehicles Conference Proceedings. Washington, DC: National Highway Traffic Safety Administration; June 2001. Available at www-nrd.nhtsa.dot.gov/pdf/nrd-01/esv/esv17/proceed/00012.pdf.

http://www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/RestraintReUse.htm


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Appendix B Agenda and List of Participants, Meeting of the Working Group

EMS Solutions for Safely Transporting Children in Emergency Vehicles July 22, 2009

Washington, DC

Agenda

8:00 – 8:15 Sign In & Refreshments 8:15 – 9:00 Welcome Drew Dawson/Sandy Sinclair

Introductions Valerie Boykin House Keeping/Logistics

Work Group Overview/Activities Update Topical Discussions 9:00 – 9:30 Final Product Hassan Aden Who is the audience?

What type of product will be most useful? What should it look like?

9:30 – 10:00 Definition of Child Delmas Johnson

Should age and/or stature be considered in developing our recommendations? Should we use previously established age categories? 10:00 – 10:15 Break 10:15 – 11:15 Tour/Demo of Ambulance and Equipment Dr. Joe Wright and Tom Stotz Cyndy Wright-Johnson 11:15 – 11:45 Crash Protection For Children In Ambulances Dr. Marilyn Bull 11:45 – 12:00 NHTSA’s 4 Steps For Kids Recommendations Sandy Sinclair


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12:00 – 1:00 Working Lunch

Evaluate/Discuss Standard Ambulance Equipment (Small Group Discussions) Identify key issues/considerations/recommendations

·

·

Transport Equipment Securing of Emergency Medical Equipment

1:00 – 3:00 Hierarchical Approach/Establishment of Benchmarks ·

·

Car Seats Side Facing Passengers

3:00 – 3:30 Wrap Up/Next Steps/Reimbursements

· NHTSA Representatives ·

·

Valerie Boykin Amy Wilson

Meeting Attendees

Workgroup Members

Name Organization Katrina Altenhofen National Association of State Emergency Medical

Services Officials Dr. Marilyn Bull The American Academy of Pediatrics Dr. James Callahan American College of Emergency Physicians Dr. Andrew Garrett National Association of Emergency Medical Service

Physicians Ken Knipper National Volunteer Fire Council Tommy Loyacono National Association of Emergency Medical Technicians Dr. John Russell American Ambulance Association Dr. Joseph Wright National Emergency Medical Services for Children

Resource Center Cynthia Wright-Johnson Emergency Nurses Association

NHTSA

Name Organization Alexander (Sandy) Sinclair Occupant Protection/TIC & Contracting Officer’s

Technical Representative for the Project Dave Bryson EMS/Traffic Injury Control (TIC) Drew Dawson EMS/TIC Thelma Kuska Region 5


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Maryn Consulting, Inc.

Name Organization Hassan Aden Alexandria Police Department/Maryn Consultant Valerie Boykin Project Manager Delmas Johnson Sr. Consultant Greg Maryn President George Perkins Business Development Manager Amy Wilson Operations and Administration Manager


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Appendix C General Considerations and Selecting Child Restraint and Cot Restraint Systems

For Ground Ambulance Transport

General Considerations: ·

·

·

·

All ground ambulances transporting children should have seats and restraints capable of safely securing children. These can be in the form of either a single system or multiple restraints as long as all sizes are accommodated.23 Swiveling seats should be tested in every position in which they are able to be locked when a child restraint is present. While there is currently no U.S. dynamic testing standard for ambulance cots, every effort should be made to ensure that the ambulance is equipped with a cot and fastener system that has been statically tested under vehicle crash conditions of at least 2,200 lbs. in accordance with AMD Standard 004. (This meets current GSA and AMD requirements and most of the proposed NFPA 1917 standard.) The working group recommends that child restraints should never be attached to a side facing seat or side-facing bench seat. Child restraints should never be attached to a side facing seat or side facing bench.”

Selecting Child Restraints and Cot Restraints for EMS:

There are many child restraint options available to EMS agencies. These may include: integrated seats, conventional child restraint systems for use in motor vehicles, cot mounted devices, board and harness systems, etc. Due to the lack of regulation and testing requirements specific to ground ambulances, many of the available devices may be designed for a different use and either tested to automotive standards or not tested at all. It is not in the purview of this document to recommend any specific product, but it is possible to categorize products based on design and testing characteristics. Ideally, this will provide EMS agencies with some criteria that should correlate to the safety and efficacy of the child restraint system they are considering. They are listed below with “A” being the best option and “D” the worst. It is important to remember that even “D” is much better than transporting a child unrestrained or held in an adult’s arms.

23 NHTSA’s Ease of Use Ratings for child restraint systems is a five-star ratings system that allows parents and caregivers to evaluate how easy certain CRS features are to use before purchasing a seat for their personal use in transporting a child. While the testing requirements and regulations do not include emergency ground ambulances, EMS agencies and providers may wish to review the Ease of Use Ratings material available at www.nhtsa.gov when selecting CRS systems for use in emergency ground ambulances.

http://www.nhtsa.gov/


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Category A ·

·

Seats and restraints (including integrated restraints) specifically designed to either be permanently mounted or secured on a rear-facing cot or EMS provider’s seat in a ground ambulance. Restraints will be dynamically tested in the same configuration as they are expected to be used in the ground ambulance; either directly mounted or secured in actual ambulance seats or cots.

Manufacturer can provide documentation of third party testing proving their cot restraints meet or exceed the standards for test pulse and ATD injury criteria specified in FMVSS No. 213. Documentation must be provided proving compliance in a rear-facing test for both infant and child seat configurations (if applicable) and also in a forward-facing test. Must also be tested forward facing for children over two years old if to be installed in a captain’s chair forward-facing or front compartment seat. Category B · Devices in this category are proven to be safely secured based on at least one published and peer

reviewed study. Must meet all the following criteria to ensure compliance: o Convertible child restraints for children up to 40 pounds and infant car beds for infants up

to 20 pounds that are designed for passenger cars/trucks and are FMVSS No. 213 tested and certified.

o Restraint system must be able to be attached to cot using two belt paths to prevent both forward and rearward motion.

o If a booster type CRS is used, it should only be used on seats with lap/shoulder belts available.

o Ambulance seat or cot must have a belt and retractor system that allows for a secure, two path attachment of the restraint.

o Amended instructions and training have been provided for correct mounting in a non-standard direction.

Category C ·

·

Seats and restraints other than those covered in Category B that may either be secured in a rear facing cot or seat and are FMVSS No. 213 tested and certified using a standard, forward facing test sled. If a booster type CRS is used, it should only be used on seats with lap/shoulder belt available.

Category D

· All other seats and restraints that are not FMVSS No. 213 tested and certified, or that the manufacturer cannot provide documentation that the seat or restraint meets or exceeds the standards for test pulse and ATD injury criteria specified in FMVSS No. 213.


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Appendix D

Recommendations for Using Convertible Child Safety Seat, Car Bed, and Securing Child on Cot in Emergency Ground Ambulances

Convertible Child Safety Seat (CSS) Child Size: 5 to 40 lbs Installation Recommendations:

• Install with rear-facing and forward-facing belt paths. • Choose seat with 5-point internal harness. • Position seat facing rear of ambulance. • Elevate cot backrest to fully upright position. • Adjust restraint recline mechanism to fit snugly against cot seat back.


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Appendix D (continued)

Recommendations for Using Convertible Child Safety Seat, Car Bed, and Securing Child on Cot in Emergency Ground Ambulances

Car Bed Child Size: 5 to 20 lbs Installation Recommendations:

• Designed for infants who must lie flat. • Only use car bed with two belt systems.

Note: Second set of loops must be purchased from the manufacturer. • Elevate cot backrest to fully upright position. • Attach belts to cot where sliding is minimized. • Position head away from side of vehicle.


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Appendix D (continued) Recommendations for Using Convertible Child Safety Seat, Car Bed, and Securing

Child on Cot in Emergency Ground Ambulances

Securing Child on Cot Using 4-Point Harness Installation Recommendations:

• Secure the child to the cot as shown. • Position cot (subject to the manufacturer’s specifications) to provide for the child’s comfort

based upon the child’s injuries and/or illness and to allow for appropriate medical care. • Attach belts to cot where sliding is minimized. •


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Appendix E Recommended Best Practices for Child Restraint System Use

Please note: in April 2011, NHTSA and the American Academy of Pediatrics released updated best-practice recommendations for the use of car seats and booster seats. To review these recommendations, please visit:

www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/4StepsFlyer.pdf

www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx

http://www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/4StepsFlyer.pdf

http://www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/4StepsFlyer.pdf

DOT HS 811 677 September 2012

8822-090712-v2