Whats Changing in Ambulance Standards NIOSH AMD Ambulance

What’s Changing in Ambulance Standards?

NIOSH – AMD Ambulance Testing: And the Changing Standards Landscape Jim Green, NIOSH, Safety Engineer

Rear Impact – 2 Tests Measured Vehicle Response at Impact • Both tests utilized the IIHS moving deformable barrier – IIHS MDB weight was 1, 500 kg or 3, 300 lbs. – Impact velocity 50 kph or 31 mph – Vehicle instrumentation package described in SAE 2007 -01 -4267 – E 350 Type II weighed 8, 840 lbs. while the E 350 Type III weighed 9, 975

Frontal Impact – 3 Conducted Matches Federal Standard

Side Impact – 4 Conducted Matches IIHS Side Impact Test

Ramp Roll Test – 30 MPH/48 KPH

Barrier Impact Test – 30 MPH/48 KPH

Occupant Excursion Concerns Standard Gurney – 30 mph Impact Pre-crash event: standard cot, restraint and antler floor fastener Mid-crash event: patient excursion exceeds 30 inches or 76 cm

Demo: Frontal Impact, Forward and Rear Facing Seating Testing provides data on ATD response under dynamic crash loading – ATD measured values must fall below fed limits

Equipment Mount Integrity Pre- and Post-Crash Prior to crash equipment and gurney either mounted or stowed in cabinets Post crash (rollover) equipment and gurney positions drastically changed

Equipment Mount Test Standard: Dynamic Test Option Equipment Mount Dynamic Test Standard Utilizes Front and Side Impact Pulses Orientation defined by Manufacturer Sled test fixture replicating side and rear wall installations of oxygen cylinder and mount – successfully tested to SAE J 2917

Testing Criteria – Frontal & Side Impact SAE J 2917 - Ambulance Patient Compartment Frontal HYGE Sled Pulse, Pub. May 2010 SAE J 2956 - Ambulance Patient Compartment Lateral HYGE Sled Pulse, Pub. June 2011

Seating and Restraint Data Sheet

SAE J 3026: Seat and Worker Restraint Publication Date: Sept 2014 Key Elements in Recommended Practice • Dynamic, crash testing is required • Seat and restraint systems must protect occupants to same crash standards as automotive seating • Utilizes H-III and ES 2 -re 50 th male ATD as appropriate. • ATD measured values must fall below federal limits for injury tolerance

Standards Landscape Tomorrow Rear Impact: SAE J 3044 Side Impact: SAE J 2956 Frontal Impact: SAE J 2917 Occupant Seating SAE J 3026 Occupant Excursion SAE J 3059 Bumper To Bumper Standards Litter Std. SAE J 3027 GSA KKK-A-1822 NFPA 1917 CAAS GVS-v. 1. 0 Equipment Mounts SAE J 3043 Cabinet Testing SAE J 3058 Modular Body Integrity SAE J 3057 Interior Surface Delethalization Litter Sub-Floor Test SAE J 3102

SAE Documents – SAE J 3057 SAE J 3058 SAE J 3043 SAE J 3059 SAE J 3026 SAE J 3027 SAE J 3012 SAE J 3044 SAE J 2956 SAE J 2917

SAE Documents Referenced So Far Document Name GSA 1822 CN#8 NFPA 1917 CAAS GVS 2016 SAE J 3027 Patient Litter Yes Yes SAE J 3026 Seating and Restraints Yes Yes SAE J 2917 Frontal Crash Pulse Yes Yes SAE J 2956 Side Impact Crash Pulse Yes Yes SAE J 3043 Equipment Mount Test Partially Yes Partially

Summary – Pending SAE Documents Document Name Status SAE J 3059 Occupant Excursion With SAE for review SAE J 3102 Floor Sub-Structure Test To SAE by Mar 2016 SAE J 3058 Cabinet Testing To SAE by Mar 2016 SAE J 3057 Modular Body Test To SAE by Mar 2016 SAE JXXXX Interior Surface Softening Summer 2016

KKK CN#8 Compliance as of 1/1/2016 State ALABAMA K Compliant Rev 8 Compliant X X State K Compliant Rev 8 Compliant MONTANA ALASKA NEBRASKA X X ARIZONA NEVADA X X X X ARKANSAS NEW HAMPSHIRE X CALIFORNIA NEW JERSEY COLORADO NEW MEXICO CONNECTICUT X X NEW YORK DELAWARE X X NORTH CAROLINA FLORIDA X X NORTH DAKOTA OHIO GEORGIA HAWAII X X OKLAHOMA X IDAHO X X OREGON X ILLINOIS X PENNSYLVANIA X X INDIANA RHODE ISLAND X X IOWA SOUTH CAROLINA X X KANSAS X X SOUTH DAKOTA KENTUCKY X X TENNESSEE X LOUISIANA TEXAS X MAINE UTAH MARYLAND VERMONT X X X MASSACHUSETTS X VIRGINIA MICHIGAN X WASHINGTON MINNESOTA X X WEST VIRGINIA MISSISSIPPI X X WISCONSIN MISSOURI X X WYOMING

Ambulance Patient Compartment Design Standards Jennifer Marshall Office of Special Programs National Institute of Standards and Technology

Design Assumptions • Designs are based on requirements and criteria • Design is not “standard” and only serves the purpose of visualizing optional layouts • One patient on cot • Curbside & roadside seats on track • Cables, tubing, & leads are routed along wall/ceiling • Design does not necessarily address crashworthiness • CPR/intubation cannot be performed while seated • IV bag will be hung prior to transit • Curbside workstation is the primary medic seat • Jump bags are the primary storage for immediate care items 23

Key Human Performance Requirements • Use the human performance requirements to drive the design. • The EMS provider shall be able to reach the patient’s body from head to knee while in a seated and restrained position. • The EMS provider shall be able to reach common and critical equipment/supplies from a seated and restrained position. • The EMS provider is able to face and interact with the patient while in a seated and restrained position. 24

Conceptual Design – Helps to Validate Design Requirements 25

Roadside Seat 26

Curbside Seat 27

Modeling with Mannequins 28

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Guidebook • Ambulance Design Guidebook covers best practices, recommendations, and ergonomics. – Final, pending release by DHS – Intended to be a practitioner guide and not a standard – Covers user-defined process, steps to take to develop design requirements and basic systems engineering – Also addresses some best practices or recommendations in the following areas: • Equipment layout and workflow • Lighting, noise, HVAC • Storage • Ingress/egress (patient and EMS worker) • Labeling • Communications and information technology • Restraints and seating • Surfaces and materials (incl. decontamination) 30

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Standards vs Standards 1. Testing Standards for Specific Safety Criteria a. AMD b. NIOSH = SAE 2. Bumper to Bumper Vehicle Standards vs. Standards a. KKK-A-1822 F b. CAAS GVS v. 1. 0 c. NFPA 1917

States Regulate the Design of Ambulances • 14, 500 EMS agencies licensed in the US • State approaches fall into 5 categories: (2011) (2012) – “K” specs incorporated in whole or part in rule – “K” specs in policy – Regulate design, but not using “K” specs – No design regulation – “Other” NASEMSO

2012 Survey Results Regulatory Method • Only 6 states do not regulate the design of ambulance vehicles • Only 13 states regulate design without referencing “K” specs • Only 1 state (CO) is “other” • 30 states regulate design using “K” specs in whole or part Do Not Regulate w/out "K" Other Use "K" NASEMSO

THE TRIGGER • GSA announces intent to “cancel” the “K” specs effective September 30, 2013 • Presidential Executive Order: if an NGO is in the business, the feds should get out of it • NASEMSO successfully appealed for a delay until September 30, 2015 NASEMSO Annual Meeting, October 2014

Retirement of the “K”Specifications: Significance • State Administrative Procedure Acts usually allow incorporation by reference only of “current” documents • Rule promulgation is a lengthy and expensive process, including public notice and comment opportunities • States “cycles” for promulgation vary widely NASEMSO Annual Meeting, October 2014

KKK-A-1822 F NFPA 1917 CAAS GVS

Who is CAAS? Commission on Accreditation of Ambulance Services Accreditation Standards: • Standards for enhancing quality and performance for licensed ambulance service providers • Established in 1990 • “Gold Standard”- exceeds state EMS licensure requirements • Voluntary, or as required by state/county or local ordinance • When met- the ambulance service/organization is granted accreditation • www. caas. org

CAAS Involvement The Commission on Accreditation of Ambulance Services (CAAS) was asked by several National Organizations to develop an Ambulance Standard to replace the KKK specification. CAAS represents the complete EMS spectrum, not just one specific sector of EMS. The CAAS Board of Directors representation is multifaceted, representing the broad industry.

CAAS GVS Ground Vehicle Standard v. 1. 0: • Standard for the design of new ambulances • Establishes minimum standards, performance parameters and essential criteria for the design of ambulances • Provides a practical degree of standardization • Effective July 2016 • When built to the GVS standard- the vehicle will bear the GVS logo • Does not require or imply CAAS accreditation which is a separate program • www. groundvehiclestandard. org

Specification • GVS foundation is KKK • Applicable to new production vehicles only • Accommodates current chassis offerings • Maintains certain important quality criteria • Includes new NIOSH/SAE Safety Standards • Allows purchaser flexibility with consideration for local requirements

It does include • Purchaser ability to define emergency lighting configuration • Purchaser ability to define exterior graphics design and colors • Continuity of KKK enhanced electrical system requirements- “Class 3 Life Support” • Continuity of KKK enhanced floor structure and loading requirement (AMD 20) • New defined minimum payload requirement of 1, 300 pounds for every vehicle including options

It does include • Ability for purchaser to deviate from standard as allowed by state, exceptions to be defined by FSAM • Additional enhancements are suggested, not required • Required compliance for all AMD testing standards #01 -25. • FSAM required to provide Type Testing and Certification for each ambulance model from certified independent testing facility.

Required Safety Features GVS includes new safety requirements that are fully researched and proven by NIOSH: • SAE 3026 Patient Compartment Seating • SAE 3027 Litter Fasteners and Anchorage • SAE 3043 Ambulance Equipment Mounting and Retention (partial) Additional NIOSH/SAE requirements will be included in future revisions of the GVS standard as they are published

Cost Factors • Minimum requirements of GVS v. 1. 0 as outlined should not significantly increase cost of vehicle conversion. • New NIOSH/SAE safety features will have cost impact on vehicle conversion. Incremental cost will vary based on: a) Purchaser’s specifications b) Level of vehicle currently purchased

Potential Cost Impact of Safety Features • SAE 3026 Patient Compartment Seating Incremental cost will be dependent on your current specification • SAE 3027 Litter Fasteners and Anchorage Incremental cost for COT MOUNT SYSTEM ONLY will be $1 K-$4 K (over current antler system) for a compliant manual mount. Power systems vary between manufacturers and could exceed $40 K for a complete system including vehicle mount and cot. • SAE 3043 Ambulance Equipment Mounting and Retention Incremental cost will be dependent on your current specification

Future plans for GVS v. 1. 0 • Two (2) year revision plan is scheduled • Additional SAE standards to be included as they are published • Inclusion of remounts to be developed.

What’s Next? • Spring 2016 KKK Change Order 9 public comment • Jul 2016 KKK Change Order 9 • Jul 2016 CAAS GVS v. 1. 0 effective • Oct 2016 KKK retires? Not likely for 2016