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

1
(No Transcript)
2
Relative Risk of Injury and Death in Ambulances
and Other Emergency Vehicles

• Les R. Becker, Ph.D., NREMT-P
• Associate Research Scientist
• Public Services Research Institute
• Pacific Institute for Research Evaluation
• Calverton MD 20705

3
Acknowledgements

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

4
Introduction

• EMS response is a fundamental feature of EMS
  systems (Boyd et al., 1983).
• Ambulance crash studies have lagged behind the
  growth of EMS in the U.S.
• The first examinations of ambulance crashes began
  in the early 90s.

5
Overview

• Review of Early Studies
• Review of the PIRE Study
• Review of EMS Seat Belt Use
• Discussion of Prevention Approaches
• Proposal of a New Approach

6
Earlier Studies

• Auerbach (1987) studies a very small sample of
  Tennessee ambulance crashes
• Approximately 50 of vehicle-drivers and
  front-seat occupants were wearing occupant
  restraints
• Over one-half of prone stretcher patients were
  restrained
• 15 of bench seat and 100 of jump seat patients
  were wearing restraints.

7
We conclude that passenger restraints for both
ambulance attendants and passengers should be
mandatory and we suggest that traffic signals be
strictly heeded at intersections and speed limits
in urban settings be obeyed.
Auerbach et al., 1987
8
Earlier Studies

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

9
Earlier Studies

• Saunders and Heye (1993)
• San Francisco Public Health Department ambulance
  crashes
• Over 27 months

Locale Vehicle Type Collisions per 100-million miles traveled
All CA. All 213.2
SF Ambulances 13,333
10
Earlier Studies

• Four percent of 439 emergency medical technicians
  responding to a survey in New England reported
  that they had been involved in a crash (Schwartz
  et al. 1993)
• Sayeh et al. (1998) surveyed 2,672 EMTS in New
  England and Los Angeles.
• 37 in New England reported crash involvement
• 26 in LA reported crash involvement.

11
Earlier Studies

• Pirrallo and Swor (1994) compared emergency and
  non-emergency ambulance crash fatalities.
• Retrospective, cross-sectional, comparative
  analysis of 109 fatal crashes (126 deaths) from
  1987-1990 using FARS data
• NY, MI, CA and NC accounted for 37 of all fatal
  crashes.

12
Earlier Studies

• Pirrallo and Swor (1994) contd
• 69 occurred during emergency runs and 31
  occurred during non-emergency runs
• Most emergency run fatal crashes occurred between
  1200h and 1800h.
• Most non-emergency fatal crashes occurred when
  lighting conditions were poor.

13
Earlier Studies

• Pirrallo and Swor (1994) contd
• No statistically significant differences between
  emergency and non-emergency crashes based

Day of week Season Atmos. Conditions Roadway Surface Type
Roadway Alignment Relation to Junction Manner of Collision Year Manufactured
Vehicle Role Vehicle Maneuver Manner Leaving Scene Extent of Deformation
Violations Charged of Fatalities Roadway Surface Condition Speed Limit
14
Earlier Studies

• Biggers et al. (1996) studied one year of
  ambulance crash data in Houston.
• Driver history of a prior EMS vehicle crash was a
  key risk factor for future crashes.
• Drivers with a history of previous crashes were
  involved in 33 of all collisions.
• Five drivers accounted for 88.2 (15/17) of all
  injuries.

15
Earlier Studies

• Kahn et al. (2001) analyzed 1987-1997 FARS data
  and found that unrestrained rear occupants were
  most at risk for fatal and/or incapacitating
  injuries.
• Most crashes occurred at intersections
• Dry, straight, improved roads
• On clear days
• Striking a second vehicle
• 84 of the crashes involved fatalities
• 78 of the fatalities were not ambulance
  occupants

16
Our Work
17
Methods

• Merged 1988 through 1997 GES and FARS data
• Police, ambulance vehicles and fire trucks
• Modified KABCO scale
• No injury
• Possible/non-incapacitating injury
• Incapacity injury
• Fatal injury

18
Methods

• Ordinal logistic regression rather than separate
  odds ratio calculations
• Independent variables
• Vehicle type
• Response Mode
• Restraint Use
• Seating position
• Dependent variable
• Injury severity (KABCO score)

19
Results
20
Number of Crashes, 1988-1997
Fatal Non-fatal Total
Ambulance 305 36,693 36,998
Fire trucks 166 29,790 29,956
Police Cars 1,113 183,371 184,984
21
Number of Fatalities, 1988-1997
EVOs Others Total
Ambulance 74 286 360
Fire trucks 43 152 195
Police Cars 228 971 1,199
22
Number of Non-Fatals,1988-1997
EVOs Others Total
Ambulance 10,398 12,545 22,943
Fire Trucks 3,660 6,851 10,511
Police Cars 49,950 45,442 91,392
23
Injury Severity of Ambulance Occupants, 1988-1997
Fatal 71 (0.11)
Incapacitating 1,669 (2.70)
Possible/ Non-incapacitating 7,796 (12.62)
No Injury 52,248 (84.57)
Total 61,784
24
Incapacitating InjuriesBy Response, Restraint
Use Seating Position
Emergency Front R 390
U 13
Back R 5
U 531
Routine Front R 313
U 220
Back R 0
U 197
Total 1,669
25
Fatal InjuriesBy Response, Restraint Use
Seating Position
Emergency Front R 4
U 3
Back R 6
U 18
Routine Front R 7
U 6
Back R 8
U 19
Total 71
26
Relative Risks
27
Summary of Findings

• Unrestrained ambulance occupants involved in a
  crash had nearly 4 times greater risk of fatality
  than did restrained ambulance occupants.
• Unrestrained ambulance occupants involved in a
  crash had nearly 6.5 times greater risk of
  suffering an incapacitating injury than did
  restrained ambulance occupants.

28
Summary of Findings

• The risk of a fatality versus no injury for
  ambulance rear occupants was over 5 times greater
  for ambulance rear occupants than for front-seat
  occupants if involved in a crash.
• Ambulance occupants traveling non-emergency were
  2.7 times more likely than occupants traveling
  emergency to be killed if involved in a crash.

29
Summary of Findings

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

30
Conclusions

• Clearly, occupant restraints are not used
  consistently in ambulances.
• Unrestrained ambulance occupants, occupants
  riding in the rear compartment and especially
  unrestrained occupants riding in the rear
  compartment are at substantially increased risk
  of injury and death when involved in a crash.
• One prior study suggests that occupant restraints
  are more commonly used for patients than for crew
  members.

31
Implications for EMS Safety Practices

• Ambulance occupants, including providers, should
  use safety restraints whenever feasible.
• Individuals accompanying patients during
  transport should ride in the front seat of the
  ambulance whenever feasible.

32
SEAT BELTS PREVENTION
33
Prevention Fact!
34
The use of safety belts is the single most
effective means of reducing fatal and nonfatal
injuries in motor vehicle crashes. Dinh-Zarr,
Sleet, Schultz et al., 2001
35
Seat Belt Use in the U.S.
36
Seat Belt Use in the U.S.
37
Seat Belt Use in the U.S.
38
What do we know about seat belt use in EMS?
39
Perceived Need for Freedom
Cardiac Arrest 82
Chest Pain or Dysrhythmia 63
Shortness of Breath 38
Trauma 41
Cook et al., 1991
40
Seat Belt Use by Providers
Rarely Wearing Safety Belts (lt5 use) Always Wearing Safety Belts (gt95 use)
Routine front seat 3.7 74.0
Emergency front seat 3.9 80.6
Routine back compartment 59.4 7.0
Emergency back compartment 77.4 3.2
Larmon et al., 1993
41
Prevention Approaches

• The Three Es
• Education
• Engineering
• Enforcement

42
More Prevention Fact!
43
Single Approaches In Isolation are Rarely
Effective!
44
Solutions?

• Education
• EVOC
• Driving Simulators
• Engineering
• Speed regulators (governors)
• Black Box Approaches
• Harness Systems
• Enforcement
• Organizational policies and sanctions

45
Solutions?
46
Effectiveness?

• At least one small-scale study
• 36 vehicles over 18 months
• gt250 drivers
• Over 1.9 million miles, distance between penalty
  counts increased from baseline of 0.018 to high
  of 15.8 miles
• Seatbelt violations from 13,500 to 4
• The vendors of systems marketed today advocate
  effectiveness based on small-scale trials.
• NIOSH will be reporting preliminary findings from
  their harness studies at the upcoming
  NHTSA-sponsored Ground Ambulance Safety
  Roundtable.

47
Another Approach?
Aligning provider safety with patient safety.
48
Provider Safety
49
Provider Safety
50
Patient Safety
51
Patient and Provider Safety Together (PaPST)

• Integrating optimal patient care with optimal
  provider safety.
• Preplanning ALS BLS activities to occur during
  natural lulls in call time.
• Performing ALS skills early in the time sequence
  of a call when the provider is already out of the
  vehicle.
• Engineering the vehicle interior so that
  routinely used equipment is safely within
  restrained reach of the provider.

52
PaPST
Provider Safety ?
Patient Safety ?
Task
?
?
Airway Accessed Prior to Transport
?
?
IV Access Prior to Transport
?
?
Infusion Pumps Checked at Originating Facility
?
?
Crucial Equipment Secured Within Reach of a
Restrained Provider
53
PaPST

• Even if harnesses are effective, there are costs
  to upgrade a fleet.
• New technology diffuses slowly and every day we
  wait translates into additional injures and
  deaths.
• We start by retraining providers in methods of
  managing the call environment (e.g., continuing
  education).
• We establish policies and monitoring practices.
• Ultimately, we incorporate PaPST-like concepts
  into our training curricula.

54
References

• Available Upon Request

55
Coming Soon!

• In late May.

56
Thank You!!
57
(No Transcript)