**4. Ambulance operations**

The creation of a safe ambulance only goes so far in ensuring the safety of patients. A large onus belongs to the prehospital clinicians caring for the patient. The manner in which a vehicle is operated is paramount to ensure safety features function as designed. Speed, the use of lights and siren warning devices, and positioning of the vehicle at scenes are all things to consider.

#### **4.1 Traffic laws**

Many people falsely believe that just because an ambulance has lights and sirens they can ignore traffic laws related to speed, intersection control devices, and passing. That is not the case, however, and emergency vehicle operators should be familiar with their jurisdiction's laws. In New Jersey, for example, there is a statutory requirement that an emergency vehicle must be operated in a manner showing "due regard for the safety of all persons," but ambulances are missing from the "exemption from speed regulations" provision of NJ Code Title 39 [12]. In Pennsylvania, however, ambulances are specifically noted in their motor vehicle code. Per their state law, ambulances are prevented from exceeding speed limits or proceeding through traffic control devices or stop signs until they have come to a full stop and ascertained that they have been given the right of way [13]. All EMS clinicians should review their local rules and regulations to make sure they understand how they are allowed to operate in their jurisdiction. It should be noted, though, that just because an ambulance can operate in a certain manner does not mean that it should. There has been much discussion about improved patient outcomes when prehospital clinicians drive calmly, deliberately, and without speeding as this allows treatments to continue and for minimizing hemodynamic changes that can occur with excessive endogenous epinephrine release [14].

#### **4.2 Emergency warning devices**

One of the most serious risks in providing prehospital care is surprisingly not related to medical treatment, but rather how the patient is transported from the scene to the hospital. Though the use of lights and sirens (L&S) decreases response and transport times for just a couple of minutes on average, it increases the risk of ambulance crashes during response by 50% and threefold during patient transport [15]. Despite these statistics, a vast majority of responses and nearly a quarter of patient transports occur using L&S [14]. Not only does this pose a direct threat to the EMS clinicians and patients on board but also can cause delays in patient care, injure the public, ruin expensive essential equipment, and tie up resources that could otherwise be used elsewhere. In a joint position statement released by NAEMSP and various other organizations in 2022, it is advised that "L&S should only be used for situations where the time saved by L&S operations is anticipated to be clinically important to a patient's outcome" [9]. However, there are different factors that must be taken into consideration when discussing which circumstances require L&S in response to a call versus transport to a hospital.

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

Determination of response priority should be determined by standardized emergency medical dispatch protocols [16]. When writing and implementing these protocols, L&S should be reserved for medical conditions in which a few-minute delay in medical care would be detrimental to the patient's health. Such conditions include significant airway compromise, respiratory and cardiac arrest, loss of consciousness, advanced stages of shock, obstetrical emergencies, and severe trauma. Recent studies have shown these situations to be exceedingly rare [17]. Special exceptions to this standard may be made in situations where significantly delayed response is anticipated due to distance or traffic and the patient has a real potential to decompensate into one of the above categories due to the extended response. In addition to EMD protocols that reflect cautious use of L&S, it is also imperative that dispatchers are properly certified and receive continuing education, which enforces the necessity of keeping priority responses at a safe minimum [14].

Though L&S responses to scenes can be standardized, the utilization of L&S when transporting to the hospital is much less scriptable and statistically more dangerous [14]. When deciding whether or not to utilize L&S, an EMS clinician must quickly evaluate whether or not shortening the transport time by an average of three or four minutes would actually be beneficial [14]. In some cases, such as STEMIs, strokes, and trauma, early notification of the hospital of the impending arrival of the alert allows for advanced preparation leading to improvement in patient outcomes [18]. This time saving may allow for a non-L&S transport, during which the prehospital clinician maximizes medical treatment and stabilization of the condition without the increased risk of being involved in a motor vehicle accident. However, in situations where the patient is rapidly deteriorating or has significant airway compromise, the use of L&S during transport may be warranted. If the use of L&S is unavoidable, there are ways to optimize safety throughout transport.


While this list is not exhaustive, these are some steps that can improve the safety of using lights and sirens. No one step can totally remove the risk involved in L&S use, so agencies are encouraged to take a comprehensive quality improvement approach when it comes to decreasing the use of L&S during transport and response. Each agency needs to weigh the risks and benefits of L&S use and nonuse with other aspects of their system's operation and performance and decide how to proceed. The data are clear though, agencies provide safer care when there is a focus on decreasing the use of L&S, as such every agency should cut their use in some part of their operation [16].
