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Relative Risk of Injury and Death in Ambulances and Other Emergency Vehicles. Les R. Becker, Ph.D., NREMT-P Associate Research Scientist Public Services Research Institute Pacific Institute for Research & Evaluation Calverton MD 20705. Acknowledgements.

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Relative risk of injury and death in ambulances and other emergency vehicles

Relative Risk of Injury and Death in Ambulances and Other Emergency Vehicles

Les R. Becker, Ph.D., NREMT-P

Associate Research Scientist

Public Services Research Institute

Pacific Institute for Research & Evaluation

Calverton MD 20705


Acknowledgements
Acknowledgements Emergency Vehicles

  • This research was supported by US Health Resources and Services Administration Emergency Medical Services to Children Grant No. 1 H15 MC00069 to the Johns Hopkins University and Grant Number 5 RO1 OH03750-02 to the Pacific Institute for Research and Evaluation.

THOMCO EMS SAFETY NET SEMINAR, 2007


Introduction
Introduction Emergency Vehicles

  • EMS response is a fundamental feature of EMS systems (Boyd et al., 1983).

  • Ambulance crash studies have lagged behind the growth of EMS in the U.S.

  • The first examinations of ambulance crashes began in the early 90’s.

THOMCO EMS SAFETY NET SEMINAR, 2007


Overview
Overview Emergency Vehicles

  • Review of Early Studies

  • Review of the PIRE Study

  • Review of EMS Seat Belt Use

  • Discussion of Prevention Approaches

  • Proposal of a New Approach

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies
Earlier Studies Emergency Vehicles

  • Auerbach (1987) studies a very small sample of Tennessee ambulance crashes:

    • Approximately 50% of vehicle-drivers and front-seat occupants were wearing occupant restraints;

    • Over one-half of prone stretcher patients were restrained;

    • 15% of bench seat and 100% of jump seat patients were wearing restraints.

THOMCO EMS SAFETY NET SEMINAR, 2007


Emergency VehiclesWe conclude that passenger restraints for both ambulance attendants and passengers should be mandatory and we suggest that traffic signals be strictly heeded at intersections and speed limits in urban settings be obeyed.”

Auerbach et al., 1987

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies1
Earlier Studies Emergency Vehicles

  • Larmon et al. (1993) reported that 67.9% of 900 EMTs surveyed identified inhibition of patient care as a reason for non-use in the patient compartment.

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies2
Earlier Studies Emergency Vehicles

  • Saunders and Heye (1993)

    • San Francisco Public Health Department ambulance crashes;

    • Over 27 months;

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies3
Earlier Studies Emergency Vehicles

  • Four percent of 439 emergency medical technicians responding to a survey in New England reported that they had been involved in a crash (Schwartz et al. 1993)

  • Sayeh et al. (1998) surveyed 2,672 EMTS in New England and Los Angeles.

    • 37% in New England reported crash involvement;

    • 26% in LA reported crash involvement.

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies4
Earlier Studies Emergency Vehicles

  • Pirrallo and Swor (1994) compared emergency and non-emergency ambulance crash fatalities.

    • Retrospective, cross-sectional, comparative analysis of 109 fatal crashes (126 deaths) from 1987-1990 using FARS data;

    • NY, MI, CA and NC accounted for 37% of all fatal crashes.

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies5
Earlier Studies Emergency Vehicles

  • Pirrallo and Swor (1994) [cont’d]:

    • 69% occurred during emergency runs and 31% occurred during non-emergency runs;

    • Most emergency run fatal crashes occurred between 1200h and 1800h.

    • Most non-emergency fatal crashes occurred when lighting conditions were poor.

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies6
Earlier Studies Emergency Vehicles

  • Pirrallo and Swor (1994) [cont’d]:

    • No statistically significant differences between emergency and non-emergency crashes based:

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies7
Earlier Studies Emergency Vehicles

  • Biggers et al. (1996) studied one year of ambulance crash data in Houston.

    • Driver history of a prior EMS vehicle crash was a key risk factor for future crashes.

      • Drivers with a history of previous crashes were involved in 33% of all collisions.

      • Five drivers accounted for 88.2% (15/17) of all injuries.

THOMCO EMS SAFETY NET SEMINAR, 2007


Earlier studies8
Earlier Studies Emergency Vehicles

  • Kahn et al. (2001) analyzed 1987-1997 FARS data and found that unrestrained rear occupants were most at risk for fatal and/or incapacitating injuries.

    • Most crashes occurred at intersections;

    • Dry, straight, improved roads;

    • On clear days;

    • Striking a second vehicle;

    • 84% of the crashes involved fatalities;

    • 78% of the fatalities were not ambulance occupants;

THOMCO EMS SAFETY NET SEMINAR, 2007


Our work

Our Work Emergency Vehicles


Methods
Methods Emergency Vehicles

  • Merged 1988 through 1997 GES and FARS data;

  • Police, ambulance vehicles and fire trucks;

  • Modified KABCO scale

    • No injury;

    • Possible/non-incapacitating injury

    • Incapacity injury

    • Fatal injury

THOMCO EMS SAFETY NET SEMINAR, 2007


Methods1
Methods Emergency Vehicles

  • Ordinal logistic regression rather than separate odds ratio calculations;

  • Independent variables:

    • Vehicle type

    • Response Mode

    • Restraint Use

    • Seating position

  • Dependent variable

    • Injury severity (KABCO score)

THOMCO EMS SAFETY NET SEMINAR, 2007


Results

Results Emergency Vehicles


Number of crashes 1988 1997
Number of Crashes, 1988-1997 Emergency Vehicles

THOMCO EMS SAFETY NET SEMINAR, 2007


Number of fatalities 1988 1997
Number of Fatalities, 1988-1997 Emergency Vehicles

THOMCO EMS SAFETY NET SEMINAR, 2007


Number of non fatals 1988 1997
Number of Non-Fatals,1988-1997 Emergency Vehicles

THOMCO EMS SAFETY NET SEMINAR, 2007


Injury severity of ambulance occupants 1988 1997
Injury Severity of Ambulance Occupants, 1988-1997 Emergency Vehicles

THOMCO EMS SAFETY NET SEMINAR, 2007


Incapacitating injuries by response restraint use seating position
Incapacitating Injuries Emergency VehiclesBy Response, Restraint Use & Seating Position

THOMCO EMS SAFETY NET SEMINAR, 2007


Fatal injuries by response restraint use seating position
Fatal Injuries Emergency VehiclesBy Response, Restraint Use & Seating Position

THOMCO EMS SAFETY NET SEMINAR, 2007


Relative risks
Relative Risks Emergency Vehicles

THOMCO EMS SAFETY NET SEMINAR, 2007


Summary of findings
Summary of Findings Emergency Vehicles

  • Unrestrained ambulance occupants involved in a crash had nearly 4 times greater risk of fatality than did restrained ambulance occupants.

  • Unrestrained ambulance occupants involved in a crash had nearly 6.5 times greater risk of suffering an incapacitating injury than did restrained ambulance occupants.

THOMCO EMS SAFETY NET SEMINAR, 2007


Summary of findings1
Summary of Findings Emergency Vehicles

  • The risk of a fatality versus no injury for ambulance rear occupants was over 5 times greater for ambulance rear occupants than for front-seat occupants if involved in a crash.

  • Ambulance occupants traveling non-emergency were 2.7 times more likely than occupants traveling emergency to be killed if involved in a crash.

THOMCO EMS SAFETY NET SEMINAR, 2007


Summary of findings2
Summary of Findings Emergency Vehicles

  • Ambulance occupants traveling non-emergency were nearly 1.7 times more likely than occupants traveling emergency to suffer an incapacitating injury if involved in a crash.

THOMCO EMS SAFETY NET SEMINAR, 2007


Conclusions
Conclusions Emergency Vehicles

  • Clearly, occupant restraints are not used consistently in ambulances.

  • Unrestrained ambulance occupants, occupants riding in the rear compartment and especially unrestrained occupants riding in the rear compartment are at substantially increased risk of injury and death when involved in a crash.

  • One prior study suggests that occupant restraints are more commonly used for patients than for crew members.

THOMCO EMS SAFETY NET SEMINAR, 2007


Implications for ems safety practices
Implications for EMS Safety Practices Emergency Vehicles

  • Ambulance occupants, including providers, should use safety restraints whenever feasible.

  • Individuals accompanying patients during transport should ride in the front seat of the ambulance whenever feasible.

THOMCO EMS SAFETY NET SEMINAR, 2007


Seat belts prevention

SEAT BELTS & PREVENTION Emergency Vehicles


Prevention fact

Prevention Fact! Emergency Vehicles


“The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

Dinh-Zarr, Sleet, Schultz et al., 2001

THOMCO EMS SAFETY NET SEMINAR, 2007


Seat belt use in the u s
Seat Belt Use in the U.S. means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Seat belt use in the u s1
Seat Belt Use in the U.S. means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Seat belt use in the u s2
Seat Belt Use in the U.S. means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


What do we know about seat belt use in ems

What do we know about seat belt use in EMS? means of reducing fatal and nonfatal injuries in motor vehicle crashes.”


Perceived need for freedom
Perceived Need for means of reducing fatal and nonfatal injuries in motor vehicle crashes.”Freedom

Cook et al., 1991

THOMCO EMS SAFETY NET SEMINAR, 2007


Seat belt use by providers
Seat Belt Use by Providers means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

Larmon et al., 1993

THOMCO EMS SAFETY NET SEMINAR, 2007


Prevention approaches
Prevention Approaches means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • The ‘Three E’s’

    • Education

    • Engineering

    • Enforcement

THOMCO EMS SAFETY NET SEMINAR, 2007


More prevention fact

More Prevention Fact! means of reducing fatal and nonfatal injuries in motor vehicle crashes.”


Single approaches in isolation are rarely effective

Single Approaches In Isolation are Rarely Effective! means of reducing fatal and nonfatal injuries in motor vehicle crashes.”


Solutions
Solutions? means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • Education

    • EVOC

    • Driving Simulators

  • Engineering

    • Speed regulators (“governors”)

    • “Black Box” Approaches

    • Harness Systems

  • Enforcement

    • Organizational policies and sanctions

THOMCO EMS SAFETY NET SEMINAR, 2007


Solutions1
Solutions? means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Effectiveness
Effectiveness? means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • At least one small-scale study

    • 36 vehicles over 18 months

    • >250 drivers

    • Over 1.9 million miles, distance between penalty counts increased from baseline of 0.018 to high of 15.8 miles

    • Seatbelt violations from 13,500 to 4

  • The vendors of systems marketed today advocate effectiveness based on small-scale trials.

  • NIOSH will be reporting preliminary findings from their harness studies at the upcoming NHTSA-sponsored Ground Ambulance Safety Roundtable.

THOMCO EMS SAFETY NET SEMINAR, 2007


Another approach
Another Approach? means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

Aligning provider safety with patient safety.

THOMCO EMS SAFETY NET SEMINAR, 2007


Provider safety
Provider Safety means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Provider safety1
Provider Safety means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Patient safety
Patient Safety means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

THOMCO EMS SAFETY NET SEMINAR, 2007


Patient and provider safety together papst
Patient and Provider Safety Together (PaPST) means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • Integrating optimal patient care with optimal provider safety.

  • Preplanning ALS & BLS activities to occur during ‘natural’ lulls in call time.

  • Performing ALS skills early in the time sequence of a call when the provider is already out of the vehicle.

  • Engineering the vehicle interior so that routinely used equipment is safely within restrained reach of the provider.

THOMCO EMS SAFETY NET SEMINAR, 2007


Papst
PaPST means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

Task

Patient Safety +?

Provider Safety +?

Airway Accessed Prior to Transport

IV Access Prior to Transport

Infusion Pumps Checked at Originating Facility

Crucial Equipment Secured & Within Reach of a Restrained Provider

THOMCO EMS SAFETY NET SEMINAR, 2007


Papst1
PaPST means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • Even if harnesses are effective, there are costs to upgrade a fleet.

  • New technology diffuses slowly and every day we wait translates into additional injures and deaths.

  • We start by retraining providers in methods of managing the call environment (e.g., continuing education).

  • We establish policies and monitoring practices.

  • Ultimately, we incorporate PaPST-like concepts into our training curricula.

THOMCO EMS SAFETY NET SEMINAR, 2007


References
References means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • Available Upon Request

THOMCO EMS SAFETY NET SEMINAR, 2007


Coming soon
Coming Soon! means of reducing fatal and nonfatal injuries in motor vehicle crashes.”

  • In late May….

THOMCO EMS SAFETY NET SEMINAR, 2007


Thank you

Thank You!! means of reducing fatal and nonfatal injuries in motor vehicle crashes.”


THOMCO EMS SAFETY NET SEMINAR, 2007 means of reducing fatal and nonfatal injuries in motor vehicle crashes.”


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