**3. Ambulance configuration**

One of the first aspects of safety to consider is the design of the ambulance. These vehicles serve their communities by responding to emergency calls and transporting patients to the hospital, so ensuring they operate appropriately and safely is vital to the nation's EMS systems. Whether it is how they are visible to other drivers, how their lights and sirens are configured for emergency responses, how necessary equipment is stored, or how the patient is secured inside the vehicle, there are standards that exist to describe how to safely design an ambulance. These standards are described in detail in this chapter.

While ambulance design and configuration can be viewed as an occupational safety initiative intending to keep our EMS clinicians safe, it also serves as a patient safety consideration as well since these vehicles deliver life-saving care and transport our patients [4, 5]. The absence of an ambulance at a scene or an unnecessary delay can result in worse outcomes for some time-sensitive conditions that the patient is experiencing. Likewise, the patient can be seriously injured inside the ambulance in the event of a crash or stretcher loading mishap**.** For this reason, aspects of ambulance configuration will be discussed to emphasize their importance for patient safety.

There are 3 main recognized ambulance configuration standards: (1) Federal Specification for Star-of-Life Ambulances (KKK-A-1822(F)) published by the United States General Services Administration; (2) National Fire Protection Agency (NFPA) 1917: Standard for Automotive Ambulances; and (3) Commission on Accreditation of Ambulances Services (CAAS) Ground Vehicle Standards (GVS). These are generally referred to as K-Specs, NFPA 1917, and GVS, respectfully, and this nomenclature

#### *Patient Safety in Emergency Medical Services DOI: http://dx.doi.org/10.5772/intechopen.108690*

will be used in this document. It is important to note the K-specs undergo annual updates posted as separate notices and not attached to the published standard document, whereas the other documents are updated occasionally, and the full published document is updated. This fact makes interpretation and understanding K-spec more difficult than other standards due to the need to review and cross-reference different documents.

While these three organizations publish separate but similar standards, it is rarely up to the individual agency to decide which standard to follow. Since EMS is regulated at the state level, each state decides which standards ambulances must follow. The National Association of State EMS Officials (NASEMSO) developed a project called SafeAmbulances.org through a grant from the National Institute of Standards and Technology (NIST) in 2015 that outlined how different states handle these regulations and provided a background of how each of the backgrounds developed. **Table 1** below shows a breakdown of how many states require each standard in the regulations [6]. It should be noted that CAAS and NFPA have fees associated with their organization and as such, no states require only one of these organization's standards, typically allowing a choice to utilize them if an organization wishes to. GSA K-specs are by far the most popular with over half of the states requiring at least this standard. Lastly, for those states that utilize their own state-specific standards, many employ at least some of the K-spec standards as the foundation [6].

Perhaps the largest change in ambulance safety configuration occurred in 2015 when the GSA adopted a new standard published by the Society of Automobile Engineers (SAE). This new standard, SAE J3027, changed the allowed amount of movement for a stretcher in the event of a frontal impact. Through years of analyzing crash data involving EMS units and creating their own simulated crashes, this organization took steps to make sure that all patients are protected in the event of an ambulance crash [7]. As a result of this change, the old stretcher mounting system was no longer compliant with K-spec standards since the SAE specification is noted in the K-spec standard. At the same time, SAE's new standard also recommended changes to the restraint system on the stretcher itself, which is a huge advancement for the safety of patients as these standards actually considered the varying sizes of the US patient population to ensure ergonomically efficient standards [8]. The pairing of these two changes together ensures that patients, when properly restrained, minimize their risk of injury from dislodgement of the stretcher or breaking free from the restraints.

Nosocomial infections represent a significant burden to the healthcare system, as they are associated with increased mortality, length of stay, and costs [9]. One systematic review identified a high prevalence of organisms, commonly associated with these nosocomial infections [10]. Because of this impact, an important aspect of the design of ambulances is infection prevention. Specifically, all 3 standard-setting organizations have requirements for materials that can and cannot be used inside the vehicle. To prevent cross-contamination between patients, the inside of the ambulances may not contain "absorbent material such as carpeting, fabric, or indoor/outdoor plastic-type


**Table 1.** *Ambulance safety standards breakdown.*

carpeting, that resists cleaning and decontamination" [11]. From the design of the structure to the materials used inside the ambulance, all these complex standards contribute to keeping Americans safe while receiving care inside ambulances.
