THOMCO EMS SAFETY NET SEMINAR, 2007. Relative Risk of Injury and Death in Ambulances and Other...
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Transcript of THOMCO EMS SAFETY NET SEMINAR, 2007. Relative Risk of Injury and Death in Ambulances and Other...
THOMCO EMS SAFETY NET SEMINAR, 2007
Relative Risk of Injury and Death in Ambulances and Other Emergency Vehicles
Les R. Becker, Ph.D., NREMT-PAssociate Research ScientistPublic Services Research InstitutePacific Institute for Research & EvaluationCalverton MD 20705
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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 90’s.
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
“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
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
Earlier Studies
• Pirrallo and Swor (1994) [cont’d]:– 69% occurred during emergency runs
and 31% occurred during non-emergency runs;
– Most emergency run fatal crashes occurred between 1200h and 1800h.
– Most non-emergency fatal crashes occurred when lighting conditions were poor.
THOMCO EMS SAFETY NET SEMINAR, 2007
Earlier Studies
• Pirrallo and Swor (1994) [cont’d]:– 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 Manufact
ured
Vehicle Role
Vehicle Maneuver
Manner Leaving Scene
Extent of Deformati
on
Violations Charged
# of Fatalities
Roadway Surface
Condition
Speed Limit
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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;
Our Work
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
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)
Results
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
Number of Fatalities, 1988-1997
EVO’s Others Total
Ambulance 74 286 360
Fire trucks 43 152 195
Police Cars 228 971 1,199
THOMCO EMS SAFETY NET SEMINAR, 2007
Number of Non-Fatals,1988-1997
EVO’s 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
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
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
THOMCO EMS SAFETY NET SEMINAR, 2007
Relative Risks
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
SEAT BELTS & PREVENTION
Prevention Fact!
THOMCO EMS SAFETY NET SEMINAR, 2007
“The use of safety belts is the single most effective means of reducing fatal and nonfatal injuries in motor vehicle crashes.”
Dinh-Zarr, Sleet, Schultz et al., 2001
THOMCO EMS SAFETY NET SEMINAR, 2007
Seat Belt Use in the U.S.
THOMCO EMS SAFETY NET SEMINAR, 2007
Seat Belt Use in the U.S.
THOMCO EMS SAFETY NET SEMINAR, 2007
Seat Belt Use in the U.S.
What do we know about seat belt use in EMS?
THOMCO EMS SAFETY NET SEMINAR, 2007
Perceived Need for Freedom
Cardiac Arrest 82%
Chest Pain or Dysrhythmia
63%
Shortness of Breath 38%
Trauma 41%
Cook et al., 1991
THOMCO EMS SAFETY NET SEMINAR, 2007
Seat Belt Use by Providers
% Rarely Wearing Safety Belts (<5%
use)
% Always Wearing Safety Belts (>95%
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
THOMCO EMS SAFETY NET SEMINAR, 2007
Prevention Approaches
• The ‘Three E’s’– Education– Engineering– Enforcement
More Prevention Fact!
Single Approaches In Isolation are Rarely
Effective!
THOMCO EMS SAFETY NET SEMINAR, 2007
Solutions?
• Education– EVOC– Driving Simulators
• Engineering– Speed regulators (“governors”)– “Black Box” Approaches– Harness Systems
• Enforcement– Organizational policies and sanctions
THOMCO EMS SAFETY NET SEMINAR, 2007
Solutions?
THOMCO EMS SAFETY NET SEMINAR, 2007
Effectiveness?
• At least one small-scale study– 36 vehicles over 18 months– >250 drivers– Over 1.9 million miles, distance between penalty
counts increased from baseline of 0.018 to high of 15.8 miles
– Seatbelt violations from 13,500 to 4• The vendors of systems marketed today advocate
effectiveness based on small-scale trials.• NIOSH will be reporting preliminary findings from their
harness studies at the upcoming NHTSA-sponsored Ground Ambulance Safety Roundtable.
THOMCO EMS SAFETY NET SEMINAR, 2007
Another Approach?
THOMCO EMS SAFETY NET SEMINAR, 2007
Provider Safety
THOMCO EMS SAFETY NET SEMINAR, 2007
Provider Safety
THOMCO EMS SAFETY NET SEMINAR, 2007
Patient Safety
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
PaPST
Crucial Equipment Secured & Within
Reach of a Restrained Provider
Infusion Pumps
Checked at Originating Facility
IV Access Prior to
Transport
Airway Accessed Prior to Transport
Provider Safety +?Patient Safety +?Task
THOMCO EMS SAFETY NET SEMINAR, 2007
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.
THOMCO EMS SAFETY NET SEMINAR, 2007
References
• Available Upon Request
THOMCO EMS SAFETY NET SEMINAR, 2007
Coming Soon!
• In late May….
Thank You!!
THOMCO EMS SAFETY NET SEMINAR, 2007