Perspectives

New Territory
NFPA’s Ken Holland and Laurence Stewart on the forthcoming ambulance standard and on NFPA’s activity in emergency medical services.

NFPA Journal®, July/August 2011 

In the unfortunate event that you need emergency transportation to a hospital, you can take comfort in knowing that NFPA is helping make future models of ambulances even safer.

In 2008, NFPA’s Standards Council approved NFPA 1917, Automotive Ambulances, for inclusion in the 2012 revision cycle. The new standard establishes the minimum requirements, performance parameters, and essential criteria for new emergency medical services (EMS) vehicles and could replace federal specification requirements currently guiding ambulance construction. The document’s Report on Proposals (ROP) was released in June, and the public has until August 30 to submit comments on the ROP.  

The new standard is part of a recent series of EMS-related efforts undertaken by NFPA. While dispelling myths that NFPA is solely a fire protection and prevention organization with little or no involvement in EMS, staff members have educated the EMS community on a number of existing codes and standards relevant to their line of work and have developed key contacts in the process. 

NFPA Journal talked with NFPA fire service specialists Laurence Stewart and Ken Holland about the new standard and how it complements NFPA’s push into the EMS world.   

What spurred NFPA 1917?

Stewart: This goes back to when NFPA 1901, Automotive Fire Apparatus, was in its revision cycle. In 2007, the Fire Department Apparatus Committee debated if they should address the issue of developing a standard for ambulances. A member of the technical committee represented the General Services Administration (GSA), the entity responsible for the Triple K [KKK–1822] federal purchasing specification. That document had become the de facto standard for building ambulances. During the debate, the GSA representative explained this might be the time to produce a new standard, as the GSA was examining its document and evaluating options, including using the NFPA process.

The technical committee chair then submitted a request to the NFPA Standards Council to develop the standard. The Council considered it and posed the request for public input. We overwhelmingly received positive input. We empaneled a technical committee of 30 experts, career and volunteer, who represented private EMS services as well as public sector-based services. 

Was it a smooth process?

Stewart: It was definitely an eye-opener for everyone. We assembled a balanced committee, including ambulance manufacturers and emergency medical service providers. The committee also included people who have never been exposed to the NFPA process. We had several NFPA documents on the table for reference. The committee had two paths it could have taken. It could take the existing Triple K document and start building on that, including requirements for every safety component they could ever dream of and supporting that with some scientific data, but they realized this process was going to take more time. You’d have to collect data, analyze it, and try to come to a consensus. The path taken was to use NFPA 1901 as a template and then incorporate the provisions of the Triple K document. The result was an NFPA document that provides more occupant safety than the existing Triple K document. If you’re building an ambulance to the Triple K document, and if you migrate over to the NFPA document, there won’t be a substantial difference. 

What are some of the occupant safety provisions?

Stewart: We developed requirements for seatbelts for any seated position. We’re also looking at design aspects of where controls are placed in ambulances so that they’re all in arm’s reach, so workers won’t have to move to activate a switch that turns on suction or an aspirator. Tire pressure safety sensors were also included.

Are the safety concepts the biggest difference between this document and Triple K? Is there anything else that will make proposed NFPA 1917 unique?

Stewart: The NFPA document is a performance-based standard, so not only does it have design requirements, there’s also a measurable testing aspect to it. Triple K is prescriptive and says how you need to build an ambulance. For example, Triple K provides specific text on placement, flash sequence, and color of warning lights on an ambulance. NFPA 1917 states that these warning devices need to meet specific technical requirements. 

Did everything that was proposed make it into the new document?

Stewart: In using NFPA 1901 as a template, the whole section on vehicle data recorders (VDRs) came into the document. The VDR records throttle position, brake activations, and engine speed, among other things, for safety purposes. A VDR is a tool that  monitors how the equipment is being used and helps with fleet maintenance programs and operator safety training. As a result of comments submitted by the EMS community, VDRs were moved to the annex as optional equipment because currently not all original equipment manufacturers can provide a chassis that will accept a VDR. The committee did not want to eliminate 90 percent of the current market chassis suppliers from the ambulance business.

Will Triple K eventually be phased out?

Stewart: The committee was aware that Triple K was ending its current revision in July 2012 and that the GSA would consider options to assume the continued development and maintenance of ambulance purchasing specifications. The committee elected to put its standard into the annual 2012 cycle so it will come out as GSA considers the future of its document.

How will this standard complement NFPA’s other EMS efforts? 

Stewart: Our hope is the EMS community will become more aware of the NFPA process and existing documents that can assist them. For example, we have NFPA 450, Guide for Emergency Medical Services and Systems, that can be used to establish system performance benchmarks for any EMS system. The NFPA process, along with the participation of EMS providers in it, will help make the jobs of EMTs and paramedics safer.

Holland: As an example, there’s an organization using NFPA 1021, Fire Officer Professional Qualifications, as a template to develop an EMS officer certification course. The National Emergency Medical Services Management Association has looked at the value of this document and used it to develop their curriculum.

What other areas would benefit from NFPA codes and standards?

Holland: What we have to remember is that EMS is not just the ambulance or fire department showing up at your house. EMS is the 9-1-1 call taker/dispatcher for police, fire, ambulance service, and ER physicians. EMS is a whole spectrum or series of events. We have almost 40 documents that touch upon EMS issues in some form or another, including NFPA 450, Guide for Emergency Medical Services and Systems; NFPA 1061, Professional Qualifications for Public Safety Telecommunicator; NFPA 1710, Organization and Deployment of Fire Suppression Operations, Emergency Medical Operations, and Special Operations to the Public by Career Fire Departments; and the documents on protective clothing and respiratory protection. 

Are there misconceptions about NFPA that may affect efforts in the EMS community? 

Stewart: Some believe NFPA, because of our long history with the fire service, can’t support the EMS community, and that’s not the case. The fire service is one of the largest providers of emergency medical services, and we have many documents addressing their needs. We hope folks look beyond our name.

Holland: To combat these myths, we’ve gotten involved in as many EMS-related events as we can, using a grassroots philosophy, in hopes of educating people and explaining our mission to various stakeholders. Seven of the eight technical staffers in my division have EMS experience. I’ve been a paramedic since 1996. I think what helps is that when the voice for EMS from NFPA is an EMS provider, someone who has worked in an ambulance and delivered emergency care, it offers a higher level of credibility to what we’re trying to do.    

How have you already established connections in the EMS community?

Holland: I have attended several meetings with the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on Emergency and Medical Services (FICEMS). NEMSAC is an advisory council on EMS issues, and FICEMS is a federal group that is made up of state, local, tribal, and federal EMS folks that channels their their concerns up through the federal government.

We have also been involved with the Transportation Safety Advisory Group for the NexGen 9-1-1 Program, which looks to develop what the next generation of 9-1-1 would be like from a fire, EMS, law, and highway operations perspective. I will also be serving on a review panel for the EMS Culture of Safety Project that is being developed by the American College of Emergency Physicians and identifies the safety issues concerning this industry.    

I am also a member, through the NFPA, of the National Association of State EMS Officials, the National Association of EMS Physicians, and the National EMS Management Association to help with our involvement in EMS issues.

I have been a reviewer for the Medical Directors Handbook that is being published by the International Association of Fire Chiefs. It should be hitting the streets soon. The handbook provides guidance and direction to those physicians who serve as medical directors for EMS agencies or locations. It addresses the various areas of EMS, including staffing, agency design types, types of response service, resource deployment, emergency medical dispatching, and response components. Several NFPA standards are referenced.

We want everyone to recognize us as a resource. We do have a good model of doing things, and we can certainly work to meet the needs and demands of the EMS community.

When you were looking at the needs of the EMS community, did you see other areas for possible NFPA involvement?

Holland: At a FICEMS meeting, Dave Strickland, the administrator who was speaking to us, said their biggest challenge is developing a safety standard on crash safety for the patient compartment. We’re already developing a standard for the ambulance. Why can’t our next standard be for the back of the ambulance? The point is we’ve done a good job with the vehicle. Now we need to make sure the occupants are safe. I think that’s the next place we should go.

Stewart: The Fire Protection Research Foundation is looking at ambulance fatality and injury data from all 50 states. They want to use that information to make ambulances even safer.

Holland: Another recognized need is for a driver trainer/operator standard for those who drive ambulances. We have NFPA 1002, Fire Apparatus Driver/Operator Professional Qualifications.

Should there be a separate standard for those who drive ambulances?

Stewart: During Ambulance Technical Committee meetings, members discussed, along with requirements for the ambulance, how the vehicle is being operated. They realized the operator aspect is outside the standard’s scope. The committee has formed a task group to address this issue and is working with the technical committee for NFPA 1451, Fire Service Vehicle Operations Training Program. The task group is actively submitting proposals to this document since it’s in cycle for revision. 

What are the other concerns you’re hearing?

Holland: The EMS community has identified several challenges for EMS agencies, including a lack of national standards and coordination. Different organizations are doing different things without the others knowing about it. NFPA is ready to respond to these challenges by providing an open consensus process that has had success in improving responder health and safety along with vehicle design and maintenance. 

What do you think of the committee’s efforts?

Stewart: The process has demonstrated NFPA’s ability to bring all interested and affected parties together to establish consensus around a challenging issue. NFPA’s open consensus process and the expertise of our technical committee members provides an environment where difficult issues can be worked out and clear solutions can be established. This is one of the principles of the NFPA standards process, and the results are clear to see in the ambulance standard.