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					                                                                                           Emergency Medical Services
                                                                                             (EMS) Transport Safety
                                                                                                      This afternoon’s scope
                                                          To quote Steve “Sid” Caesar –     Key Issues
     Safety Strategies for EMS                            Director IHS ES                      • Where is the state of the art
               Fleets:                                                                         • What are the questions we need to ask
                                                                                               • Which are effective systems safety solutions
           What Works?                                    “We want everyone to get home     Future
                                                          safely each day”                     •   Goals
                                                                                               •   New technologies
                                                                                               •   Futuristic vehicles
                                                                                               •   New policies
Nadine Levick, MD MPH
Research Director, EMS Safety Foundation
                                                                                               •   New practices
CEO, Objective Safety                                                                          •   New Standards
New York, NY




      Emergency Medical Services                               EMS Safety Crisis                Firstly, the DANGER…
                 (EMS)
     An important and unique system                        "The Chinese word for           The state of EMS transport safety research is
                                                                                           an EMBARRASSMENT
       Public safety, public health and                     'crisis' (危機) is made          Lags at least 30 years behind general
                                                                                           automotive and transportation safety research
       emergency service                                              up of                Global EMS vehicle safety research is sparse
       Is there to save lives
       A more recent service compared to
                                                           the words 'danger' (危)          EMS Safety research is NOT EVEN ON THE
                                                                                           PLAYING FIELD of state of the art automotive
       Fire and Police                                     and 'opportunity' (機)"          safety research
                                                                                           ‘Reinventing the wheel’ – should be avoided at
                                                                                           all costs




         Then, The OPPORTUNITY                                        Firstly!
                                                                                               Your Interactive Handout
    This is vehicles, and this is transportation safety                                         awaits you online at…
    Vehicle and transportation safety technology
    and infrastructure exists
          drivers
    Ditto drivers, and driver safety technology
                                                           An accident ?                    www.objectivesafety.net
    Collaboration, and the multidisciplinary model
    Optimal use of very scarce resource                   or                                     This WILL be FAST!!
                                                                                          No need to take any notes – all text
                                                          a predictable and preventable
                                                                                          slides will be awaiting you in your
                                                          event                                     online Handout
  http://www.objectivesafety.net                 Real world answers to real world                               Emergency Medical Service
                                                           questions -                                                 Transport
                                               What policies offer the safest system?                          What are the transport safety issues that
                                               What features will enhance safety of ambulance                  pertain to this important public service
                                               vehicles?                                                       and public safety industry?
                                               What t h l i          ill ti i t        t f t
                                               Wh t technologies will optimize transport safety
                                               performance?
                                                                                                               What do we know of the risks and
                                                                                                               hazards and how can we measure these ?
                                               What color scheme is best for vehicles and staff
                                               to make it safest?                                              How can the safety of this transport
                                               What data should be collected when something                    system be optimized?
                                               goes wrong, and how to best analyze it?




A tragic emergency health care intervention        EMS Transportation Safety                                      A serious fleet and safety
                outcome
                                                        Key elements                                                     problem…
                                                                                                               Ambulance transport
                                                What is the appropriate data to collect?                        the most lethal vehicle on the road
                                                Which is the optimal method to capture it?                      both per mile travelled and per vehicle
                                                How do you identify and implement                               i exempt from federal safety oversight
                                                                                                                is       tf     f d    l f t        i ht
                                                appropriate solutions?                                          has the worst transportation safety
                                                                                                                data capture for any ground
                                                                                                                transportation system AND…..
                                                                                                                Is THE VEHICLE THAT COMES TO
                         It does happen….                                                                       RESCUE YOU ON THE HIGHWAY!!




                                                Ground Ambulance Transport Safety
                                                 IS Complex AND Multidisciplinary                                the EMS transport process
                                                        Epidemiological           Risk          Public          communications/dispatch
                                                        Data Collection        Management       Safety          the patient                                   T
                                                                                                                restraining device/seat                       I
                                                   Ergonomic
                                                    Research                                                    transporting device/gurney
                                                                                                 Transport                                                    M
                                                                                                   Policy
                                                                                                        y       paramedics/transport nurses, doctors & family
                                               Biomechanical                                                    patient monitoring equipment                  E
                                              Automotive Safety           Transport                             clinical care & interventions
                                                                                                     PPE
                                                                            Safety                              protective equipment
                                                                                                                                                              &
                                                Biohazard/Chem                                    Driver        the vehicle
                                                   Research                                      Training       the driver/driving skill
                                                                                                                other road users
                                                                                                                                                           PLACE
                                              Communications                                    Fleet Safety    the road
                                                                    Safety       Regulations
                                                technology                                       Program
                                                                  Technology    and Standards
Ambulance Transportation Safety                 Occupational transportation                                                                              2003 a problem...
                                                        fatalities..
                                                                                   Occupational transportation fatalities/100,000 workers
   Dispatch policy and procedures                                             12




                                                 fatalities/100,000 workers
   Vehicle Operations Safety                                                  10
                                                                              8                                                             EMS
   Vehicle Crashworthiness                                                    6                                                             Police

   Vehicle Ergonomics                                                         4                                                             Fire
                                                                              2
   Clinical care policies                                                     0

   Scene Safety
                                               WE HAVE A BIG PROBLEM HERE

                                          * Maguire, Hunting, Smith & Levick, Occupational Fatalities in Emergency
                                          Medical Services: A Hidden Crisis, Annals of Emergency Medicine, Dec 2002




                                             What do ambulance crashes
                                                    really cost ?                                                                                    EMS CANNOT afford to keep
      2007 a bigger problem
                                          Loss of life and injury                                                                                      paying out like this….
                                          Negative impact on EMS system
 2007 Insurance data –
                                          Collisions are the largest liability cost and
                                          exceeds malpractice or negligence
    27 fold more likely to have a claim                                             p   g
                                          Besides the direct financial costs of replacing a
   based on transport than related to     damaged ambulance and equipment, there are
   medical care                           additional hidden costs incurred:
                                              investigating the ambulance collision
                                              litigation /settlement/lawsuit
                                              medical/disability costs of injured EMTs
                                              hiring of new employees to replace injured personnel
                                              retraining and psychological counseling of personnel
                                              involved and others
                                              increased insurance rates




       So an ambulance is..                   Absence of standards and                                                                               Why is this crash different
                                                     oversight                                                                                        from every other crash
  Most lethal vehicle on the road per
  mile traveled
  >3 times more lethal per vehicle than      Challenges in identifying best practice
  other vehicles on the road                 Myriad of unregulated commercial
  Not designed by automotive engineers       products
  - nor are design features based on         No safety performance standards
  known automotive safety technology
  or ergonomic science                       Absent national safety oversight
  NO transportation systems oversight
                                                                Friday July 20th 2007...
     A devastating tragedy…                                  The worst ambulance crash in
In contrast to medical error – such as                               USA history
an ETT down the wrong hole which
may kill the patient and be a terrible
burden for the pts family and for the
medic involved
BUT an EMS crash can kill all involved
AND wipe out an EMS systems
response capacity……




              Jan 25th, 2008                                                                     Very Important Principle
                                                               EMS Transport Safety

                                                             ‘patient safety’                 Ambulance transport safety is
                                                             AND also                         part of a SYSTEM, the overall
                                                             ‘provider’ and ‘public safety’   balance of risk involves the
                                                                                              b l        f i ki   l     h
                                                                                              safety of all occupants and
                                                                                              the public




                  USA EMS                                            USA 1960’s                           History of EMS

  EMS Systems - >15,000                                                                       EMS is a relatively new industry
                                                                                              An unusual history of beginnings within the
  Personnel -   ~1 million
                                                                                              mortician industry.
   (~30% F/T professional & 70% volunteer)
                                                                                                 • Early ambulances were hearses, once motorized usually
  Vehicles -               50,000
                          ~50 000                                                                    Cadillac,
                                                                                                   a Cadillac a vehicle in which an occupant could be
  (Type I, Type II, Type III, Freightliners, ?motorcycles)                                         transported in the recumbent position

  Transports -            ~50 million                                                         Over the past 100 years, the sophistication of
   (to Emergency Depts ~ 50%, < 1/3 emergent)                                                 EMS medical care has advanced dramatically
  Cost -           ~$8 Billion annually                                                       EMS communications and transportation
                                                                                              technology have not kept up with that pace
  Safety Oversight -   ? Disparate
                1960 to 2007                                        Some recent adverse outcomes    UPS and Laundry trucks have
                  A passenger vehicle - sure
                                                                                                     very similar design and even
                                                                                                        more stringent safety
                                                                                                    requirements to EMS vehicles
                                   A ‘laundry or mail truck’ - ??                                                 BUT
                                                                                                       very different cargo……

                                                                                                      People are passengers and
              A passenger vehicle – yes!
                                                                                                       NOT packages or parcels




              Some odd facts                                                                               What is a survivable impact?
                                                                                                               E= ½ mv2      v2 = 2as
   Ambulances are generally not built by the
   automotive industry
   Intelligent Transportation Systems (ITS),
   transportation safety engineering is not
         p             y g            g
   generally integrated into EMS systems
   Although all EMS systems have medical
   direction and oversight, it is rare for there
   to be transportation expertise oversight
                                                                                                                 ~ 30 mph - survivable
                                                                                                   IRMRC




        What is a survivable impact?                                  A survivable impact??                 Thursday July 5th 2007……
           E= ½   mv2              v2 =    2as                                                             Paramedic Allan Parson’s killed




         ~ 60 mph – not survivable
IRMRC
“…I’d like to know what can be done
  so this never happens again….”               Transport oversight?                                Safety oversight of what and ….
                                                                                                              by whom
                                      In contrast to the bus and truck industries, which
                                      have -                                                         Vehicle Safety
                                        comprehensive safety oversight                               Vehicle Design
                                        transportation safety interventions
                                        transportation safety data capture via the Federal Motor
                                                                                                     Transportation systems safety
                                        Carrier Safety Administration (FMCSA)                        Safety Equipment Design
                                      EMS has been focused more as an acute health                   Vehicle and Safety Equipment
                                      care delivery and emergency medical service and
                                                                                                     Testing and Standard development
                                      largely outside of much of the other transportation
                                      oversight infrastructure that exists                           Safety policies




 There are more safety standards                    Why ISN’T EMS on the NTSB’s
for moving cattle than for moving                      “Most Wanted List”??                                Clinical Care?
            patients                                                                                   Occupational Health and
                                                                                                            Safety…..?

                                                                                                    This IS a Transportation and
                                                                                                    Automotive Safety issue
                                                                                                    This is a Systems safety issue




      … Nov 8th’s Fatality                           Jan 28th, 2008
                                  April 20, 2008..??                June 17th 2008
     April 14th, 2008
                                                            a paramedic and a patient killed




     In this vehicle…        October 31, 2008 - Kentucky   February 11, 2009 – North Carolina




April 30, 2009 - Tennessee
                                                              Arlington, Texas – June 18,
                                                                          2009
 Minnesota - June 20, 2009          Fatalities and funerals          Charged with Vehicular Homicide




2 counts of vehicular homicide…    An interhospital transport
    November 5, 2007 - PA             ? “Do no harm….”?                 EMS Transportation Safety
                                                                       Standards…. An oxymoron?




   October 2008 JEMS Article                                         Valuable information… EMS exempt
       “Rig Safety – 911”                     Goals


                                  Standards for safety

                                  Policy based on Science

                                  Databases to demonstrate outcome
           FMCSA - Exceptions                                                                            Canada - Corporate Manslaughter                                 EMS safety data estimates
Unless otherwise specifically provided, the rules do not
                                                                                                       Corporate Homicide Act: 8th April, 2008
apply to —                                                                                                                                                        In the USA*
  (f)(1) All school bus operations as defined in §390.5;
  (f)(2) Transportation performed by the Federal government, a State,
                                                                                                                                                                    ~ 50,000 vehicles
  or any political subdivision of a State, or an agency established                                                                                                 ~ 5,000 crashes a year
  under a compact between States
  (f)(3) The occasional transportation of personal property by
  individuals not for compensation nor in the furtherance of a
                          p
                                                                                                                                                                    ~ One fatality each week
  commercial enterprise;                                                                                                                                                 ~ 2/3 pedestrians or occupants of other car
  (f)(4) The transportation ofhuman corpses or sick                                                                                                                      Approximately 4 child fatalities per year
  and injured persons;                                                                                                                                              ~10 serious injuries each day
  (f)(5) The operation of fire trucks and rescue                                                                                                                    Cost estimates > $500 million annually
  vehicles while involved in emergency and
  related operations;                                                                                                                                               USA crash fatality rate/capita 35x higher than in
                                                                                                                                                                    Australia                   *FARS/BTS 2005-6




                                                                                                        Commercial vehicle comparisons                                   Ambulance Safety Research:
 Is it your service’s tragic year?                                                                                                                                              A New Field
                                                                                                         Estimates for ambulance fatality/mile traveled                                         Dan Berry
                                                                                                         are 3 to 50 fold the rate of large truck fatal                                         Transport Canada, Ministry of Health

                                                                                                         crashes                                                                        Turbell et         Best,
                                                                                                                                                                                                                             Levick Levick Levick Levick Levick Levick Levick
    ~ 50 fatalities a year                                                                                 Large trucks - 2.2 fatal crashes/100 million miles
                                                                                                                                                                 engineering            al,
                                                                                                                                                                                        Sweden
                                                                                                                                                                                                           Zivkovic,
                                                                                                                                                                                                           Ryan
                                                                                                                                                                                                                             et al  et al  et al  et al
                                                                                                                                                                                                                                        EMSC PED-SAFE-T
                                                                                                                                                                                                                                                         et al  et al  et al
                                                                                                                                                                                                                                                                   Levick Levick
                                                                                                                                                                                                                              Bull,
                                                                                                           traveled in 2005                                                                                                             Levick et al               et al  et al

    15,000 EMS services                                                                                                          09
                                                                                                           Ambulance - 7.7 to 109 fatal crashes/100 million
                                                                                                                                                / 00             ergonomic
                                                                                                                                                                                                                              Talty
                                                                                                                                                                                                                              et al
                                                                                                                                                                                                                                                       Graeve,
                                                                                                                                                                                                                                                    De Graeve
                                                                                                                                                                                                                                                                     Highnett
                                                                                                                                                                                                                                                                     et al
                                                                                                                                                                                                                                                                              Gilad
                                                                                                                                                                                                                                      Woodward,
                                                                                                                                                                                                                                      W d       d                                 l
                                                                                                                                                                                                                                                                              et al
                                                                                                           ambulance miles traveled                                                                    Saunders et al                 Fleeger et al Deroo, Calle        Johnson,
    Each year one in 300 EMS                                                                             Injury estimates                                        epidemiology NHTSA/
                                                                                                                                                                                                       FEMA
                                                                                                                                                                                                                      Biggers,
                                                                                                                                                                                                                                      Weiss, Maguire, al
                                                                                                                                                                                                                                 Calle,
                                                                                                                                                                                                                                 et alet al
                                                                                                                                                                                                                                                    et
                                                                                                                                                                                                                                              Hunting,MMWR
                                                                                                                                                                                                                                                            Becker, Lindholm,
                                                                                                                                                                                                                                                            Zaloshnja, Dowd
                                                                                                                                                                                                                                                            Levick, Li,
                                                                                                                                                                                    NTSB/ Auerbach          Pirrallo, Zachariah,      Kahn, Smith, NIOSH,Miller
    services experiences a fatality                                                                        37 truck crash injuries/100 million miles
                                                                                                                                                                                    EVOC et al              Swor      Pepe            PirralloLevick CDC
                                                                                                                                                                                                                                                                         Ray
                                                                                                                                                                                                                                                                         Kupas


                                                                                                           Ambulance estimates of crash injury of 308 to 4,360
                                                                                                           injuries/100 million ambulance miles traveled          1960      ‘70   ‘78       ‘86      ‘93 ‘95 ‘96 ‘98 2001 ‘02 ‘03 ‘04 ‘05 ‘06 ‘07
                                                                                                         Ambulance vehicle occupant crash fatality                        non                         ? safe                                              safer
                                                                                                         percentage is double that for large trucks.                     issue




              Predictable risks                                                                                                                                          So.. The real world for an EMS
                                                                                                               And very Predictable…                                     vehicle approaching a red light
Fatal crashes more often at intersections, & with another
vehicle (p < 0.001)*
70% of fatal crashes EMS crashes during Emergency Use*                                                                                                                    You think they heard you…
Most serious & fatal injuries occurred in rear (OR 2.7 vs                                                  Intersections are lethal environments
front) & to improperly restrained occupants (OR 2.5 vs                                                                                                                    You know they must have seen you..
restrained)**
82% of fatally injured EMS rear occupants unrestrained
                                            unrestrained**                                                                                                                And maybe they did
> 74% of EMT occupational fatalities are MVC related***
Serious head injury in >65% of fatal occupant injuries#                                                                                                                   ….. But..
More likely to crash at an intersection with traffic lights                                                                                                               There is NO way humanly possible
(37% vs 18% p=0.001) & more people & injuries/crash than
similar sized vehicles##                                                                                                                                                  that they could stop…..
                          *Kahn CA, Pirrallo RG, Kuhn EM, Prehosp Emerg Care 2001 Jul-Sep;5(3):261-9
                          **Becker, Zaloshnja, Levick, Li, Miller, Acc Anal Prev 2003
                          ***Maguire, Hunting, Smith, Levick, Annals Emerg Med Dec 2002
                          #NIOSH, 2003
                          ##Ray AM, Kupas DF, Prehosp Emerg Care 2005 Dec; 9:412-415
                            The real world                                                                  What is actually happening
    Intersection passenger car stopping distance*
                at 40 mph dry and wet
                                                                                                            during an ambulance crash
                                                                                                         Test 1 – Right side impact




                                                                                                                                          2
                                     44 feet                                                                              1
                                                                      Dry
                                                                      Stopped at
                                                                      176 feet                   1 – Target vehicle,
                                                                                                 Type I ambulance
              Perception + Reaction time            Vehicle Braking time (dry)                   2 – Bullet vehicle,
              Perception + Reaction time            Vehicle Braking time (wet)                   Type II ambulance
40 mph
                                                                                                 Closing speed 44 mph
                                                                                                                                 Johns Hopkins University
                                                                                   Wet
                                                                                   Stopped at
                                                                                   220 feet


* Stopping distance:
                                                  +
      Perception time + Reaction time + Vehicle braking time
     (varies with age, skill, agility, alertness + vehicle type, tire pressure, road etc)




And this all takes place in 60 millisecs                                                                         NOT new technical data…
         – the blink of an eye




                                                                                                      Richardson S.A., et al, Int. J. of Crash., 4:3, 239 – 259, 1999
                                                                                                Side facing 4-point harnesses demonstrated to be                        Side facing 4-point harnesses demonstrated to be
                                                                                                    lethal, even at slow ground vehicle speeds                              lethal, even at slow ground vehicle speeds




    Balance of concerns and risk                                                                                                                                                   EMS Driver issues
                                                                                                                          The Driver
          during transport

                                                                                                         Driver selection
                                                                                                         Driver monitoring and feedback
                                                                                                         Driver Impairment
                 Response and transport time
                 Clinical care provision
                                                                                                         Driver training
                 Occupant safety/protection
                 Public Safety
                                                    Fleet Driver Training… what really works?
Which is best, how many hours…??
                                                                                                           Innovation




                                                                                                EMS Association Policies -WEMSA
                   R&D                                Safety concepts out there now
          “Ripoff and Duplicate”                     Fleet Safety Management
                                                       Z-15
     Avoid reinventing the wheel at all                Driver monitoring and feedback
     costs                                           Enhanced ambulance vehicle design
                                                     Intelligent Transport Technologies - ITS
     Where are the best practices that we            Visibility and Conspicuity
     need to transfer knowledge from                 New Safety Standards




        WEMSA – October 2007                          WEMSA covered some key and                         ASSE September 2007,
                                                    important policies and procedures                 Fleet Forum November 2008
                                                                                                    and NIOSH/OSHA February 2009,
                                                                  But….
                                                                                                            Its not magic…..
1.   Emergency Vehicle Operations Policy
                                                    What about hours of service?
2.   Vehicle operations training and evaluation
3.   A program of graduated driver responsibility   What about visibility at the scene? For
4.   Drivers only age 25 and over
                                                                      vehicles ?
                                                    providers and the vehicles…?
5.   Complete stop at an intersection               What about protective equipment?
6.   Restricted use of Red Lights and Sirens        What about ambulance design safety?
7.   Monitoring of emergency vehicle operations     What about reporting of adverse events?
     American National Standard                                                                                           Z15 Incident Rates
       ANSI/ASSE Z15.1-2006
                                                        What Z15 encompasses                        Incident rate based on number of vehicles operated:
                                                                                                     Incident rate = Number of incidents x 100
Safe Practices for Fleet Motor Vehicle Operations   Safety Program                                                    Number of vehicles


                                                    Safety Policy                                   Incident rate based on vehicle mileage:
                                                                                                     Incident rate = Number of incidents x 1,000,000
                                                    Responsibilities and Accountabilities                                Vehicle mileage

                                                                                                    Injury incident rate based on vehicle mileage:
                                                    Driver Recruitment, Selection and                   Injury incident rates, the most frequently used indicator of incident severity, are useful for tracking events
                                                                                                        th t h     the t ti l to ff t financial or operational performance of th operating unit.
                                                                                                        that have th potential t affect fi     i l         ti   l    f          f the       ti      it
                                                    A
                                                    Assessment  t                                    Injury incident rate = Number of incidents with injury x 1,000,000
                                                                                                                                   Vehicle mileage
                                                    Organizational Safety Rules
                                                                                                    Incident rates based on service activity:
                                                    Orientation and Training                            Motor vehicle operations that pose injury risks other than those associated with driving should also use
                                                                                                        the service activity as the basis of a safety performance rate. The number of deliveries, stops, or loads
                                                                                                        should be considered as appropriate indicators of performance.
                                                    Reporting Rates and Major Incidents to            Incidents per 10,000 transports = Number of incidents x 10,000
                                                                                                                                          Number of transports
                                                    Executives
                                                                                                    Vehicle injury rates based on work hours:
                                                    Oversight                                         Vehicle incidents per 200,000 hours = Number of incidents x 200,000
                                                                                                                                          Number of hours worked




  ISO 39001 – Being developed                       ISO 39001 - Principles of RTS                         Road Safety at Work Library
                                                                                                  http://www.geolibrary.org/library/default.aspx?CategoryID=627
                                                       management systems
                                                         a) Focus on loss of life and health
                                                         b) Holistic view
                                                         c) Focus on results
                                                         d) Leadership
                                                         e) Process approach
                                                         f) Continual improvement
                                                         g) Best available information
                                                         h) Transparent and inclusive process
                                                         i) Tailored implementation
                                                         j) Systematic and structured
                                                         k) Part of decision making




        UPS: The ‘Big Brown’                            BHP - Key learnings for the                       Safety Improvement Roadmap
                                                           organization were:
                                                    Fatalities often have similar underlying
 No left turns – instead make three rights          causes
 Don’t back up
                                                      g                p     g
                                                    High near miss reporting often correlates
 Don’t employ any drivers under 25 years
 Don t                                              with declining injuries or fatalities
 of age
 Don’t employ anyone with a history of              Leadership visibility in the field is vital
 driving convictions
                                                    Hazard identification and risk awareness
                                                    are fundamental to success.
What about changing driver                         Real-time invehicle telematics
behavior in the real world??                         feedback and monitoring                              Purpose of ‘Telematics Real –
                                                                                                          time Feedback box’ Program
                                                   Not a “black box”
                                                   Driver feedback operates instantly, in                   Enhance Safety
                                                   real time and automatically as thresholds                Improve Driver Performance
                                                                h d
                                                   are approached                                           Save Maintenance Dollars
                                                   No manual component to identify                          Aid Accident / Incident Investigation
                                                   hazardous performance
                                                   Data downloads wirelessly
                                                   IS effective form of driver monitoring –
                                                   but also is a TRAINING device




                                                               MEMS Snapshot                              Graduated implementation for
     How the Device Works
                                                                                                                  evaluation
 Computerized monitoring device installed
                                                   Serve 500,000 people in Little Rock area                Phase I-
 on each vehicle to measure parameters
                                                   Deploy 29 units daily                                     Blind data - no growls or tones, no ID
 Each driver has individual key “fob”
                                                   58,000 calls per year                                     capture
 Data collected every second
   including: vehicle speed and                    2,400
                                                   2 400 square mile service area                                II-
                                                                                                           Phase II
    performance, driver behaviors                  195 full time / 75 part time uniformed                    Warning growls and penalty tones only
    and emergency mode                             employees
                                                                                                           Phase III-
 Auditory feedback of warning                      1.9 million miles annually
 ‘growls’, and penalty tones                                                                                 Fully operational, identified data capture
                                                   Mean response time: 6 minutes
 Data downloaded automatically every day




                   Pilot 1                                              Pilot 1                                             Pilot 1
Parameters monitored                              A fleet of 36 ambulances, 250 drivers and
                                                  1.9 million miles of vehicle operations were            Parameters are monitored every second
  Vehicle speed, cornering, seat belt use, back                                                             • Penalty counts for exceeding these parameters
  up spotters
                                                  monitored by the system for 18 months.                      are recorded, stored on an on-board computer
                                                     • Blind data collected from March 2003 for 3/12          and downloaded daily to a base station for
  Use of lights and sirens                           • Identified data captured with the system fully         analysis and reports generated.
                                                                                                                   y         p     g
  Miles t    l d
  Mil traveled                                         operational from June 2003.
Penalty counts for exceeding parameters           The parameters measured are –                           Response times and fiscal balances
are recorded, stored and downloaded                  • Speed against user set limits – both hot & cold    were reviewed pre and post
daily for analysis and reports generated             • Cornering velocity, g-forces, hard                 implementation of the monitoring and
                                                       braking/acceleration                               feedback system
Response times and fiscal balances were              • Use of seat belts, lights & sirens, turn signals
reviewed pre and post implementation                 • Parking brake, back up spotters
                      MEMS Settings Pilot 1                                                                    Initial Demonstrated Effectiveness                                                                                                                                                                                                                                                                                                                                   Sustained Effectiveness - speed
                                                                                                                                                                   MEMS MONTHLY OVER SPEED VIOLATION TREND 2003/2004
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  MEMS - Overspeed Violations per Month
                                                                                                               600,000
                                                                                                                                            550,353
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   600,000
                                                                                                               500,000


                                                                                                                                                                                                                                         Series1
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       550,353
                                                                                                               400,000

             Speed - 15 second warning period                                                                  300,000                                                                                                                                                                                                                                                                                                                                                             500,000

                Non Emergency 74 / 78 mph                                                                      200,000
                                                                                                                                  216,922             179,721


                                                                                                                                                                                                                4,046
                                                                                                               100,000

                Emergency     84 / 88 mph                                                                           0
                                                                                                                                                                2,074
                                                                                                                                                                             1,609
                                                                                                                                                                                          285
                                                                                                                                                                                                      547
                                                                                                                                                                                                                                  207        407
                                                                                                                                                                                                                                                        710        780
                                                                                                                                                                                                                                                                              3,069
                                                                                                                                                                                                                                                                                            1,004       1657
                                                                                                                                                                                                                                                                                                                           2709                                                                                                                                                    400,000


             Cornering - warning at 25%




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                                                                                                                                                                                                 m




                                                                                                                                                                                                                          m




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                                                                                                                                                                                                            ct
                                                                                                                    M




                                                                                                                                                                                                                                                                         M
                                                                                                                                                                                                te




                                                                                                                                                                                                                        ve




                                                                                                                                                                                                                                                           F eb
                                                                                                                                                                                                                                                Ja
                                                                                                                                                                                                                                   Dec
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              25




                                                                                                                                                                                                            O
                                                                                                                                                                                           Sep




                                                                                                                                                                                                                     No
                                                                                                                                                                                                                     MONTH                                                                                                                    MEMS ABC Miles Per Month
                                                                                                                              I             II                   III                                                                                                                                                                                                                                                                                                               300,000




                                                                                                                                                                                                                                                                                                                                                                                                                                                                 2
                                                                                                                                                                                                                                                                                                                                                                                                                                                            19 .3
                Low Over Force - 39%




                                                                                                                                                                                                                                                                                                                                                                                                                                            17 .49
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              20




                                                                                                                                                                                                                                                                                                                                                                                                                 17 .43


                                                                                                                                                                                                                                                                                                                                                                                                                                   16 .61
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        216,922




                                                                                                                                                                                                                                                                                                                                                                                                                                                      .76
                                                                                                                                                                                                                                                                                               3




                                                                                                                                                                                                                                                                                                                              3




                                                                                                                                                                                                                                                                                                                                                                                                                          15 .25
                                                                                                                                                                                                                                                                                           15 .84




                                                                                                                                                                                                                                                                                                                                                                                                                                                     15
                                                                                                                                                                                                                                                                                                                          14 .82
                                                                                                               I – blind data, no growls




                                                                                                                                                                                                                                                                                                                                        9




                                                                                                                                                                                                                                                                                                                                                                                                                                                                     13 .11
                High Over Force - 55%




                                                                                                                                                                                                                                                                                                                                    .42
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              15   200,000




                                                                                                                                                                                                                                                                                                        9
                                                                                                                                                                                                                                                                                                    12 .05




                                                                                                                                                                                                                                                                                                                                   13
                                                                                                                                                                                                                                                                                                             9. 94
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        179,721




                                                                                                                                                                                                                                                                                                                                               9




                                                                                                                                                                                                                                                                                                                                                                                  9. 61
                                                                                                               II – growls & tones ON




                                                                                                                                                                                                                                                                                                                                          9. 31


                                                                                                                                                                                                                                                                                                                                                           9. 41




                                                                                                                                                                                                                                                                                                                                                                                                         9. 27
                                                                                                                                                                                                                                                                                                                                                                                                 7. 57
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              10
             Seat Belt Distance




                                                                                                                                                                                                                                                                                                                                                                          8. 39
                                                                                                                                                                                                                                                                                                                                                   7. 24


                                                                                                                                                                                                                                                                                                                                                                   6. 9
                                                                                                                                                                                                                                                                                          4
                                                                                                                                                                                                                                                                                      5.24
                                                                                                               unidentified data capture                                                                                                                                                                                                                                                                                                                                                                                                                                    75,242




                                                                                                                                                                                                                                                                                                                                                                                                         9
                                                                                                                                                                                                                                                                                                                                                                                                     4.28
                                                                                                                                                                                                                                                                                    886
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   100,000




                                                                                                                                                                                                                                                                                                                                                                                          2.27
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              5




                                                                                                                                                                                                                                                                               4 3.
                2 / 10ths mile                                                                                 III – identified data




                                                                                                                                                                                                                                                                  March 0.018

                                                                                                                                                                                                                                                                    May 0.04
                                                                                                                                                                                                                                                                   April 0.017
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         11,243                                                  13,958
                                                                                                                                                                                                                                                                                                                                                                                                                                                                              0                                  547             710              3,207   1,096   567 765 376        834   375        412




                                                                                                                                                                                                                                                                    July




                                                                                                                                                                                                                                                                                                                                           January




                                                                                                                                                                                                                                                                                                                                                                     July




                                                                                                                                                                                                                                                                                                                                                                                                                  *January 2005
                                                                                                                                                                                                                                                                 August




                                                                                                                                                                                                                                                                                                                                                                                                    August
                                                                                                                                                                                                                                                                                                              November




                                                                                                                                                                                                                                                                                                                                                                                                                      November
                                                                                                                                                                                                                                                                                                                                          February




                                                                                                                                                                                                                                                                                                                                                                                                                       February
                                                                                                                                                                                                                                                                   June




                                                                                                                                                                                                                                                                                                                                                                    June
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                                                                                                                                                                                                                                                                                                                                                                                                                                                      May
                                                                                                                                                                                                                                                                                                                                            March




                                                                                                                                                                                                                                                                                                                                                                                                                                                     March
                                                                                                                                                                                                                                                                                                                                                                    April




                                                                                                                                                                                                                                                                                                                                                                                                                                                      April
                                                                                                                                                                                                                                                              September
                                                                                                                                                                                                                                                                                                                October

                                                                                                                                                                                                                                                                                                              December




                                                                                                                                                                                                                                                                                                                                                                                                 September
                                                                                                                                                                                                                                                                                                                                                                                                   October

                                                                                                                                                                                                                                                                                                                                                                                                                     December
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       -




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   3

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              3

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             4

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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             5

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           05


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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             6

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             6
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  3




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            4




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            5




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            6
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Sustained Effectiveness – seat belt                                                                                                                                             MEMS - Percent of Drivers Below Standard
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      And when a rare crash happens….
                                                                                                                50
                               MEMS - Seatbelt Violations per Month                                                                                   46
                                                                                                                45
                                                                                                                                                                                                                                             41
16,000
                                                                                                                40                                                                                                                                   39
             13,884                                                                                                                                                                                                     35
14,000                                                                                                          35
                                                                                                                                                                                                                29                                          33
12,000                                                                                                          30
                                                                                                                                                           28
                                                                                                                                                                                                                                                                                                                           25
                                                                                                                25
  ,
10,000                                                                                                                                                                                               20                       25                                                                                                                                                  22
                                                                                                                                                                                                                                                                   20                                                                       19                                                       20
                                                                                                                                                                                18
                                                                                                                20
                                                                                                                                                                   18
 8,000                                                                                                                                                                                                                                                                                                  19
                 7,621                                                                                          15                                                                                                                                                                                                                                                          15
                                                                                                                                                                                                                                                                                  15                                                                                                                                      15
                                                                                                                                                                                                                                                                                                                                                           14                                                                                               14
 6,000                                                                                                                                                                   13                             12
                                                                                                                10

 4,000                                                                                                             5
                 3,624
                                                                                                               -
 2,000
                                                                                                                           3




                                                                                                                                                                    4




                                                                                                                                                                    4




                                                                                                                                                                                                                                                                5




                                                                                                                                                                                                                                                                5




                                                                                                                                                                                                                                                                                                                                                                   6




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                                                                                                                                                                   3

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                                                                                                                                                                   4


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                                                                                                                                                                                                                                                               4




                                                                                                                                                                                                                                                               5


                                                                                                                                                                                                                                                               5




                                                                                                                                                                                                                                                                                                                                                                  5

                                                                                                                                                                                                                                                                                                                                                                  5




                                                                                                                                                                                                                                                                                                                                                                  6


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                                         10           17
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                                                                11   15   11
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                           4         8        6   4        23                                   15   14
   -                                                                                      4 4
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               4

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                               Unit 302 Accident                                                                                                                                                                                                                                                                                                                                                                                                                                                Implementation Environment
                                                                                                                                                                                          Results Summary
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          Pilot 2
                                                                                                                         Implementation was well received by the providers.
                                                                                                                         Over 1.9 million miles of vehicle operations recorded.
                                                                                                                         Performance improved from a baseline low of 0.017 miles                                                                                                                                                                                                                                                                                                       CAC deploys 13 units daily, covers
                                                                                                                         btw penalty counts (>56 counts/mile) to a high of 15.8                                                                                                                                                                                                                                                                                                        450,000 miles annually
                                                                                                                         miles btw penalty counts.
                                                                                                                         Seatbelt violations dropped from 13,500 to 4                                                                                                                                                                                                                                                                                                                  CAC has 20 Emergency Vehicles and 11
                                                                                                                         20% cost saving in vehicle maintenance within 6 months.                                                                                                                                                                                                                                                                                                       Non-emergency Vehicles
                                                                                                                         No increase in response times
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Mean response time of 11 minutes
                                                                                                                         Fewer crashes and less severe crashes - Only one vehicle
                                                                                                                         mishap                                                                                                                                                                                                                                                                                                                                                        152 drivers
                                                                                                                         Sustained improvement in safety proxies over 18 months,
                                                                                                                         with no inservice or retraining after the initial introduction
                                                                                                                         period.
  Graduated implementation for                             Auditory alarm warning thresholds
                                                                         Pilot 2                                                     Demonstrated Results
          evaluation
                                                          Speed                       10 second warning period                  Over 950,000 miles of vehicle operations
    Phase I-                                                               Low Speed - 73 / 78 mph                              were recorded
                                                                          (LSCOUNT)
        Blind data - no tones, no ID capture                                                                                    Major reduction in high over speed penalty
                                                                           High Speed - >79 mph
        11/1/04 to 4/30/05                                               (HSCOUNT)                                              counts
                                                                                                                                  14.94 penalties/mile in Phase I
    Phase II-                                             Cornering                      warning at 25%
                                                                                                                                  0.00003 penalties/mile in Phase III.
        Warning and penalty tones only                     Low Over Force (LFCOUNT) - 38%
                                                                      High Over Force - 48%                                     Major reduction in seatbelt violations
        5/1/05 to 6/30/06                                                                                                         4.72 violations/ mile traveled in Period I
                                                                         (HFCOUNT)
    Phase III-                                                                                                                    0.001 violations/ mile traveled in Period III a fold
                                                          Reverse Count                  -    1 count for each time vehicle       reduction in seat belt violations
        Fully operational, identified data capture                    (RVCOUNT)         is placed in reverse without
        7/1/06 to 8/31/06                                                               engaging reverse spotting switch        Similar trends were seen in low over speed
                                                          Seat Belt Distance             -    1/10th mile                       and over force parameters
                                                                     (SBCOUNT)               with no belt secured




                     Results                                           Response times                                                             Crashes
                    Phase I
                    11/01/04-
                                  Phase II
                                  05/01/05-
                                              Phase III
                                              07/01/06-
                                                             There was no increase in average
                       04/30/05   06/30/06    08/31/06       response times during the study                                   There were:
Distance -miles     193,210       682,320     75,957
                                                             period:                                                            19 vehicle incidents in 2004
LSCOUNT             89,250        100,195     96
[LSCOUNT/mile]      [2.16]        [0.15]      [0.001]          11:14 minutes in 2004
HSCOUNT             12,936        14,448      2                                                                                 11 in 2005
[HSCOUNT/mile]      [14.94]       [0.02]      [0.00003]
                                                               10:36 minutes in 2005
LFCOUNT             37,347        64,328      1,250            10:46 minutes in 2006
                                                                                                                                no major vehicle crash during the fully
[LFCOUNT/mile]      [0.19]        [0.09]      [0.02]                                                                            implemented phase of the study period.
HFCOUNT             552           1,210       56
[HFCOUNT/mile]      [0.003]       [0.002]     [0.001]          suggests a moderate overall improvement
RVCOUNT             15,697        69,779      7,100            in response times during the study period.
[RVCOUNT/mile]      [12.31]       [0.10]      [0.09]
SBCOUNT             40,893        45,366      90
[SBCOUNT/mile]      [4.72]        [0.07]      [0.001]




              Direct Cost savings                                                                                             A key to safe ambulance transport
                                                             Extensive Indirect cost savings

       Decreased crashes                                      Fewer out of service vehicles
       Cost saving in vehicle maintenance                     Improved transport times
       expenses:
         p
                                                              Decreased administrative lost in
           $271,091in 2004
                                                              managing unsafe behaviors
           $242,965 in 2005
                                                              Decreased legal burden
           $237,193 in 2006
                                                              Automatic system wide data
                                                              Insurance benefits
                                                  Monitor and feedback device in
              Limitations                                                                             Demonstrated clearly
                                                            summary
                                                   The system works
No categorization of type/severity of crash
                                                   Has objectively improved performance
Variable performance and exposure data per                                                        Driver risk behavior can be modified
individual providers                               No increase in response times
                                                   At fault accidents reduced                     and improved with monitoring
Unique environment may not be uniform across                                                             ,                      y
                                                                                                  device, with real time auditory
EMS services or generalizable                      Now accepted into the culture
                                                    However:                                      feedback.
No metric exists to provide a performance
measure of the safety or risk exposure of an       The system requires monitoring
EMS system – which may differ depending on         Must be reinforced by management
environment, transport hazards, call incidence     Rewards for good safety performance
and frequency, driver training and age..           Consequences for poor performance




                                                 Intelligent Transport Safety Systems
 Demonstrated Effectiveness
                                                                                                  Visibility and lighting issues
  Change driver behavior
  Carrot not stick
  Vehicle maintenance improvement
  Decreased administrative burden
  Insurance benefits


                                                                               Prevent IP, 2005




 Policy and practice ignorant of                                                                  Emergency Vehicles – Viewer
  existing technical safety data                                                                         Awareness
 X                                      X                                                         For a timely, appropriate and safe response

                                                                                                    Location
                                                                                                    Size
                                                                                                    Shape
                                                 “Anything that lengthens                           Speed
                                                  reaction time increases the                       Intended path
                                                  chance of an unwanted
                                                  event”     Stephen Solomon
                                                              But whatever color …. If you run       Color-blindness affects 10% of the
                                                              a red light someone will be killed                population




                                                                                                       As seen with normal vision




          Full vehicle outline with direction                                                          As seen with color blind vision




 Help has arrived !! Worker visibility Act:                         Not rocket science..
           November 24th 2008
                                                                                                    This addresses some very real risks,
                                                                                                    very creatively – and currently ONLY
                                                                                                       available in London Ontario!




“ The multicolored (patterned) ambulance while distinctive,
may suffer decreased conspicuity because of the effects of
        camouflage” De Lorenzo & Eilers Annals EM 1991
                                                                 International approaches                  EMS Safety Foundation
                                                                                                    Innovation, collaboration & knowledge transfer
                                                              The state of the art non-USA




               X
                                                              vehicles have NO squad bench nor
                                                              the after market structural vehicle
                                                              modifications that can potentially
                                                                        crashworthiness integrity
                                                              decrease crash orthiness integrit
                                                              that were seen in study vehicles.
                                                                                                             Vehicle Occupant Safety design
                                                                                                           European design
                                                                                                           Safety technology
                                                                                                           is a key focus




Safe and Ergonomic design                                                                                   Ergonomic layout and equipment




                                Safety first - Passive Safety                                                     Is safety crash tested by
                                                                                                                     automotive experts



                            Fold-in ridges on subframe       Front axle module


                                                            • A main feature in a front-end crash is the
                                                              "disconnectable" front axle, which
                                                              releases additional deformation zones in
                                                              the longitudinal frame member when a
                                                              particular force level is reached.
                                                            • On a frontal crash, transmission and
                                                              engine will be pushed underneath front
                                                              occupants.
                            Front axle module after crash
Unlike this vehicle                                            Were we safer in the Cadillac???
                                     So….
                       Which vehicle do you want to be in ?
                       Which vehicle is the best for
                       efficient and effective patient care?
                       efficient,
                       Which vehicle provides optimal risk
                       management ?
                       What is the optimal fleet mix?




     Fleet Mix ?      No need to reinvent the wheel...         Transportation Research Board is an
                                                                excellent resource… we should be
                                                                             using it!!




                         Tips for Emergency Vehicle             USFA Emergency Vehicle Safety
March 2007 - FHWA
                                  Operations                             Initiative
Traffic Incident Management Systems                             Risk/Hazards
                 (TIMS)                                                                                    What you can do now

 Released April 2008                                    Predictable risks                            Have a written and implemented ‘safety program’
 FEMA, USFA, IFSTA                                      Predictable fatal injuries                   Secure all equipment
 Covers setting up                                                                                                p
                                                                                                     Secure occupants with standard belts
                                                        Serious occupational hazard
 safe roadway incident                                                                               Don’t drive through red lights/stop signs
 work areas and using                                   Public safety hazards
                                                                                                     Use properly implemented “Telematics”
 unified command at
 these incidents




  What do we know works…                                  Important Principles !                          Very Important Principle
                                                 1.   A culture of safety
 Vehicle Operations Safety Policies
                                                 2.   Drive cautiously                                 Ambulance transport safety is
 Squad bench lap seat belts
                                                 3.   Wear your belts & restrain all occupants
 Patient over the shoulder belts                                                                       part of a SYSTEM, the overall
                                                 4.   Secure all equipment
 S     i       i
 Securing equipment  t                                                                                 balance of risk involves the
                                                                                                       b l        f i ki   l     h
 Forward and rear facing seating                 5. Integrate scientific data into your
                                                    policies and procedures                            safety of all occupants and
 Telematics feedback devices
                                                                                                       the public
 Safety awareness
                                                      - Unrestrained occupants and equipment
 Cultural change                                      are a potential injury risk to all occupants




  small changes can make a
                                                                   Summary                                     Thank you!
     BIG DIFFERENCE
                                                  Transport systems engineering and
                                                  human factors safety hazards are serious
                                                                                                             Any Questions??
                                                  issues in EMS transport injury and fatality         a .pdf handout of this presentation awaits you
PREPARE – TEACH – REACH – RESPOND                                                                                         online
 Look at your own safety record
                                                  Ambulance transport is devoid of                              www.objectivesafety.net
                                                  acceptable safety standards, and national
 Teach safety and hazard awareness                oversight and minimally addressed by
 Reach out with safety information to all your    any meaningful data
 EMS providers
 Respond with the best safety practices           Transport safety technologies exist and
                                                  have been demonstrated to have a
                                                  substantial and sustained improvement in
                                                  safety performance

				
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