A Bibliography of Ambulance Patient 

Compartments and Related Issues

Mehdi Dadfarnia

Y. Tina Lee

Deogratias Kibira

NISTIR 7835
NISTIR 7835

A Bibliography of Ambulance Patient 

Compartments and Related Issues

Mehdi Dadfarnia

Y. Tina Lee

Deogratis Kibira

Systems Integration Division

Engineering Laboratory

February 2012

U.S. Department of Commerce

John E. Bryson, Secretary

National Institute of Standards and Technology

Patrick D. Gallagher, Under Secretary of Commerce for Standards and Technology and Director
 

A Bibliography of Ambulance Patient Compartments and Related Issues

Mehdi Dadfarnia 

Y. Tina Lee

Deogratias Kibira

Manufacturing Simulation and Modeling Group

Manufacturing Systems Integration Division

Engineering Laboratory

National Institute of Standards and Technology

Gaithersburg, MD 20899-8260

Abstract

Safety in the patient compartment of ambulances is an issue of growing concern 

for emergency medical technicians (EMTs), paramedics, patients, and others 

affected by ambulances. A lot of research has been conducted by different 

players and much of it is scattered. As a quick reference, this report is to 

enhance the ability of researchers of this field to sift through a collection of 

standards and documents from books, journals, websites, and reports. This 

annotated bibliography is categorized into different fields for further ease of use. 

A brief abstract follows every bibliographical reference.

Keywords 

Ambulance; Ambulance Standards; Crash; Design Layout; Patient Compartment; 

Safety Hazards; Task Frequency.
2

Table of Contents

Abstract............................................................................................................................... 1

Keywords............................................................................................................................ 1

1. INTRODUCTION .......................................................................................................... 3

2. OVERVIEW OF THE REPORT.................................................................................... 3

3. BIBLIOGRAPHY.......................................................................................................... 5

3.1 Ambulance Problems Awareness.................................................................... 5

3.2 Injury & Accident Reports .............................................................................. 9

3.3 Layout & Space Design .................................................................................. 16

3.4 Crash Test Procedures ................................................................................... 20

3.5 Other Research & Proposed Solutions ......................................................... 23

3.6 Overall Design Evaluations and Examples................................................... 30

3.7 Securing People & Equipment....................................................................... 35

3.8 Standards & Guidelines ................................................................................. 42

4. ACRONYMS................................................................................................................ 47

Acknowledgements........................................................................................................... 48

Disclaimer......................................................................................................................... 48
3

1. INTRODUCTION

Emergency medical services (EMS) personnel today face many safety issues in 

their working environment, the ambulance. This is because comprehensive 

standards for ambulance interior design, based on scientific methods, are lacking 

in the United States. The result is that EMS personnel are exposed to bloodborne pathogens from needle sticks, injuries from lifting and moving patients, 

attacks by violent patients, and injuries caused by traffic accidents involving 

ambulances. As a consequence, the rate of work-related fatalities among EMS 

personnel is more than two times higher than that for the general public. 

To reduce this danger the Department of Homeland Security (DHS) has 

collaborated with the National Institute of Standards and Technology (NIST), the 

National Institute of Occupational Safety and Health (NIOSH), and BMT 

Designers and Planners in a new ambulance design research. The findings of 

this effort will be a set of recommendations for incorporation into the next draft 

(2013) of the National Fire Protection Agency (NFPA) 1917 standard. The results 

should enhance the physical layout of the ambulance patient compartment and 

also address broader human factors and human performance issues once the 

necessary research, development, and testing are completed.

The very first step of NIST’s ambulance standard project is to perform a literature 

survey. A lot of research has already been conducted in ambulance design and 

is found in disparate locations. Thus the purpose of this report is to provide an 

annotated bibliography of the literature for a quick, single-source reference for 

the researchers who are studying the same or related research topic.

2. OVERVIEW OF THE REPORT

This report is a compilation of research that has been done on the ambulance 

design with the focus on safety and performance in the patient compartment of 

ambulances, especially for emergency medical technicians, paramedics, and 

patients. This report is a collection of standards and documents from standard 

development organizations, journals, websites, and conference proceedings. 

There are more than eighty papers included in this report. The author(s), title, 

journal, volume, page(s), publisher, date, and other referential information are 

noted in the bibliographical annotation. An abstract and parts of the article 

directly copied from contents of its complimentary referenced document is 

marked with an asterisk, (*).

The categorization set for this is to make searching the paper in particular topics 

an easier task for researchers. The major categories that have been identified for 

the purpose include:
4

• Ambulance Problems Awareness: Gives background idea behind the 

types of problems and issues that emergency medical services personnel 

face from working in their ambulances.

• Injury & Accident Reports: Includes statistics or reports that involve 

ambulance injuries, fatalities, and accidents.

• Layout & Space Design: Consists of studies conducted to survey and 

evaluate the space and layout of the ambulance patient compartment.

• Crash Test Procedures: Puts together a few sources that have critiqued 

and analyzed current ambulance crash test procedures, with suggestions 

for progress in this field.

• Other Research & Proposed Solutions: Consists of sources that have not 

been categorized in any other categories, and they include literature about 

surveys, exterior conspicuity, and more.

• Overall Design Evaluations and Examples: Incorporates surveys and 

evaluations that have been conducted in order to look at major design 

problems inside an ambulance. It also includes a few newer design 

concepts that have been presented by manufacturers.

• Securing People & Equipment: Deals with various restraint systems that 

are used in ambulances.

• Standards & Guidelines: Reviews national and international ambulance 

standards and guidelines.

In some instances, these categories do overlap.
5

3. BIBLIOGRAPHY

3.1 Ambulance Problems Awareness

About.com. “The Difference Between an EMT and a Paramedic.” Accessed 

July 15, 2011. 

http://firstaid.about.com/od/emergencymedicalservices/qt/06_EMTBvsP.ht

m.

ABSTRACT: This paper describes the differences among different emergency 

medical technician (EMT) levels: EMT-Basic, EMT-Intermediate, and EMTParamedic. The biggest difference between paramedics and EMTs is in the tasks 

they are allowed to perform. Also, the amount of training they receive is different. 

Basic EMTs receive about 120 to 150 hours of training while paramedics receive 

around 1200-1800 hours of training. In most states, Basic EMTs do not have the 

privilege to give injections to the patient. Paramedics are usually trained to use 

30-40 different medications and are trained to give injections. Ambulance crew 

members are expected to be at least an EMT-Basic.

Center for Disease Control - National Institute of Occupational Safety and 

Health. “A Story of Impact: NIOSH Research Leads to a Reduction in Safety 

Hazards Among Ambulance Service Workers and EMS Responders.” 

Accessed July 18, 2011. http://www.cdc.gov/niosh/docs/2010-164/. 

ABSTRACT: In 2006, there was an estimated 201000 emergency medical 

technician (EMT) and paramedics workforce and at least 700000 volunteer 

EMTs. Unfortunately, in 2002 it was found that the fatality rate among this 

workforce was greater than 2 times the national average for workers. Thus, the 

National Occupational Research Agenda, along with the National Institute of 

Occupational Safety and Health, set out a mission to evaluate and find any risk 

factors that are associated with the integrity of the ambulance structure, layout, 

and human and mechanical barriers. These evaluations and findings will in turn 

help with revising the federal ambulance standards, which is being done in 

conjunction with the Ambulance Manufacturers Division (AMD) and the General 

Services Administration.

Cook, R.I., M. Render, and D.D. Woods. “Gaps in the continuity of care and 

progress on patient safety.” British Medical Journal, 2000, 320: pp 791-794.

*ABSTRACT: The patient safety movement includes a wide variety of 

approaches and views about how to characterise patient safety, study failure and 

success, and improve safety. Ultimately all these approaches make reference to 

the nature of technical work of practitioners at the “sharp end” in the complex, 

rapidly changing, and intrinsically hazardous world of health care. It is clear that a 

major activity of technical workers (physicians, nurses, technicians, pharmacists, 

and others) is coping with complexity and, in particular, coping with the gaps that 

complexity spawns. Exploration of gaps and the way practitioners anticipate, 

detect, and bridge them is a fruitful means of pursuing robust improvements in 

patient safety.
6

Elling, R. “Dispelling Myths on Ambulance Accidents.” Journal of 

Emergency Medical Services, July 1989. 

*ABSTRACT: There appears to be a self-perpetuating trail of misinformation 

surrounding the issue of ambulance accidents. As with all problems, we must first 

acknowledge that a problem does exist and clearly distinguish the facts from the 

myths. The intent of this article was to clarify some of those misconceptions by 

using an analysis of one state's four-year experience with ambulance accidents. 

The next step in solving this problem is to create driver education programs that 

modify the behavior of ambulance drivers, adjust their attitudes about driving an 

emergency vehicle and make them fully aware of the hazards encountered in 

driving an ambulance. In addition, consider adjusting the agency standard 

operating procedure so that all ambulances must come to a complete stop at all 

stop signs and red lights to minimize the number of accidents that occur in the 

intersection. Readers who would like to learn more about this subject should 

contact their state EMS offices to determine if they offer emergency vehicle 

operator courses or continuing education programs that deal with ambulance 

driving. New York State has developed a network of 90 instructors who are 

qualified to teach the Ambulance Accident Prevention Seminar, a nine-hour 

classroom-based ambulance driver "attitude adjustment" program. Two other 

organizations that have developed driving courses geared specifically for 

ambulance driving are: Failsafe Driving Inc. Alvin F. Davenport, president 2529 

San Pablo Ave. Pinole, CA 94564 National Academy for Professional Driving 

Dick Turner, chairman 1001-A South Interstate 45 P.O. Box 649 Hutchins, TX 

75141.

Thompson, J. “Ambulance transports safety standards a ‘disgrace,’ EMS 

Expo told.” Accessed August 17, 2011. 

http://www.ems1.com/safety/articles/886729-CareFlite-CEO-calls-transportsafety-standards-a-disgrace/.

ABSTRACT: An EMS Expo session was told that the U.S has more safety 

standards in place for the transport of cattle than for the transport of prehospital 

care providers and patients. Measures that have been proved to reduce risk, 

according to the CareFlite CEO Jim Swartz, include: Vehicle operations safety 

policies, squad bench lap seat belts, patient over the shoulder harnesses, 

securing equipment, forward and rear facing seating, some electronic technical 

devices, and safety awareness.

Finkelstein, A., and J.A. Dowell. “A comedy of errors: The London 

Ambulance Service case study.” Paper presented at the proceedings of the 

8th International Workshop on Software Specification and Design, Schloss 

Velen, Germany, March 22-23, 1996.

*ABSTRACT: This paper provides an introduction to the IWSSD-8 case study -

the “Report of the Inquiry into the London Ambulance Service”. The paper gives 

an overview of the case study and provides a brief summary. It considers how 

the case study can be used to orient discussion at the workshop and provide a 

bridge between the various contributions.
7

Levick, N. “Rig Safety 911: What You Need to Know About Ambulance 

Safety and Standards.” Journal of Emergency Medical Services, October 

2008: pp 66-67.

ABSTRACT: This article highlights the absence of meaningful, scientific-based 

federal standards for ambulance patient compartments. It also discusses

challenges and recommendations to identify best practices in vehicle safety, and 

new developments in vehicles, technology, policies, and standards that will save 

lives, time, and money. The article identifies the lack of intrusion testing on 

current standards.

Louis-Smith, E. “Human engineering concerns in ambulance interior 

design.” Human Factors and Ergonomics Society Annual Meeting 

Proceedings, 1986, 30(4): pp 345-348.

*ABSTRACT: Although federal specifications do exist and are strictly applied, 

(Fed. Spec KKK-A-1822) sources of inefficiency and hazard still result in interior 

ambulance design. Since the “ultimate” ambulance design is not yet a reality and 

most departments cannot afford to modify everything they please it was 

considered important to set certain priorities concerning the design of ambulance 

interiors.

Middleman, S. “Considerations in Medical Ground Transportation.” The 

Case Manager, 2004.

*ABSTRACT: Physicians and nurses, therapists and specialists, case managers 

and patients and families each form a piece of the health care puzzle. Each party 

plays a vital role in patient wellness, but if patients do not or cannot get to 

therapy, they cannot be expected to get better. Patient transportation is 

improving because case managers can ensure that they have proper 

transportation to get to appointments locally and out of town.

Slattery, D.E., and A. Silver. “The Hazards of Providing Care in Emergency 

Vehicles: An Opportunity for Reform.” Pre-hospital Emergency Care, 2009, 

13(3): pp 388-397.

*ABSTRACT: The risk of occupational death is disproportionately high for 

emergency medical services (EMS) personnel, largely as a consequence of the 

high incidence of transportation-related fatalities. The purpose of this narrative 

review is twofold: to raise awareness in the EMS community by examining the 

various factors that contribute to vehicular EMS injuries and fatalities and to 

outline practical strategies for mitigating these risks to EMS professionals. This 

review describes three main categories of factors that contribute to personnel risk 

during ambulance transport: the inherent risks of driving/riding in an ambulance, 

poor ambulance safety standards and design, and increased provider 

vulnerability to injury while delivering critical patient care in the back of a moving 

ambulance. Specific educational, technologic, regulatory, and behavioral 
8

strategies for mitigating these risks are offered in hopes of improving ambulance 

safety practices.

Studnek, J.R., A. Ferketich, and J.M. Crawford. "On the job illness and 

injury resulting in lost work time among a national cohort of emergency 

medical services professionals." American journal of industrial medicine

2007, 50(12): pp 921-931. Accessed July 15, 2011.

*ABSTRACT: Background: The objective of this study was to estimate the 

prevalence and incidence of job-related illness or injury resulting in lost work time 

among a national cohort of Emergency Medical Services (EMS) professionals. 

Also, it was hypothesized that individual and work life characteristics were 

associated with the occurrence of illnesses or injury. Methods: Data for this

analysis were obtained from the Longitudinal Emergency Medical Technician 

Attributes and Demographics Study (LEADS), a prospective study of EMS 

professionals. The outcome variable of interest was self-reported absence from 

their EMS job due to an EMS work related illness or injury. The prevalence and 

incidence of injury with lost work time was estimated using cross-sectional and 

follow-up data. Multivariable logistic regression analyses were performed to 

determine if individual and work life characteristics were associated with 

occupational injury. Results: The prevalence of job-related illness or injury with 

time away from work was estimated at 9.4 %, while the 1-year incidence was 

estimated at 8.1 per 100 EMS providers. The results from the logistic regression 

model fit to follow-up data indicate that increasing call volume (OR=3.12 for very 

high vs. moderate, 95 % CI 1.40-6.97), an urban work environment (OR=2.79, 95

% CI 1.65-4.72) and a history of back problems (OR=1.72, 95 % CI 1.06-2.78) 

were associated with reporting job-related illness or injury. Conclusions: Results 

from this analysis provide estimates of the prevalence and incidence of on the 

job illness and injury resulting in lost work time among a national cohort of EMS 

professionals.
9

3.2 Injury & Accident Reports

Auerbach, P.S., J.A. Jr. Morris, J.B. Jr. Phillips, S.R. Redlinger, and W.K. 

Vaughn. “An Analysis of Ambulance Accidents in Tennessee.” The Journal 

of the American Medical Association, 1987, 258: pp 1487-1490.

*ABSTRACT: In an effort to improve our program for ambulance crash and 

related injury prevention, we analyzed 102 consecutive ambulance accidents. 

Incidents reported included those that resulted in human injury or in which 

property damage exceeded $200. Multiple logistic regression was used to 

determine the association between circumstances reported at the time of the 

accidents and the risk of injury. Twenty-nine accidents contributed to a total of 65 

injured victims, with one death. The variable most strongly associated with the 

probability of an injury-accident was use of a passenger restraint device. 

Darkness and occurrence at an intersection were variables showing increased 

risk, but were not statistically significant. The interaction of variables did not have 

a combined influence on the incidence of injury. The mean delay to hospital care 

after an accident was 9.4 minutes. Based on our data, 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.

Ballam, E. “Ambulance Crash Roundup: A Review of Emergency Vehicle 

Crashes During 2010.” EMS World, March 2011, 40(3): pp 74-75.

ABSTRACT: A roundup of ambulance crashes that made the news tells us that 

264 ambulance-related crashes occurred in the United States, although it is likely 

that there were even more collisions as there are around 50,000 ambulances on 

duty on any given day. Of these crashes, 43 % occur where two or more roads 

cross, and which in the bulk of this 43 % the ambulances were hit by vehicles as 

they attempted to go through the intersection. Apart from intersection controls, 

which is the largest factor in these crashes, about 10 % of these crashes 

appeared to come from the loss of control of the ambulances. Another crash 

factor road conditions, especially icy and snowy conditions, made up for at least 

20 of these crash cases. 21 of the 264 crashes came from rear-end collisions, 

no fewer than 16 was connected to drug/alcohol abuse, and moose, deer, debris, 

and rairlroad crossing gates contributed to a few more of the crashes. 

Furthermore, at least 10 of these collisions involved another ambulance.

Reviewing these reported statistics tells us that ambulances are especially prone 

to danger at intersections. In scenarios involving the ambulances to cross an 

intersection, slowing down and watching out for changing road conditions may 

save lives.

EMS World. “Ambulance Crashes: Fatality Factors for EMS Workers.” 

Accessed July 19, 2011. http://www.emsworld.com/print/EMSWorld/Ambulance-Crashes--Fatality-Factors-for-EMS-Workers/1$1796.

ABSTRACT: In the Morbidity and Mortality Weekly Report article published in 
10

February 2003, the National Institute for Occupational Safety and Health 

(NIOSH) identified 27 EMS worker fatalities. These fatalities were a result of 

ambulance crashes reported to the National Highway Traffic Safety 

Administration's Fatality Analysis Reporting System (FARS) for the years 1991-

2000. This article presents a more in-depth look at the 25 crashes that resulted in 

these 27 fatalities, focusing primarily on ambulance configurations, roadway and 

environmental conditions, and driver-related factors. A key finding was that 

weather and road conditions did not appear to play significant roles in most 

crashes, but driving the ambulance too fast and/or in the wrong lane were 

notable factors. Another interesting characteristic of these fatality factors was that 

nearly half of the ambulance drivers in all of the fatal crashes had some kind of 

collision/moving driving violation within 3 years of the fatal event.

Kahn, C.A., R.G. Pirallo, and E.M. Kuhn. “Characteristics of fatal ambulance 

crashes in the United States: an 11-year retrospective analysis.” 

Prehospital Emergency Care: The Official Journal of the National 

Association of EMS Physicians and the National Association of State EMS 

Directors, 2001, 5(3): pp 261-269. Accessed July 15, 2011.

*ABSTRACT: Background: Ambulance crashes have become an increasing 

source of public concern. Emergency medical services directors have little data 

to develop ambulance operation and risk management policies. Objective: This 

paper describes fatal ambulance crash characteristics, identifying those that 

differentiate emergency and non-emergency use crashes. Mehods: This was a 

retrospective analysis of all fatal ambulance crashes on U.S. public roadways 

reported to the Fatality Analysis Reporting System (FARS) database from 1987 

to 1997. Main outcome measures were 42 variables describing crash 

demographics, crash configuration, vehicle description, crash severity, and

ambulance operator and vehicle occupant attributes. Results: Three hundred 

thirty-nine ambulance crashes caused 405 fatalities and 838 injuries. These 

crashes occurred more often between noon and 6 PM (39 %), on improved (99 

%), straight (86 %), dry roads (69 %) during clear weather (77 %), while going 

straight (80 %), through an intersection (53 %), and striking (81 %) another 

vehicle (80 %) at an angle (56 %). Most crashes (202/339) and fatalities 

(233/405) occurred during emergency use. These crashes occurred significantly 

more often at intersections (p < 0.001), at an angle (p < 0.001), with another 

vehicle (p < 0.001). Most crashes resulted in one fatality, not in the ambulance. 

Thirty pedestrians and one bicyclist comprised 9 % of all fatalities. In the 

ambulance, most serious and fatal injuries occurred in the rear (OR 2.7 vs. front) 

and to improperly restrained occupants (OR 2.5 vs. restrained). Sixteen percent 

of ambulance operators were cited; 41 % had poor driving records. Conclusions:

Most crashes and fatalities occurred during emergency use and at intersections. 

The greater burden of injury fell upon persons not in the ambulance. Rear 

compartment occupants were more likely to be injured than those in the front. 

Crash and injury reduction programs should address improved intersection 

control, screening to identify high-risk drivers, appropriate restraint use, and 

design modifications to the rear compartment of the ambulance.
11

Lutman, D., M. Montgomery, P. Ramnarayan, and A. Petros. “Ambulance 

and aeromedical accident rates during emergency retrieval in Great 

Britain.” Emergency Medicine Journal, 2008, 25: pp 301-302. Accessed on 

July 25, 2011. doi: 10.1136/emj.2007.046557.

*ABSTRACT: The retrieval of critically ill patients is frequently done in difficult 

circumstances and often under considerable time pressures. These adverse 

conditions have a finite risk of serious injury or death. The level of risk is poorly 

described in the literature and reliable data on accident rates are hard to find. 

Most of the information comes from North America. There are no clear published 

statistics for the UK. We report for the first time data on accidents and casualties 

involving vehicles classified as having an ambulance body type and air 

ambulances within Great Britain between 1999 and 2004.

Maguire, B.J., K.L. Hunting, G.S. Smith, and N.R. Levick. “Occupational 

Fatalities in Emergency Medical Services: A Hidden Crisis.” Annals of 

Emergency Medicine, 2002, 40(6): pp 625-632.

*ABSTRACT: Study Objective: We estimate the occupational fatality rate among 

emergency medical services (EMS) personnel in the United States. Methods: We 

undertook descriptive epidemiology of occupational fatalities among EMS 

providers. Analysis was conducted by using data from 3 independent fatality 

databases: the Census of Fatal Occupational Injuries (1992 to 1997), the 

National EMS Memorial Service (1992 to 1997), and the National Highway Traffic 

Safety Administration's Fatality Analysis Reporting System (1994 to 1997). These 

rates were compared with the occupational fatality rates of police and firefighters 

and with the rate of all employed persons in the United States. Results: The 

Census of Fatal Occupational Injuries database documented 91 EMS provider 

occupational fatalities. The National EMS Memorial Service database contained 

70 fatalities, and the Fatality Analysis Reporting System identified 8 groundtransportation EMS occupational fatalities. There was also wide variation in 

fatality counts by cause of injury. Using the highest cause-specific count from 

each of the databases, we estimate that there were at least 67 ground 

transportation-related fatalities, 19 air ambulance crash fatalities, 13 deaths 

resulting from cardiovascular incidents, 10 homicides, and 5 other causes, 

resulting in 114 EMS worker fatalities during these 6 years. We estimated a rate 

of 12.7 fatalities per 100,000 EMS workers annually, which compares with 14.2 

for police, 16.5 for firefighters, and a national average of 5.0 during the same 

time period. Conclusion: This study identifies an occupational fatality rate for 

EMS workers that exceeds that of the general population and is comparable with 

that of other emergency public service workers.

Proudfoot, S.L., P. Moore, and R. Levine. “Safety In Numbers: A Survey on 

Ambulance Patient Compartment Safety.” Journal of Emergency Medical 

Services, March 2007, 32(3): pp 86-90.
12

ABSTRACT: A study in 2004 was conducted by the National Registry of EMTs 

(NREMT) and the National Highway Traffic Safety Administration (NHTSA) in 

order to identify safety issues related to the ambulance patient compartment. In 

this study, 1773 EMTs and paramedics responded to a questionnaire. 55 % of 

the respondents said that they would use patient compartment restraints if they 

allowed mobility, while 23 % said they will rarely wear such restraints. 29 % said 

they would wear a helmet with integrated communications system, while 49 % 

said they will rarely wear the helmet. Over 66 % have transported 2 or more 

patients within the past year, and only 26 % of them have ever used the 

defibrillator. The results of this study showed that, in order to increase safety 

measures in the ambulance patient compartment, providers and equipment 

within the ambulance should always be secured or fastened. Also, when 

transporting patients, the EMTs or paramedics must sit in a side-facing or rearfacing position. In general, the findings from this study shows an increasing need 

to research better seating and equipment location and security, as well as mobile 

restraint systems. 

Proudfoot, S.L., N.T. Romano, T.G. Bobick, and P.H. Moore. “Ambulance 

crash-related injuries among emergency medical services workers - United 

States, 1991-2002.” Journal of the American Medical Association, April 

2003, 289(13): pp 1628-1629.

*ABSTRACT: Ambulance crashes are one of many hazards faced by Emergency 

Medical Services (EMS) personnel. Although no complete national count of 

ground ambulance crashes exists, the total number of fatal crashes involving 

ambulances can be ascertained by using the National Highway Traffic Safety

Administration (NHTSA) Fatality Analysis Reporting System (FARS). To 

characterize risk factors for EMS workers involved in ambulance crashes, CDC's 

National Institute for Occupational Safety and Health (NIOSH) and NHTSA 

investigated three case reports of ambulance crashes. This report summarizes 

these investigations, presents surveillance data, and discusses 

recommendations for prevention measures. NIOSH is identifying and testing 

alternative measures to reduce injury risk for EMS workers.

Ray, A.M, and D.F. Kupas. “Comparison of Rural and Urban Ambulance 

Crashes in Pennsylvania.” Prehospital Emergency Care, 2007, 11(4): pp 

416-422.

*ABSTRACT: Objective: To describe and compare the characteristics of, and 

associated injuries caused by, ambulance crashes that occur in rural versus 

urban areas. Methods: Crash data collected by the Pennsylvania Department of 

Transportation were obtained for ambulance crashes from 1997 to 2001. Crash 

demographics (e.g., location of crash, road conditions, and intersection type) and 

injuries reported by police were analyzed to determine differences, if any, 

between crashes occurring in rural and urban areas. Results: 311 rural and 1,434 

urban ambulance crashes were identified. Day and time of crash, light conditions 
13

and road type were similar. Rural crashes were more likely to occur on snowy 

roads (13 % vs. 5 %) and at nighttime without street lighting (25 % vs. 4 %). 

Operator error was the most common cause of crashes (75 % for rural; 93 % for 

urban), whereas vehicle or environmental conditions more frequently affected 

rural drivers (25 % vs. 7 %). Urban crashes were more likely to involve angled 

collisions with other vehicles (54 % vs. 19 %), intersections (67 % vs. 26 %), and 

occur at a stop sign or signal (53 % vs. 14 %). Rural crashes often involved 

striking a fixed object (33 % vs. 7 %). Urban crashes more often involved more 

than one vehicle (88 % vs. 56 %) and more than four people total (35 % vs. 23

%). Pedestrian involvement was rare in both groups (<5 %). Injury severity was 

similar between both types of crashes, although rural crashes more frequently 

did not involve any injuries (33 % vs. 20 %). Alcohol and/or drug use by drivers 

was rare (<1 %). Conclusion: Rural ambulance crashes usually do not involve 

other vehicles and are more often due to environmental or vehicle factors. Urban 

ambulance crashes typically involve intersections, other vehicles, and traffic 

signals. Although more people and vehicles are often involved in urban 

ambulance crashes, the severity of injuries sustained are similar.

Reichard, A.A., and L.L. Jackson. “Occupational Injuries Among 

Emergency Responders.” American Journal of Industrial Medicine, 2009: 

pp 1-11.

*ABSTRACT: Background: Emergency responders frequently incur injuries while 

providing medical, fire, and law enforcement services. National surveillance 

systems provide fragmented perspectives on responder injuries because they 

omit specific classes of workers (e.g., government or volunteers); they report only 

selected injuries; and employment information is incomplete. Methods: We 

characterized injuries among emergency medical services (EMS), firefighting, 

and police occupations by using data from the National Electronic Injury 

Surveillance System-Occupational Supplement (NEISS-Work) for injuries treated 

in U.S. hospital emergency departments in 2000-2001. Results: Sprains and 

strains were the leading injury (33 to 41%) among EMS, firefighter, and police 

occupations. Police officers and career firefighters had the highest injury rates 

(8.5 and 7.4 injuries per 100 full-time equivalent workers, respectively). 

Conclusions: The physical demands of emergency response are a leading cause 

of injuries that may benefit from similar interventions across the occupations. To 

assess risk, improved exposure data need to be acquired, particularly for 

volunteers.

Sanddal, N.D., S. Albert, J.D. Hansen, and D.F. Kupas. “Contributing factors 

and issues associated with rural ambulance crashes: literature review and 

annotated bibliography.” Prehospital Emergency Care, 2008, 12(2): pp 257-

267.

*ABSTRACT: Ambulance crashes occur with greater frequency and severity than 

crashes involving vehicles of similar size and weight characteristics. Crashes in 

rural areas tend to be more severe in terms of injury or death to vehicle 
14

occupants. The purpose of this article was to examine the extant literature, as 

well as summarize and discuss the overlapping findings of that body of literature. 

A stepwise literature search was conducted using the following MeSH search 

terms ambulance; accident, traffic; emergency medical technician; occupational 

health; and rural in descending combination. MEDLINE was used as the primary 

database but was augmented by searches of Academic Search Premier, 

Comprehensive Index of Nursing, Allied Health Literature, and ProQuest 

Dissertation International. The search resulted in 32 article citations, and of 

these, 28 were included. An annotated bibliography is followed by a discussion 

and conclusion that identify opportunities for prevention activities in the areas of 

education, enforcement, and engineering.

Sanddal, T.L, N.D. Sanddal, N. Ward, and L. Stanley. “Ambulance Crash 

Characteristics in the US Defined by the Popular Press: A Retrospective 

Analysis.” Emergency Medicine International, 2010: 7 pages. Accessed 

July 14, 2011. doi: 10.1155/2010/525979.

*ABSTRACT: Ambulance crashes are a significant risk to prehospital care 

providers, the patients they are carrying, persons in other vehicles, and 

pedestrians. No uniform national transportation or medical database captures all 

ambulance crashes in the United States. A website captures many significant 

ambulance crashes by collecting reports in the popular media (the website is 

mentioned in the introduction). This report summarizes findings from ambulance 

crashes for the time period of May 1, 2007 to April 30, 2009. Of the 466 crashes 

examined, 358 resulted in injuries to prehospital personnel, other vehicle 

occupants, patients being transported in the ambulance, or pedestrians. A total of 

982 persons were injured as a result of ambulance crashes during the time 

period. Prehospital personnel were the most likely to be injured. Provider safety 

can and should be improved by ambulance vehicle redesign and the 

development of improved occupant safety restraints. Seventy-nine (79) crashes 

resulted in fatalities to some member of the same groups listed above. A total of 

99 persons were killed in ambulance crashes during the time period. Persons in 

other vehicles involved in collisions with ambulances were the most likely to die 

as a result of crashes. In the urban environment, intersections are a particularly 

dangerous place for ambulances.

Studnek, J.R., and A.R. Fernandez. “Characteristics of emergency medical 

technicians involved in ambulance crashes.” Prehospital Disaster 

Medicine, 2008, 23(5): pp 432-437.

*ABSTRACT: Objectives: This study utilizes a [US] national sample of 

emergency medical services (EMS) professionals to explore the hypothesis that 

demographic and work-related characteristics are associated with involvement in 

ambulance crashes. Methods: In 2004, a cohort of nationally registered EMS 

professionals was surveyed to determine ambulance crash involvement during a 

12-month period. Involvement in an ambulance crash was the outcome variable 

of interest. Demographics such as age, community size, service type, call 
15

volume, time spent in an ambulance, and current sleep problems were analyzed 

as independent variables. A multivariate logistic regression model identified 

variables associated with involvement in an ambulance crash within the past 

year. Results: Surveys were received from 1775/5565 (32.0 %) participants; 

1297 (73.1 %) met the inclusion criteria. A total of 111 (8.6 %) of participants 

reported being involved in an ambulance crash within the past 12 months. When 

controlling for call volume and time in an ambulance, the odds of involvement in 

an ambulance crash within the past year were significantly higher for younger 

EMS professionals and those reporting sleep problems. Conclusions: Results 

from this analysis suggest age and sleep problems are associated with 

involvement in an ambulance crash. Future studies should investigate 

interventions to minimize the effects of these associations.

Tetreault, M.W. “Evaluating Injuries to Firefighters While Performing Patient 

Care in a Moving Ambulance.” An applied research project submitted to the 

National Fire Academy as part of the Executive Officer Program, 

Londonderry, New Hampshire, May 2009.

*ABSTRACT: The Londonderry firefighters and their equipment are not properly 

restrained while performing patient care in the back of a moving ambulance. In 

the event of a crash the firefighter or the patient could be injured or killed due to 

this uncontrolled movement of personnel and equipment. This research is to 

evaluate the types and mechanisms of injuries to passengers in the back of a 

moving ambulance and to determine which methods are most effective in 

preventing such injuries. The purpose of this research is to prevent injury and 

death to firefighters and patients be transported in an ambulance. The descriptive 

research method was used to answer the following relevant questions: (1) What 

are the current mechanisms for preventing uncontrolled movement of firefighters 

while caring for patients in a moving ambulance? (2) What are the types and 

mechanisms of injury that occur to firefighters while riding in the patient 

compartment of a moving ambulance? (3) What strategies would have been 

successful in preventing uncontrolled movement during patient care, and how 

have these affected patient care? (4) What modifications can be made from 

technological and/or procedural perspective to decrease the effects of 

uncontrolled movement of firefighters riding in the patient compartment of a 

moving ambulance? The results focused upon necessary policy modifications, 

and the technological modifications needed for current in-service ambulances, 

current ambulance purchases and what to expect in the future. Finally advocating 

for comprehensive crash worthiness standards for ambulances including, federal 

oversight and crash testing to determine what changes need to be made in 

ambulance design. 
16

3.3 Layout & Space Design

Alejo, J.S., M.G. Martin, M. Ortega-Mier, and A. Garcia-Sanchez. “Mixed 

integer programming model for optimizing the layout of an ICU vehicle.” 

BMC Health Services Research, 2009, 9(224): pp 1-14. Accessed July 21, 

2011. doi: 10.1186/1472-6963-9-224.

*ABSTRACT: Background: This paper presents a Mixed Integer Programming 

(MIP) model for designing the layout of the Intensive Care Units' (ICUs) patient 

care space. In particular, this MIP model was developed for optimizing the layout 

for materials to be used in interventions. This work was developed within the 

framework of a joint project between the Madrid Technical University and the 

Medical Emergency Services of the Madrid Regional Government (SUMMA 112). 

Methods: The first task was to identify the relevant information to define the 

characteristics of the new vehicles and, in particular, to obtain a satisfactory 

interior layout to locate all the necessary materials. This information was 

gathered from health workers related to ICUs. With that information, an 

optimization model was developed in order to obtain a solution. From the MIP 

model, a first solution was obtained, consisting of a grid to locate the different 

materials needed for the ICUs. The outcome from the MIP model was discussed 

with health workers to tune the solution, and after slightly altering that solution to 

meet some requirements that had not been included in the mathematical model, 

the eventual solution was approved by the persons responsible for specifying the 

characteristics of the new vehicles. According to the opinion stated by the 

SUMMA 112's medical group responsible for improving the ambulances (the socalled "coaching group"), the outcome was highly satisfactory. Indeed, the final 

design served as a basis to draw up the requirements of a public tender. Results: 

As a result from solving the Optimization model, a grid was obtained to locate the 

different necessary materials for the ICUs. This grid had to be slightly altered to 

meet some requirements that had not been included in the mathematical model. 

The results were discussed with the persons responsible for specifying the 

characteristics of the new vehicles. Conclusion: The outcome was highly 

satisfactory. Indeed, the final design served as a basis to draw up the 

requirements of a public tender. The authors advocate this approach to address 

similar problems within the field of Health Services to improve the efficiency and 

the effectiveness of the processes involved. Problems such as those in operation 

rooms or emergency rooms, where the availability of a large amount of material 

is critical are eligible to be dealt with in a similar manner.

Ferreira, J., and S. Hignett. “Reviewing ambulance design for clinical 

efficiency and paramedic safety.” Applied Ergonomics, 2005, 36: pp 97-105.

*ABSTRACT: This study aimed to review the layout of the patient compartment in 

a UK ambulance for paramedic efficiency and safety using: (1) link analysis; (2) 

postural analysis. Paramedics were observed over 16 shifts (130 hours) carrying 

out a range of clinical tasks. The most frequently occurring clinical tasks were 
17

checking blood oxygen saturation, oxygen administration, monitoring the heart 

and checking blood pressure. Access to the equipment and consumables to 

support these tasks had been designed for the attendant seat (head end of the 

stretcher), however, a link analysis found that paramedics preferred to sit along 

side the stretcher which resulted in increased reach distances. The higher 

frequency tasks were found to include over 40 % of working postures which 

required corrective measures. It was concluded that future ambulance design 

should be based on an ergonomics analysis (including link analysis and postural 

analysis) of clinical activities.

Gilad, I., and E. Byran. “Ergonomic Evaluation of the Ambulance Interior to 

Reduce Paramedic Discomfort and Posture Stress.” Human Factors, 2007, 

49, pp 1019-1032.

*ABSTRACT: OBJECTIVE: This study aims to evaluate safety and accessibility 

of an advanced life support (ALS) ambulance interior. BACKGROUND: The 

standard ambulance's interior design is unsatisfactory based on perceived 

discomfort and postures that constrain paramedics and medical staff, resulting in 

unsafe treatment of patients, mainly when being transported. METHODS: Two 

procedures were used to evaluate performance during a wide range of rescue 

tasks: a survey, based on questionnaires, interviews, and observation of 

paramedics performing routine tasks; and upper body and back posture analysis, 

based on postural considerations. RESULTS: Findings revealed that 74 % of the 

paramedics stated that the location of the paramedic's seat is inefficient while 

they perform clinical procedures; 94 % found the bench uncomfortable; 77 % felt 

that the vertical distance between the bench and the stretcher is too far; and 86% 

needed to steady themselves when the vehicle was moving. Posture analysis 

showed that paramedics undergo several non-neutral back postures, including 

twisted back (>20°) and sitting with back flexion between 20 degrees and 45

degrees. CONCLUSION: Because the interior of the ALS ambulance was found 

to be unsatisfactory both to paramedics and patients, alternative design issues 

are proposed. APPLICATION: The suggested practical layout contains four main 

modifications: (a) replacing the bench with two adjustable paramedic seats, (b) 

redesigning the medical cabinet for easy access, (c) adding an adjustable folding 

seat opposite the two new seats, and (d) adding a swiveling base and lifting 

apparatus that will accommodate the stretcher and enable better accessibility to 

patients by the paramedic personnel.

Mueller, J. “Naturalistic data collection in rural emergency medical services 

transportation.” Paper presented at the annual national rural IIT Conference 

Student Paper Competition, 2010. 

*ABSTRACT: This paper examines the behaviors of emergency medical service 

(EMS) workers during emergency medical transport. The study uses an 

advanced naturalistic data collection system to record visual, vehicle, and 

accessory parameters associated with each ambulance trip. Visual data was 

analyzed to look at restraint characteristics, position within the ambulance data, 
18

and posture data to identify areas where medics are subject to poor working 

conditions.

Safar, P., and R.A. Brose. “Ambulance Design and Equipment for 

Resuscitation.” Archives of Surgery, 1965, 30(3): pp 343-348.

ABSTRACT: Improved emergency care for the critically ill or injured physician 

leadership in community-wide teaching and organization of (1) first aid; (2) 

ambulance transportation; and (3) hospital emergency room coverage. Airway 

obstruction, respiratory depression, and cardiac arrest from unconsciousness 

per se (e.g., head injury, poisoning) and from such conditions as drowning, 

coronary occlusion, electric shock, and others can often be prevented or 

reversed if the rescuer is trained in the proper techniques, begins resuscitation 

immediately, and continues resuscitation during transportation to the hospital. 

Modern inhalation therapy and resuscitation during transportation are often 

hampered by inadequate design and equipment. Personal experience with the 

deficiencies of existing ambulance design, experience with many resuscitations 

outside of ambulances, established principles of resuscitation, and successful 

use of some of the modifications recommended prompted us to write this paper. 

Locally, appropriate modifications were made on a model ambulance, which was 

used during the first nine months in 21 calls. Suction was used 4 times; oxygen, 

31 times; and bag-mask ventilation, 19 times, all satisfactorily. In addition, the 

new equipment was used successfully during manikin practice in the moving 

ambulance. 

Sanchez, F.J., A. Garcia-Sanchez, M. Ortega-Mier, and J.M. Lopez. “Design 

of the patient care space inside an ICU vehicle or ambulance through an 

optimization model.” International Journal of Heavy Vehicle Systems, 2010, 

17(1): pp 35-51.

*ABSTRACT: The primary results of a project aimed at improving interior patient 

care space design of Madrid (Spain) regional government medical emergency 

services intensive care units in vehicles such as ambulances are presented. To 

carry out the study, researchers gathered data and criteria from health workers, 

from which they developed an optimization model. This model allowed them to 

obtain a solution as to how to locate all medical health materials and equipment 

so that the more critical and frequent operations could be performed. These 

operations needed to be done in with shortest possible time, without interfering 

with the efforts of health care workers and with materials as close as possible to 

person needing the equipment.

Snook, R. “Medical Aspects of Ambulance Design.” British Medical 

Journal, 1972, 3: pp 574-578.

*ABSTRACT: Various observations have shown that the interior layout of many 

ambulances leaves much to be desired. The lighting levels are inadequate, heat 

loss could be prevented, vehicle identification and passage through traffic could 

be improved, and measurable differences exist between the ride characteristics 

of commercially available ambulances, a prototype purpose-built ambulance, and 
19

a private car. Moreover the condition of some patients may be affected by the 

motion of the vehicle either directly or indirectly. Even though they form a small 

percentage of the total number carried, they represent a very considerable 

financial risk. A personally conducted survey of ambulance chief officers showed 

a deep interest and involvement in the upgrading of the service with a general 

dissatisfaction with many of the vehicles currently available. Hence there is a 

market for the purpose-built ambulance, which would benefit the patient and the 

ambulanceman alike.

The inadequacies of many vehicles currently in use as ambulances have been 

shown to work against the interests of the patient requiring life support treatment, 

and it is suggested that this warrants urgent attention and action. A more 

extensive research project involving medical observations on the supine sick and 

injured, attendant task performance, and instrumentation analysis of linear and 

angular vehicle motions should enable the harmful effects of ride motion to be 

identified.

None of these investigations, however, will be of any value unless they are used 

in developing future ambulances. Such development must also parallel an 

increase in the awareness of the importance of ambulance design and its relation 

to the increased comfort and chance of survival of the patients carried.
20

3.4 Crash Test Procedures

Current, R.S., P.H. Moore, J.D. Green, J.R. Yannaccone, G.R. Whitman, and 

L.A. Sicher. “Crash Testing of Ambulance Chassis Cab Vehicles.” 

Presented at the SAE 2007 Commercial Vehicle Engineering Congress & 

Exhibition, October 2007.

*ABSTRACT: The National Institute for Occupational Safety and Health (NIOSH), 

in cooperation with the Canadian Forces Health Services Group Headquarters, 

U.S. Army Tank-Automotive and Armaments Command (TACOM), and the 

Ministry of Health & Long-Term Care, Ontario (Canada), conducted a test 

program to evaluate the capability of mobile restraint systems to protect 

occupants in the patient compartment of an ambulance. This paper focuses on 

the vehicle chassis behavior and acceleration pulses as seen in each test 

conducted to support the program. This program consisted of testing one Type I 

ambulance mounted on a Ford F-350 truck chassis (1994 vintage), and three 

Type III ambulances mounted on Ford E-350 van chassis (two 1993, and one 

1999 vintage). A vehicle-to-vehicle side impact test was conducted using the 

Type I ambulance with a targeted change in velocity of 27.4 kph (17 mph). A 

1984 Chevrolet Sierra 2500 was the impacting vehicle for the side test. Fixed 

barrier frontal tests were conducted using the Type III ambulances with a 

targeted impact velocity of 48 kph (30 mph). In addition to an x-axis, or forward 

component, each of the frontal crash pulses was found to have a significant zaxis, or vertical, component which caused a forward rotation of the patient 

compartment ranging up to approximately 16.5 degrees. Significant cab-intrusion 

was observed as a result of the frontal tests that were conducted. Vehicle 

weights ranged up to 5005 kg (11,035 lbs.) and were similar to operational 

weight conditions. The paper includes a detailed description of the crash test 

setup as it pertains to the chassis, vehicles tested, instrumentation, limited crush 

measurements, testing observations, and the resulting multi-axial pulses 

measured at multiple frame and patient compartment locations. This data will be 

of interest to ambulance and other multi-stage vehicle manufacturers for use in 

design, modeling, and sled testing.

Levick, N.R., B.R. Donnelly, A. Blatt, G. Gillespie, and M. Schultze. 

“Ambulance Crashworthiness and Occupant Dynamics in Vehicle-ToVehicle Crash Tests: Preliminary Report.” Paper presented at the 

proceedings of the 17th International Technical Conference on the 

Enhanced Safety of Vehicles, Amsterdam, Netherlands, June 2001.

*ABSTRACT: There are no dynamic safety testing standards specifically for 

ambulance vehicles in the USA. These vehicles have also been identified to have 

high crash injury and fatality rates per mile, with a majority of the fatalities 

involving either an intersection or a frontal crash. This study is an interim report 

on work in progress which demonstrates occupant safety and crashworthiness of 

ambulance vehicles in vehicle to vehicle intersection type crash tests. The 

ambulance vehicles were configured with instrumented ATDs (Anthropomorphic 
21

Test Dummies) to represent 95th percentile male, 5th percentile female and 3 

year child occupants. A ‘real world’ configuration of these ATDs and some 

medical equipment was established for a frontal and side impact crash test. The 

findings demonstrated life threatening safety hazards for all occupants. Also 

measured crash pulses for both the vehicle and the interior components were 

obtained. The urgent need for improvements to ambulance crash safety 

standards and designs are discussed.

Levick, N.R., and R. Grzebieta. “Development of Proposed Crash Test 

Procedures for Ambulance Vehicles.” Paper presented for Enhanced Safety 

of Vehicles Conference, Lyon, France, June 18-21, 2007.

*ABSTRACT: Ambulance vehicles are a unique passenger environment with 

complex crashworthiness and occupant protection issues, e.g. occupants in 

various orientations, unique human factors aspects and an array of aftermarket 

interior modifications. In the USA, ambulance vehicle occupant protection, 

crashworthiness and safety testing lags 30 years behind current general 

automotive safety technology. This paper proposes crash test procedures and 

outlines some of the challenges faced for such vehicles based on manufacturer 

and consumer conducted pre-modification crash tests and previous ambulance 

sled and full scale crash tests. A typical ambulance vehicle from one of the 

largest fleets globally, was addressed. Based on manufacturer specifications, 

crash test data for the vehicle, inspections and other published data regarding 

ambulance vehicle crashes, sled and crash testing were considered – an 

approach to an impact testing procedure is outlined and developed by a 

multidisciplinary team. Assessment and development focused on vehicle 

crashworthiness performance and real world human factors aspects of 

aftermarket interior modifications. Frontal and side impact crashworthiness 

testing profiles for this vehicle were determined and developed inline with 

parameters outlined in ASA 4535 (ambulance restraint systems standard) and 

the CEN 1789 standard. The testing profiles include a recumbent occupant, rear 

and forward facing seated occupants, 50th and 95th percentile ATDs, including 

side impact ATDs for seating positions exposed to side impacts. The authors 

propose that ambulance vehicle safety testing and design should be driven by 

accepted automotive safety practice. In a setting of high crash rates, a complex 

occupant and emergency care environment, and the absence of prescribed 

dynamic crashworthiness test procedures for ambulances - the proposed test 

procedures in this paper provide a first approach to describe the approach to the 

technical development of comprehensive crash testing profiles in this setting. 

Such profiles for this environment will ensure that system safety can be 

ascertained and optimized for these vehicles, and support safety enhancements 

and occupant protection for ambulance vehicle development.

Levick, N.R., and R. Grzebieta. “USA Ambulance Crashworthiness Frontal 

Impact Testing.” Paper presented at the 21st International Technical 

Conference on the Enhanced Safety of Vehicles Conference (ESV) -

International Congress Center, Stuttgart, Germany, June 15-18, 2009.
22

*ABSTRACT: Recent epidemiological studies have identified ambulances as high 

risk passenger transport vehicles, particularly the rear compartment. It appears 

in the absence of USA ambulance safety standards or guidelines, non engineer 

end-users are driving changes in practice and policy in place of independent peer 

reviewed biomechanical and crash injury outcome data. This study’s objective is 

to compare and analyze frontal crash biomechanical and crashworthiness 

research for ambulance vehicles, with a focus on application of the real world 

environment, and development needs for future standards. Frontal impact 

ambulance crashworthiness tests conducted over past 15 years, were identified 

and evaluated with a multidisciplinary approach consisting of automotive 

crashworthiness, emergency medicine, public health and EMS care delivery. 

Crash test data identified include: 25 g-force (gravitational force) to 34 g-force

deceleration sled tests (delta V 33.6 km/h (20.9 mph) to 52.0 km/h (32.3 mph)); 

one full crash test of a bullet vehicle travelling at 57.9 km/h (36 mph) crashing 

into another vehicle, impact Delta V of 30 km/h (18.5 mph) and deceleration of 14

g-forces to the rear compartment; and three fixed barrier frontal tests at a 40

km/h (25 mph) delta V and 25 g-force impacts. There appeared to be a lack of 

correlation with real world crash forces in the conduct of the rigid barrier tests. 

The use of data from side facing occupants was also confounding. Ambulance 

crashworthiness is a complex system. Clearly demonstrated hazards have been 

identified in the limited real world crash injury/fatality data and the crash test data 

available. Testing must be based on meaningful real world parameters such as 

the forces that occur in actual crashes and the types of injury and fatality hazards 

to the occupants, so that development of standards and thus the design and 

construction of ambulance vehicles, can be focused to achieve adequate levels 

of occupant protection using current crashworthiness methodology already 

utilized in industry.
23

3.5 Other Research & Proposed Solutions

Catchpole, K., and D. McKeown. “A framework for the design of ambulance 

sirens.” Ergonomics, 2007, 50(8): pp 1287-1301.

*ABSTRACT: Ambulance sirens are essential for assisting the safe and rapid 

arrival of an ambulance at the scene of an emergency. In this study, the 

parameters upon which sirens may be designed were examined and a 

framework for emergency vehicle siren design was proposed. Validity for the 

framework was supported through acoustic measurements and the evaluation of 

ambulance transit times over 240 emergency runs using two different siren 

systems. Modifying existing siren sounds to add high frequency content would 

improve vehicle penetration, detectability and sound localization cues, and 

mounting the siren behind the radiator grill, rather than on the light bar or under 

the wheel arch, would provide less unwanted noise while maintaining or 

improving the effective distance in front of the vehicle. Ultimately, these 

considerations will benefit any new attempt to design auditory warnings for the 

emergency services.

Cooper, G., and E. Ghassemieh. “Risk assessment of patient handling with 

ambulance stretcher systems (ramp/(winch), easi-loader, tail-lift) using 

biomechanical failure criteria.” Medical Engineering & Physics, 2007, 29: 

775-787.

*ABSTRACT: The research aims to carry out a detailed analysis of the loads 

applied by the ambulance workers when loading/unloading ambulance 

stretchers. The forces required of the ambulance workers for each system are 

measured using a load cell in a force handle arrangement. The process of 

loading and unloading is video recorded for all the systems to register the 

posture of the ambulance workers in different stages of the process. The 

postures and forces exerted by the ambulance workers are analyzed using 

biomechanical assessment software to examine if the work loads at any stage of 

the process are harmful. Kinetic analysis of each stretcher loading system is 

performed. Comparison of the kinetic analysis and measurements shows very 

close agreement for most of the cases. The force analysis results are evaluated 

against derived failure criteria. The evaluation is extended to a biomechanical 

failure analysis of the ambulance worker's lower back using 3DSSPP software 

developed at the Centre for Ergonomics at the University of Michigan. The critical 

tasks of each ambulance worker during the loading and unloading operations for 

each system are identified. Design recommendations are made to reduce the 

forces exerted based on loading requirements from the kinetic analysis.

Federal Emergency Management Agency. Emergency Vehicle Visibility and 

Conspicuity Study. FA-323, August 2009.

*ABSTRACT: Over the past decade, numerous law enforcement officers, 

firefighters, and emergency medical services (EMS) workers were injured or 

killed along roadways throughout the United States. In 2008, as with the prior 10 
24

years, more law enforcement officers died in traffic-related incidents than from 

any other cause; National Law Enforcement Officers Memorial (NLEOM, 2008) 

over the past 12 years, an average of one officer per month was struck and killed 

by a vehicle in the United States. (FBI, 2007) Preliminary firefighter fatality 

statistics for 2008 ref lect 29 of 114 firefighters killed on duty perished in motor 

vehicle crashes, (USFA, 2009a) similar to figures posted in previous years. 

According to a 2002 study (Maguire, et al.) that aggregated data from several 

independent sources, at least 67 EMS providers were killed in ground 

transportation-related events over the 6 years from 1992 to 1997. 

These sobering facts clearly demonstrate the importance of addressing vehicle 

characteristics and human factors for reducing the morbidity and mortality of 

public safety personnel operating along the Nation's highways and byways. 

Studies conducted in the United States and elsewhere suggest that increasing 

emergency vehicle visibility and conspicuity holds promise for enhancing first 

responders' safety when exposed to traffic both inside and outside their response 

vehicles (e.g., patrol cars, motorcycles, fire apparatus, and ambulances). 

This report, produced in partnership between the U.S. Fire Administration 

(USFA) and the International Fire Service Training Association (IFSTA), with 

support from the U.S. Department of Justice (DOJ), National Institute of Justice 

(NIJ), analyzes emergency vehicle visibility and conspicuity with an eye toward 

expanding efforts in these areas to improve vehicle and roadway operations 

safety for all emergency responders. Emphasis in this report is placed on passive 

visibility/conspicuity treatments; additional studies are underway on active 

technologies such as emergency vehicle warning lighting systems. (USFA, 

2009b) 

A number of key findings were developed from the examination performed for 

this report. Principal among these findings is the salient need for additional 

research on emergency vehicle visibility and conspicuity in the United States, 

with particular emphasis on the interaction between civilian drivers and 

emergency vehicles during responses and on incident scenes.

Despite meaningful limitations, the existing visibility/conspicuity research, 

combined with passenger vehicle lighting and human factors, evokes several 

potential opportunities for improving the safety of emergency vehicles in the 

United States using readily available products.

Hunt, R.C., L.H. Brown, E.S. Cabinum, T.W. Whitley, H. Prasad, C.F. Owens, 

and C.E. Mayo. “Is ambulance transport time with lights and siren faster 

than that without?” Annals of Emergency Medicine, 1995, 25(4): pp 507-511.

*ABSTRACT: STUDY OBJECTIVE: To determine whether ambulance transport 

time from the scene to the emergency department is faster with warning lights 

and siren than that without. DESIGN: In a convenience sample, transport times 

and routes of ambulances using lights and sirens were recorded by an observer. 

The time also was recorded by a paramedic who drove an ambulance without 

lights and siren over identical routes during simulated transports at the same time 

of day and on the same day of the week as the corresponding lights-and-siren 

transport. SETTING: An emergency medical service system in a city with a 
25

population of 46,000. PARTICIPANTS: Emergency medical technicians and 

paramedics. RESULTS: Fifty transport times with lights and siren averaged 43.5 

seconds faster than the transport times without lights and siren [t = 4.21, P = 

.0001]. CONCLUSION: In this setting, the 43.5 second mean time savings does 

not warrant the use of lights and siren during ambulance transport, except in rare 

situations or clinical circumstances.

Jones, A., and S. Hignett. “Safe access/egress systems for emergency 

ambulances.” Emergency Medicine Journal, 2007, 24: pp 200-205.

Accessed on July 25, 2011. doi: 10.1136/emj.2006.041707.

*ABSTRACT: OBJECTIVETo comparatively evaluate the three most widely used 

ambulance stretcher loading systems; easi-loader, ramp/winch and tail lift to 

identify a preferred system based on safety and usability evidence. METHODS: 

Three data types were collected in the field, the laboratory and from a national 

questionnaire. Field data were collected using the qualitative methods of 

observation (link analysis and hierarchical task analysis) and interview (critical 

incident technique) over 12 months during 2004–5. Laboratory data were 

collected for detailed postural analysis. A national ranking questionnaire was 

used to prioritize the resulting design issues. RESULTS: The field study data 

were analyzed, triangulated and summarized in a taxonomy to identify the design 

and operational issues. A list of 14 criteria was used in a national ranking 

exercise with 134 ambulance staff and manufacturers. Patient and operator 

safety was ranked as the highest priority, followed by manual handling. The 

postural analysis found that the easi-loader system presented the highest 

postural risk. CONCLUSION: The tail lift was found to be the preferred and safest 

loading system from both the field and laboratory research and is the 

recommended option from the evaluated loading systems.

Karsh, B.T. “Clinical practice improvement and redesign: how change in 

workflow can be supported by clinical decision support.” Prepared for 

Agency for Healthcare Research and Quality, Rockville, Maryland, June 

2009.

ABSTRACT: Clinical decision support (CDS) automation has the potential to 

improve the quality of the health care and patient safety. Essentially, CDS 

automation is a system that provides clinicians with computerized clinical data 

and is typically designed to aid decisionmaking in regards to clinical procedures.

Unfortunately, CDS automation has not been fully implemented in ambulance 

care as it has yet to be integrated with the realities of clinical workflow. Methods 

already exist to measure the workflow and improving them, and these methods 

can be implemented in order to implement CDS automation and make sure that 

CDS automation works at the right time for the range of its users.

Kelly, K.M. “Building an Ambulance: ambulance manufacturing is as much

about design, engineering and technology as it is durability and

functionality.” Automotive Design & Production, April 2009, 121(4).
26

*ABSTRACT: Braun Industries in Van Wert, OH, manufactures up to 350 

ambulances each year for some of the largest municipal fleets in the country, 

including Chicago, Boston and Miami-Dade. Since the needs of each fire 

department and non-municipal customer differ, the company's applications 

engineering department must pay careful attention identifying the equipment and 

layout needed to fulfill customer requirements--down to the location of oxygen 

outlets, auxiliary control panels and cabinetry--a process that requires working 

with more than 600 medical and safety equipment suppliers. Once the details 

have been nailed down, the design engineering group uses SolidWorks to 

develop 3D CAD files outlining the exact number of pieces needed--anywhere 

from 300 to more than 900-to build the box that is fitted on the back of the cab. 

Concurrently, electrical engineers verify the equipment selected by the customer 

will work within Braun's peer-to-peer multiplex electrical architecture. Once the 

design has been approved, the fabrication department converts the SolidWorks 

files onto SigmaNest, which automatically optimizes the layout of parts on each 

of the 2.4 m (8 ft) and 3.66 m (12 ft) sheets of 3.175 mm (1/8 in) thick marinegrade aluminum, reducing waste and improving efficiency. The parts are cut with 

a plasma torch, Trumpf punch or Komo router, then brake formed; it takes an 

average of 4 hours to cut as many as 80 sheets of parts for each box. The use of 

SigmaNest also allows Braun to store detailed specifications for each truck in a 

database for reference in case replacement parts need to be fabricated on short 

notice. All of the pieces are sent to the welding shop where they are spot welded 

together by hand, completing the basic box assembly. Then it moves onto paint. 

The box moves to final assembly, where lean manufacturing principles are 

followed. The 10219.3 sq meters (110000 sq ft) assembly hall is arranged by 

"value streams": chassis prep, fabrication and quality. The combined chassis and 

box--now called an "ambulance"-travel through the assembly process via a "work 

center" arrangement, defined as specific areas of assembly, such as electrical or 

upholstery. Parts are kitted by truck number and delivered line-side for each of 

the work centers; there are up to five work centers per assembly station. Once 

the kitted parts are placed on the truck, the ambulance is moved to the next 

station, where another work center is completed. The entire build process, from 

the first cut of aluminum to the final quality check, takes up to 35 days, with cost 

ranging from $85000 to $350000.

Levick, N.R. “Emergency Medical Services: A Unique Transportation Safety 

Challenge.” Paper presented at the Transportation Research Board’s 87th 

Annual Meeting, Washington DC, 2008.

*ABSTRACT: Emergency Medical Service (EMS) is an essential and 

transportation based emergency service, and now key component of the new 

SAFETEA-LU required State Strategic Highway Safety Plans. Ground EMS 

responds to approximately 30 million emergency medical/injury calls annually. In 

contrast to other commercial transport vehicles, ambulance transport safety is 

not currently encompassed by the Federal Motor Carrier Safety Administration 

(FMCSA), nor formally by any other overseeing body and hence the safety 

oversight of this transport system is fragmented and largely devoid of current 
27

technical transportation safety input. This is of serious concern, particularly when 

the crash fatality rate for these EMS vehicles per mile traveled is estimated to be 

in excess of 10 fold higher than that for heavy trucks. Additionally there are 

ambulance ‘wake effect’ crashes, with rates in excess of five fold of the identified 

ambulance crash rates. These deficiencies in EMS transportation safety process 

range in spectrum from safety performance data capture, to transportation 

system safety engineering, and vehicle design, vehicle safety performance and 

occupant protection. There is also no process for formal knowledge transfer of 

existing transportation safety understanding and expertise or vehicle design and 

safety technical expertise either from the commercial vehicle industry or the 

automotive safety industry to the ambulance industry. This paper identifies some 

of the unique challenges of this EMS transportation system and addresses 

existing and innovative approaches for augmenting knowledge transfer potential 

from other transportation areas to enhance the safety of this special 

transportation system.

Nunnally, M., C.P. Nemeth, V. Brunetti, and R. Cook. “Lost in Menuspace: 

User Interactions with Complex Medical Devices.” IEEE Transactions on 

Systems, Man and Cybernetics, Part A: Systems and Humans, 2004, 34(6): 

pp 736-742.

*ABSTRACT: The advent of fast-acting drugs has made the infusion pump the 

most pervasive electronic medical device in the acute care (hospital) 

environment. Despite the importance of its correct operation, incident reports in 

the US Food and Drug Administration (FDA) database implicate interface 

programming as a significant aspect of adverse outcomes. This article describes 

a study of infusion pump-programming performance by experienced healthcare 

professionals in a major urban teaching hospital. Early findings indicate that 

practitioner experience with device programming does not increase proficiency. 

This suggests that a complex menu structure ("menuspace") makes 

programming difficult and inefficient in ways that impede practitioner 

development of mental models that are sufficient for reliable device operation. 

This causes operators to become disoriented in the interface structure, or "lost in 

menuspace." We relate these findings to the current study of the USFDA adverse 

events reports and indicate directions for further research.

Paul, S.A., M. Reddy, and J. Abraham. “Collaborative Sensemaking during 

Emergency Crisis Response: How do ICTs help?” Poster presented at 

GROUP 2007, Sanibel Island, Florida, 2007.

*ABSTRACT: Sensemaking is the process of understanding an unfamiliar 

situation in order to act effectively. Crisis response requires emergency 

departments and emergency medical services teams to collaboratively make 

sense of an uncertain and unfamiliar situation. We conducted focus groups to 

examine how information and communication technologies help collaborative 

sensemaking across response teams. We found that communication of 

information was a key aspect of sensemaking and communication tools like the 

radio, phones, pagers, and paper were preferred to computer-based systems for 
28

sensemaking among teams. Our findings highlight the need to develop new 

information systems, or enhance existing ones, for supporting collaborative 

sensemaking among geographically-distributed teams engaged in time-critical 

work. 

Paxton, J.A. “Improving the Safety of EMS Personnel in the Patient 

Compartment of Violet Township Fire Department EMS Transport 

Vehicles.” A research project submitted to the Ohio Fire Executive Fire 

Program, July 15, 2009.

*ABSTRACT: The problem this study will investigate is how to safely secure 

Violet Township Fire Department (VTFD) personnel during EMS transports, while 

maintaining sufficient operational mobility. The purpose of this project is to 

identify and to describe restraint options that will guide the VTFD in decision 

making that can improve the safety of crew members while performing patient 

care during EMS transport. The research design consisted of three segments: an 

internal survey of the VTFD membership, the review of the current styles and 

trends in ambulance manufacturing, and an examination of the ambulances of 

neighboring jurisdictions. 

RESEARCH QUESTIONS: The following questions will be answered by this evaluative 

research: (1) What options are available to restrain EMS/firefighter personnel, while still 

allowing the needed mobility for patient care? (2) What are other fire departments 

doing to address this same problem? (3) What can the VTFD do to improve the 

safety of its current EMS transport vehicles? (4) What engineering options are 

available and could be utilized to provide increased occupant safety in future 

VTFD EMS transport vehicles? 

The internal survey identified the occupational habits and tendencies of the 

VTFD EMS crews. The survey identified that the EMS crews in the VTFD 

ambulances were riding in the side-facing bench seats 93 % of the time. The 

survey further found mobility as the factor most likely to dictate seatbelt use by 

the patient attendant during transport. There was a 35 % reduction in seatbelt 

usage when transporting critical or unstable patients. The answers to the survey 

remained largely unaffected by time on the department or years of EMS 

experience. A review of several ambulance manufacturers found growing trends 

towards the development of safer vehicles. A look at nearby fire departments 

revealed few safety enhancements to their ambulances. 

Recommendations for improving crewmember safety during EMS transport: (1) Upgrade 

the existing lap belt restraints in the current medics. (2) Continue researching ways to 

improve existing and future EMS vehicles. (3) Establish a committee to redesign 

the VTFD ambulance of the future. (4) Increase education/awareness of the 

VTFD. (5) Incorporate emergency vehicle driver’s training into the department’s 

routine. (6) Adjust the placement of supplies and equipment in the current 

ambulances to reflect the needs and or limitations of a single attendant.

Poulymenopoulou, M., F. Malamateniou, and G. Vassilacopoulos. 

“Specifying workflow process requirements for an emergency medical 

service.” Journal of Medical Systems, 2003, 27(4): pp 325-335.
29

*ABSTRACT: Recent trends in healthcare delivery have led to a gradual shift in 

the conceptualization of healthcare information systems towards supporting 

healthcare processes in a more direct way. The move towards integrated and 

managed care, which requires designing healthcare processes around patient 

needs and incorporating efficiency considerations has led to an increased 

interest in process-oriented healthcare information systems based on workflow 

technology. This means to actively deliver the tasks to be performed to the right 

persons at the right time with the necessary information and the application 

functions needed. Moreover, workflow technology promotes a componentoriented development whereby the process logic is separated from application 

logic. This paper presents an approach to capturing process logic requirements 

for healthcare workflow systems with a view to design a system that is easily 

adjustable to process changes and to evolving organizational structures at a 

reasonable cost.

Snook, R., and R. Pacifico. “Ambulance ride: fixed or floating stretcher?” 

British Medical Journal, 1976, 2: pp 405-407.

*ABSTRACT: The alternatives of a purpose-built ambulance and a specially 

designed stretcher suspension system were considered and the features of the 

latter assessed by subjective and objective tests. The results showed a 

significant improvement in the quality of the ride offered to the patient.
30

3.6 Overall Design Evaluations and Examples

Bothwell, P.W. “An ambulance designed for the patient and crew.” Public 

Health, 1960, 74(12): pp 459-464.

*ABSTRACT: An ambulance should be regarded as an important piece of 

specialized medical equipment and should be designed as such. It is of as much 

importance to get this piece of “socio-medical” apparatus correctly designed as it 

is to have correctly designed electrocardiographs, X-ray apparatus and 

electroencephalographs. All these pieces of equipment required combined 

medical and technical attention to suit them to their tasks. Ambulances exist for 

patients and crew, operate in society, and need to be designed accordingly.

A brief account is given of an ambulance design in which the above 

considerations have been kept in mind and the layout of the proposed 

suspension and lowering mechanism is shown diagrammatically. Reference is 

made to the general need to study the human engineering aspects of “sociomedical apparatus”.

EMS World. “Next Generation Ambulance Puts Safety First.” Accessed July 

20, 2011. http://www.emsworld.com/print/EMS-World/Next-GenerationAmbulance-Puts-Safety-First/1$2481.

ABSTRACT: The American Medical Response (AMR) and the American 

Emergency Vehicles collaborated and presented a second-generation 

ambulance safety vehicle, called the Concept Ambulance-II or C2, in the 2005 

EMS Expo. It boasts safety features such as two external cameras that allow the 

driver to monitor blind spots from the cab, and rear crew seats that are 

strategically located for optimal patient care and configured with four different 

types of safety harnesses that don't inhibit that care. All have five- or six-point 

harness systems that lock during sudden deceleration; cargo nets installed along 

internal voids, such as the curbside door well, to stop providers from striking the 

bulkhead; locking docking ports to secure patient-compartment equipment like 

EKG (electrocardiograph) monitor/defibrillators and eliminate "missiles" in a 

crash. Furthermore, it boasts all extra oxygen tanks being stored externally; turnsignal indicators and brake lighting installed in the back of the ambulance to warn 

providers delivering patient care of changes in direction and braking; a "black 

box" on-board computer system that records vehicle speed, monitors driving 

behavior and warns the driver about maneuvers that exceed preset safety 

parameters; reflective paint to make the vehicle more conspicuous; and a unique 

lighting package that includes amber caution lights that flash at motorists' eye 

level, LED emergency warning lights and under-body illumination. The price tag 

is about $200000, which is approximately 100 % higher than normal ambulance 

vehicles.

Hignett, S., E. Crumpton, and R. Coleman. “Designing emergency 

ambulances for the 21st century.” Emergency Medicine Journal, 2009, 

26(1): pp 135-140.

*ABSTRACT: BACKGROUND: In 2005 the Department of Health set out a vision 
31

for the provision of future ambulance services with an increasing range of quality 

mobile healthcare services for patients with urgent and emergency care needs. 

This paper describes a scoping study funded by the National Patient Safety 

Agency and Ambulance Service Association to investigate the short and longer 

term requirements of future emergency ambulances. METHOD: Four stakeholder 

workshops were held to explore the wishes, concerns and preferences of the 

clinicians, operational staff and manufacturers about the future provision of 

ambulance services and problems and possible solutions relating to ambulance 

design and use. Incident reports relating to ambulance design and use were 

reviewed from three national and international databases. RESULTS: Nine 

design challenges were identified: access/egress; space and layout; securing 

people and equipment in transit; communication; security, violence and 

aggression; hygiene; equipment; vehicle engineering; patient experience. These 

were validated at the national UK ambulance conference (AMBEX 2006) with a 

rating questionnaire. CONCLUSION: The results are being used in the 

development of a national specification for future UK emergency ambulances.

Levick, N.R., and R. Grzebieta. “Ambulance vehicle crashworthiness and 

passive safety design -- A comparative evaluation of Australian and USA 

design and testing standards.” Presentation given at the 12th International 

Conference on Emergency Medicine, San Francisco, California, April 3-4, 

2008.

*ABSTRACT: Ambulances are largely exempt from crashworthiness and 

occupant protection passive safety design standards in the USA, and have a 

poor road safety record. This comparative evaluation of USA ‘concept safety’ 

ambulances and a standard Australian ambulance is based on basic principles of 

crashworthiness and available crash test data. There are features of USA 

ambulance design that are not within known principles and technical aspects of 

crashworthiness and safety design, and include some predictable serious 

occupant protection hazards. The USA ambulance industry should recognize and 

apply crashworthiness and occupant protection principles to reduce current 

system failures for this fleet of essential service vehicles.

Levick, N.R., and R. Grzebieta. “Crashworthiness Analysis of Three 

Prototype Ambulance Vehicles.” Paper presented at the 20th International 

Technical Conference on the Enhanced Safety of Vehicles Conference 

(ESV: Enhanced Safety of Vehicles) in Lyon, France, June 18-21, 2007.

*ABSTRACT: This paper is an evaluation of the predicted safety performance of 

three USA prototype ambulance vehicles with aftermarket structural 

modifications. Expected safety performance was analyzed using existing and 

established automotive safety principles. Information on design and construction 

of the vehicles was identified, and evaluated via application of basic engineering 

crashworthiness principles and laws of physics, with a specific focus on 

countermeasure design for reducing harmful loading and injury causation 

potential in crashes or sudden decelerations. Data sources used for the analysis 
32

included: vehicle specifications, inspections, photographs, crash tests and 

published crashworthiness and injury mitigation literature. Results demonstrated 

poor vehicle structural integrity and crashworthiness for these aftermarket 

modified ambulance vehicles. Assessed crashworthiness performance and 

occupant protection do not appear optimized even for the minimally structurally 

modified van. Current interior design features (seat design, patient transport 

device design, head strike zones and restraint systems) and layout,

demonstrated predictable serious crashworthiness and occupant protection 

hazards. These are projected findings, rather than actual crashworthiness tests –

however this is the first comparative automotive safety evaluation of prototype 

ambulance vehicles. This is key information for a major fleet of vehicles globally 

which has had minimal automotive safety attention or input to date. From this 

study it appears there are major deficiencies in safety design of these prototypes. 

Emphasis on a passenger compartment that has crashworthy features, effective 

seat design, based on existing literature and a clear focus on occupant human 

factors and equipment location and anchors, could provide for major safety 

enhancements for ambulance vehicles. There is need for vehicle safety

researchers, ambulance industry and vehicle designers to recognize and apply 

these existing principles to reduce current failures in an important and essential 

service that appears to have a poor safety record, considerably below that of 

other passenger (Maguire 2003, Ray 2005, Levick 2006) and also other 

commercial vehicles (FMCSA).

Medtec Ambulance Corporation. ActionSafe Interior Configuration.

Goshen, IN : Medtec Ambulance Corporation.

ABSTRACT: This is a redesign of the interior ambulance patient compartment 

layout that reduces the need of the Emergency Medical Service (EMS) worker’s 

movements around in the compartment. According to Medtec, their ActionSafe 

interior configuration is designed to maximize the EMS working environment by: 

incorporating 5-point safety harnesses, keeping equipment and controls at arm’s 

reach, increasing head space, adding padding throughout the compartment, and 

tapering and flaring cabinets away from impact zones.

National Patient Safety Agency (UK). Design for Patient Safety: Future 

Ambulances. NRLS 0463.

*ABSTRACT: The purpose of this joint National Patient Safety Agency (NPSA) 

and Helen Hamlyn Trust report is to promote discussion and innovative decisionmaking by NHS ambulance trusts in England and Wales, and to provide the NHS 

Purchasing and Supply Agency (PaSA) with safety criteria for the purchasing of 

ambulances. The NHS ambulance services are undergoing rapid change and 

modernisation, providing an opportunity for a servicewide approach to design 

and procurement to enhance safety.

The report sets out a three-stage design direction, for implementation over the 

next five to 10 years, to support standardisation and improvement of vehicle 

design; ensure equipment reliability and compatibility; and subsequently meet the 

evolving demands on NHS ambulance services.
33

National Patient Safety Agency (UK). Designing Future Ambulance 

Transport for Patient Safety: Research Undertaken. NRLS 0465.

*ABSTRACT: This first scoping study aims to investigate the developing models 

of service provision and the short and long term requirements of vehicles and 

equipment that will be needed to address the concerns of patient and staff safety 

in the future in the Ambulance Service. Three types of data were collected: 

archival incident reports, research literature and empirical data from workshops. 

The archival data were collected from three sources about reported incidents 

relating to ambulance, ambulance equipment design and use, and patient and 

staff safety. The research literature review was used to not only set out the 

background context but also to develop the conceptual framework for the 

analysis of the workshop data. Empirical data were collected from four user 

workshops. A dataset of 1352 incidents was received from the National 

Reporting and Learning System (NRLS) database and 1259 were retrieved from 

the Manufacturer and User facility Device Experience (MAUDE) database. Ten 

ambulance trusts responded to a request for information (from the 32 trusts 

contacted). After the analysis of the workshop data, the incident reports were 

reviewed and coded into the nine design challenges: Access/egress; space and 

layout; securing people and equipment in transit; communication; security, 

violence, and aggression; hygiene; equipment; vehicle engineering; patient 

experience. The data from the workbooks at the strategic workshop were 

analyzed thematically to identify six core areas of service provision. These areas 

of service provision were used as the discussion framework at the manufacturer 

and operational workshops. The data from the operational workshops were 

coded in two stages to allow for iterative analysis and further exploration of codes 

and themes. The coding by Roger Coleman/Merih Kunur resulted in two distinct 

design outputs for (1) design issues and (2) problems/ features. These codes 

were then scrutinized by Emma Crumpton, resulting in the 31 codes. At this 

stage a detailed secondary coding was conducted within the codes to identify 

nine higher level codes and address duplication between codes (Emma 

Crumpton/Sally Halls). These design challenges were further checked against 

the primary coding by Sally Halls to confirm inclusiveness. There was found to be 

a divergence between the NRLS data and the incidents reported by the individual 

trusts for some of the design challenges, for example securing people and 

equipment in transit, and equipment. There are a number of possible causes for 

this divergence, including the design of the NRLS interface and subsequent data 

input. Particular areas needing further research are communication, hygiene and 

the patient experience.

Van Gogh, D., K. Kawakami, and H. Shimizu. “Design Concept of Electric 

Vehicle Ambulance.” Journal of Asian Electric Vehicles, 2005, 3(1): pp 713-

719.

*ABSTRACT: Today’s emergency transportation by internal combustion engine 

ambulances has many problems: it has a high vibration for the patient and the 

medics, it has a limited size of workstation for the medical treatment, it slowly
34

accelerates with jolts and it has a high floor base which makes driving unstable 

while cornering. An Electric Vehicle ambulance, EV ambulance, is proposed to 

solve all this problems. The structural design of today’s ambulance is compared 

with the design concept of an EV ambulance. The EV component technologies 

of an in-wheel drive, component built-in frame and tandem suspension system 

are applied to the EV ambulance. Four types of ambulances are presented: one 

based upon the average outer dimensions of a conventional ambulance, second 

based upon the average inner dimensions of workspace of the medics, third with 

a driver seat in the middle of the cabin and finally with a driver seat on an

elevated position. A dual direction drive is applied in the ambulance and one 

type of EV ambulance its length is reduced to 2 m so that it can enter into 

buildings. The EV ambulances illustrate that a smooth vibration and high

acceleration of 0.4 g-force (gravitational force) is reached, the noise inside the 

cabin is reduced from 90 dbA to 60 dbA; the floor height is reduced from 50 cm 

to 30 cm, 85 % of the total inner space can be used as a workspace, and stable 

drive and cornering is most efficient during an emergency transportation.
35

3.7 Securing People & Equipment

Becker, L.R., E. Zaloshnja, N.R. Levick, G. Li, and T.R. Miller. “Relative risk 

of injury and death in ambulances and other emergency vehicles.” 

Accidenty Analysis & Prevention, November 2003, 35(6): pp 941-948.

*ABSTRACT: This study addresses of the impacts of emergency vehicle 

(ambulances, police cars and fire trucks) occupant seating position, restraint use 

and vehicle response status on injuries and fatalities. Multi-way frequency and 

ordinal logistic regression analyses were performed on two large national 

databases, the National Highway Traffic Safety Administration's Fatality Analysis 

Reporting System (FARS) and the General Estimates System (GES). One model 

estimated the relative risk ratios for different levels of injury severity to occupants 

traveling in ambulances. Restrained ambulance occupants involved in a crash 

were significantly less likely to be killed or seriously injured than unrestrained 

occupants. Ambulance rear occupants were significantly more likely to be killed 

than front-seat occupants. Ambulance occupants traveling non-emergency were 

more likely than occupants traveling emergency to be killed or severely injured. 

Unrestrained ambulance occupants, occupants riding in the patient compartment 

and especially unrestrained occupants riding in the patient compartment were at 

substantially increased risk of injury and death when involved in a crash. A 

second model incorporated police cars and fire trucks. In the combined 

ambulance-fire truck-police car model, the likelihood of an occupant fatality for 

those involved in a crash was higher for routine responses. Relative to police 

cars and fire trucks, ambulances experienced the highest percentage of fatal 

crashes where occupants are killed and the highest percentage of crashes where 

occupants are injured. Lack of restraint use and/or responding with 'lights and 

siren' characterized the vast majority of fatalities among fire truck occupants. A 

third model incorporated non-special use van and passenger car occupants, 

which otherwise replicated the second model. Our findings suggest that 

ambulance crewmembers riding in the back and firefighters in any seating 

position, should be restrained whenever feasible. Family members 

accompanying ambulance patients should ride in the front-seat of the 

ambulance.

Green, J.D., D.E. Ammons, A.J. Isaacs, P.H. Moore, R.L. Whisler, and J.E.

White. “Creating a Safe Work Environment for Emergency Medical Service 

Workers.” Paper presented for Proceedings ASSE Professional 

Development Conference and Exposition, June 9-12, 2008.

*ABSTRACT: Seat belts are required in U.S. ambulances, as with other motor 

vehicles manufactured in accordance with the current Federal Motor Vehicle 

Safety Standards (FMVSS), as regulated by the National Highway Traffic Safety 

Administration (NHTSA). These regulations are also cited in the Specification for 

the Star of Life Ambulance, KKK-A-1822F, as issued by the General Services 

Administration (GSA), which is widely adopted as the defacto industry 

specification for ambulances. The required occupant restraints do not allow 

emergency medical service (EMS) workers the mobility required to care for 
36

patients. As a result, EMS workers routinely work unrestrained in the patient 

compartment, daily risking their safety and health in the care of others. In an 

effort to solve this problem for existing and new ambulances alike, NIOSH 

(National Institute of Occupational Safety and Health) tested four different 

retrofittable restraint systems, each which improved crash protection for the 

worker while allowing mobility needed to provide patient care. In parallel, the City 

of Winter Park (Florida) Fire and Rescue Department (WPFD), in collaboration 

with Medtec Ambulance Corporation, has designed and fielded a new ambulance 

patient compartment that significantly reduces the need for the EMS worker to 

move from a seated position to care for the patient. Together, these two work 

environment changes represent unique opportunities to substantially improve 

worker safety without compromising patient care. The objective of this research 

study was to utilize digital human modeling tools to evaluate reach envelopes for 

three different human body sizes (5th percentile female, as well as, the 50th and 

95th percentile male: by stature and weight), when positioned in two different 

commercially available ambulance patient compartments. The evaluation was 

expanded to test each body size, in each environment, using two different 

restraint systems: one fixed and one allowing mobility, if needed, to assess the 

ability of a worker to care for the patient and reach equipment while remaining 

restrained. The underlying premise is that it is better to be restrained than 

unrestrained, and further, it is better to be restrained and seated than restrained 

and out of the seat. Results from this study illustrate the strengths and limitations 

of the patient compartment configuration in an ambulance built and fielded in 

accordance with the current FMVSS and the Federal Specification for the Star of 

Life Ambulance, KKK-A-1822E, as issued by the General Services 

Administration (GSA). This study also discusses potential improvements to the 

safety and health of EMS workers, if NIOSH tested mobile restraint systems, 

which increase reach envelope while allowing EMS workers to remain restrained, 

were adopted. The approach taken by the WPFD to redesign the work 

environment by substantially reducing the need for mobility, thus allowing EMS 

workers to remain seated and restrained for the majority of their work tasks, 

offers a real opportunity to improve the safety of ambulances to be fielded in the 

future if this design were to be adopted. Finally, the WPFD (Winter park Fire 

Department) design when coupled with a mobile restraint offers the best of both 

designs.

Green, J.D., J.R. Yannaccone, R.S. Current, L.A. Sicher, P.H. Moore, and 

G.R. Whitman. “Assessing the performance of various restraints on 

ambulance patient compartment workers during crash events.” 

International Journal of Crashworthiness, 2010, 15(5): pp 517-541.

*ABSTRACT: The inability of emergency medical service (EMS) workers to 

remain safely restrained while treating patients in the patient compartment of a 

moving ambulance has been identified as a key impediment to EMS worker 

safety in North America. It has been hypothesized that restraint systems 

designed to provide mobility while offering the ability to lock during an impact or 

sudden maneuver, could greatly enhance worker safety in the back of 
37

ambulances. Through a series of 33 sled and crash tests impacting the front, 

side, and rear of simulated and actual ambulance patient compartments, the 

National Institute for Occupational Safety and Health examined the 

biomechanical and kinematic effects of two-, four- and five-point restraints on 

95th percentile male Hybrid III anthropomorphic test devices. Results indicate 

that the inclusion of restraint systems offering mobility have the potential to 

improve worker safety under many working conditions in this unique work 

environment.

Green, J.D., P. Moore, R. Current, J. Yannaccone, G. Whitman, D. Day, S. 

Prooudfoot, T. Bobick, and N. Romano. “Reducing Vehicle Crash-Related 

EMS Worker Injuries through Improvements in Restraint Systems.” 

Presented at the conference proceedings for the XVIIth World Safety 

Congress, Orlando, Florida, September 20, 2005.

ABSTRACT: The National Institute for Occupational Safety and Health (NIOSH), 

Division of Safety Research, collaborated with the U.S, Army Tank-Automotive 

and Armaments Command, the Canadian Forces Health Services Group 

Headquarters, the Ministry of Health & Long-Term Care, Ontario, Canada, and 

the U.S. Fire Administration on a research effort to increase the crash protection 

afforded emergency medical service (EMS) workers in ambulance patient 

compartments. The estimated fatality rate for EMS workers is 12.7 deaths per 

100000 workers, more than twice the national average of 5.0 for all U.S. workers. 

Transportation-related events, including ambulance crashes, are the most 

common cause of death among U.S. EMS workers. Ambulance crash 

investigations from the National Highway Traffic Safety Administration (NHTSA) 

and NIOSH were used to identify injury risk and circumstances. Results of these 

investigations show that regardless of occupant location, non-use of occupant 

restraints resulting in collisions between unrestrained occupants and 

compartment bulkheads and cabinets is the primary injury risk. 

Seat belts currently provided in ambulances do not allow the mobility that EMS 

workers need to care for patients. As a result, EMS workers routinely work 

unrestrained in the patient compartment. Occupant restraints that provide 

mobility within the ambulance patient compartment, and are capable of mitigating 

crash-related injuries were evaluated using a mathematical model; a 29-run, 

laboratory-based, sled-testing program; and, a four-vehicle crash-test program. 

Each sled and crash test included four instrumented anthropomorphic test 

devices (ATDs) or crash test dummies. During these tests, the mobile restraints 

prevented the ATDs from secondary collisions in the patient compartment and 

were structurally sound at acceleration levels between 25 g-forces and 30 fforces. Use of mobile restraints has the potential to significantly reduce crashrelated injuries to EMS workers in ambulance patient compartments. 

Recognizing seat belts have been viewed as an impediment to the ability of EMS 

workers to provide patient care, future NIOSH work with mobile restraints will 

focus on factors that affect user acceptance.
38

Larmon, B., T.L. LeGassick, and D.L. Schringer. “Differential front and back 

seat safety belt use by prehospital care providers.” The American Journal 

of Emergency Medicine, 1993, 11: pp 595-599.

*ABSTRACT: The object of the study was to assess the habits and attitudes of 

prehospital care personnel regarding safety belt use in the front and rear 

ambulance compartments. Therefore, a cross-sectional descriptive survey was 

administered at emergency medical service conferences and through provider 

agencies throughout the United States and Canada. Approximately 900 public, 

private, and volunteer prehospital care providers participated. Demographic 

information, traffic collision history, percent of time safety belts were used, belief 

in safety belt use, and reasons for nonuse in the rear compartment of the 

ambulance were measured. The results showed that safety belt use was highest 

in the front seat during emergency runs (median, 100 %) and rarest in the back 

compartment during emergency runs (median, 0 %). Respondents cited the 

following reasons for non-use in the rear compartment: inhibited patient care 

(67.9 %), restricted movement (34.7 %) inconvenience (15.1 %), or lack of 

efficacy (5.3 %). Prehospital care personnel typically wear safety belts when in 

the front seat, but not while in the rear compartment of the ambulance. More 

intensive efforts at educating prehospital care providers about the importance of 

safety restraints in the rear compartment, enumerating patient care activities that 

can be performed while wearing a safety belt, and design of a functional restraint 

system for the rear compartment may increase ambulance safety.

Levick, N.R., G. Li, and J. Yannaccone. “Biomechanics of the Patient 

Compartment of Ambulance Vehicles under Crash Conditions: Testing 

Countermeasures to Mitigate Injury.” Paper presented at the SAE 2001 

World Congress, Detroit, Michigan, March 2001. doi: 10.4271/2001-01-1173.

*ABSTRACT: There has been very limited research on the biomechanics of 

occupant safety in the ambulance environment. Occupant protection or crash 

testing safety standards for these unique vehicles are lacking in the United 

States. Recent studies have identified ambulances as high risk passenger 

transport vehicles. This study was conducted to identify some of the occupant 

safety hazards in the ambulance environment and to determine the efficacy of 

some countermeasures to mitigate ambulance occupant injury. Accelerator sled 

testing of the ambulance rear patient compartment (ambulance box or rear cabin) 

with Anthropomorphic Test Devices was conducted under frontal impact 

conditions with a target sled pulse was 26 g-forces and 48.28 kp/h (30 mph). The 

ambulance box was configured with instrumented and uninstrumented 

Anthropomorphic Test Devices positioned as in the real world environment. Two 

uninstrumented 95% Hybrid-II Anthropomorphic Test Devices were lap belted 

and positioned in the occupant compartment, one on the rear-facing attendant’s 

seat and one on the side-facing bench seat. A Side Impact Dummy was 

unbelted, seated on the front of the side-facing bench seat and positioned next to 

a passive restraint device. An instrumented Hybrid-III 3 year old child 

Anthropomorphic Test Device was restrained in a child restraint system, secured 

to the gurney via a dual belt path. The actual sled pulse achieved was 34 g-
39

forces and 55.26 kp/h (34.34 mph), and due to separation of the ambulance box 

from the chassis/sled, the crash pulse imparted to the patient compartment were 

20 g-forces and 33.64 kp/h (20.9 mph). Head Injury Criterion (HIC) values 

calculated for the restrained Hybrid-III child Anthropomorphic Test Device were 

171, however for the unbelted Side Impact Dummy the HIC was projected to be 

in excess of 1000. Although this study was a preliminary study, the findings 

confirmed that there are unique occupant hazards in the ambulance vehicle 

environment and that certain restraint practices are of value and that some injury 

mitigating countermeasures are ineffective. Importantly this study also 

demonstrated the potential for unrestrained occupants to be not only a hazard to 

themselves but also a hazard to the restrained occupants in the ambulance 

patient compartment. This study highlights the need for the development of 

dynamic safety standards for occupant restraint in this environment.

Levick, N.R., and M.A. Garigan. “Solution to Head Injury Protection for 

Emergency Medical Service Providers.” Paper presented at the 

proceedings for the International Ergonomics Association, Maastricht, the 

Netherlands, July 2006.

*ABSTRACT: The purpose of this study is to identify applicable standards and 

potential devices for head protection for the ground ambulance transport 

environment. Occupational health and safety standards for Head Protection for 

Emergency Medical Service (EMS) providers in USA, Australia and Europe were 

reviewed. Existing helmets intended for, or adopted for use by EMS personnel 

were identified, and unique design elements determined via focus groups and 

expert panels. The findings demonstrated that there are no USA head protection 

standards for this population, although such standards exist in Australia and 

Europe. Unique design features, suggested by providers were: communications 

capability (with patients, 85 %; and driver 69 %) and stethoscope auscultation 

(89 %); Expert panels added: Effective in high horizontal g-forces; Identify the 

responder; Biohazard protection and Image enhancing. Although there is 

demonstrated risk for serious and/or fatal head impacts in the ambulance 

environment, there is an absence of standards or guidelines for occupational 

head protection, for USA ground EMS providers. An head protection device 

should include communication capacity, and address comfort, visibility and 

aesthetics and be protective for automotive crash forces.

Rolandelli, P.J. “Adjustable safety seat for ambulances and other 

emergency vehicles.” US Patent 4251100 filed May 11, 1979 and issued 

February 17, 1981.

*ABSTRACT: An adjustable safety seat is provided to enhance the ability of 

medical attendants to perform emergency medical services on a patient in a 

moving ambulance or other emergency vehicle. An adjustable seat, backrest and 

restraint for use with center-mounted cots in an emergency vehicle enable one 

medical attendant to perform, without interruption, the chest compressions and 

ventilations required for cardiopulmonary resuscitation, while simultaneously 
40

protecting the attendant from falls and possible injury when the vehicle is in 

motion. The adjustable safety seat enables the attendant to assume the optimal 

position for performing cardiopulmonary resuscitation. When not required for 

cardiopulmonary resuscitation, the seat can be adjusted to facilitate performance 

of other medical services on the patient.

Stanley, L., and R. Kline. “Naturalistic safety evaluation of a medic’s work 

environment during rural emergency response.” Presentation given at the

Transportation Research Board Annual Meeting, January, 2011.

ABSTRACT: In this presentation, the objectives and preliminary results for the

project to increase medic and public safety through the collection and analysis of 

data. The primary objectives of the project is to determine the rate of restraint 

use by emergency medical service (EMS) workers, determine significant causes 

leading to medics being unrestrained, identify medic activities and physical 

hardships imposed by their equipments or procedures, determine biomechanical 

forces experienced by medics during patient transport, and identify factors that

influence ambulance travel in emergency mode. After describing the methods of 

collecting and analyzing data, the presentation shows some results for restraint 

usage (average of 2.6 % of the time restrained per trip), reach analysis (20 

unique reaches identified), and the fact that the vibrant exposure is at normal 

standard (based on the International Organization of Standardization Standard, 

ISO STD 2361) levels.

Studnek, J.R., and A. Ferketich. “Organizational policy and other factors 

associated with emergency medical technician seat belt use.” Journal of 

Safety Research, 2007, 38: pp 1-8.

*ABSTRACT: INTRODUCTION: The purpose of this study was to determine 

factors associated with seat belt usage among Emergency Medical Technicians 

(EMTs). METHODS: As part of biennial re-registration paperwork, nationally 

registered EMTs completed a survey on the safety and health risks facing 

Emergency Medical Services (EMS) providers. Respondents were asked to 

describe their seat belt use while in the front seats of an ambulance. They were 

categorized as “high” in seat belt use if it had been more than a year since they 

had not worn their seat belt or “low” in seat belt use if they had not worn their 

seat belt at least once within the past 12 months. A logistic regression model was 

fit to estimate the association between seat belt use, organizational seat belt 

policy, type of EMS organization worked for, EMT certification level, and the size 

of community where EMS work is performed. RESULTS: Of the 41,823 EMTs 

that re-registered in 2003, surveys were received from 29,575 (70.7 %). A 

significant interaction between organizational seat belt policy and type of EMS 

organization was found to exist. Participants reporting no organizational seat belt 

policy had lower odds of seat belt usage when compared to individuals that do 

have a seat belt policy. Odds Ratios ranged from 0.20 (95 % CI 0.1-0.4) for 

military organization to 0.59 (95 % CI 0.38-0.93) for private EMS organizations. 

Paramedics and those working in rural areas also had lower odds of seat belt 

use. CONCLUSION: Several factors were found to be associated with seat belt 
41

usage among EMTs while in the front compartment of an ambulance. However, it 

appears that only one, organizational policy, is a modifiable characteristic.
42

3.8 Standards & Guidelines

Ambulance Manufacturers Division. AMD Standards. 2007.

ABSTRACT: This United States standard establishes minimum requirements for 

performance tests for the safety of new ambulance motor vehicles and 

associated motor vehicle equipment. This standard works in conjunction with the 

Federal Specification for the Star-of-Life Ambulances, KKK-A-1822, in order to 

meet the performance testing requirements set in the Specification.

Ambulance Manufacturers Division. Proposed AMD Standard-Final Draft: 

Equipment Mounts and Cabinet Closures. 0027, 2011.

*ABSTRACT: SCOPE AND PURPOSE: This proposed document establishes a 

method for testing interior mounted equipment, cot-mounted equipment, and 

interior cabinet doors in ambulances. This is a type test. Cots/litters/gurneys are 

not included in this document. APPLICABILITY: This document applies to all 

interior/cot-mounting solutions for equipment in excess of 1.36 kilograms (three 

pounds), and to all interior cabinets and doors. 

Ambulance Manufacturers Division. Proposed AMD Standard-Revision 11: 

Seat, Seat Mount and Occupant Restraint Dynamic Testing. 0026, 2010.

*ABSTRACT: SCOPE AND PURPOSE: This standard establishes minimum 

requirements for testing of all patient compartments designated seating positions, 

seat mounting systems, associated occupant restraints and belt mounting 

systems, either fabricated by an ambulance builder or acquired from a seat or 

restraint manufacturer. This is a type test. APPLICABILITY: This proposed 

standard applies to all patient compartment designated seating positions, seat 

mounting systems, and associated occupant restraints, whether part of the 

ambulance construction or manufactured by a third party for installation in 

ambulances.

Ambulance Manufacturers Division. Proposed Revision of AMD Standard: 

Method for Conducting Litter and Litter Retention System Dynamic Test. 

004, 2010.

*ABSTRACT: SCOPE AND PURPOSE:This document establishes the method 

for testing the litter, litter retention system, and litter-based patient restraints 

when installed per the litter manufacturer’s directions. This is a type test.

APPLICABILITY: This proposed document applies to all litters, litter attaching 

hardware, and litter-based patient restraints manufactured for installation in 

ambulances.

ASTM International. Standard Guide for Training Emergency Medical 

Services Ambulance Operations. F1705-96, 2007.

*ABSTRACT: SCOPE: This guide provides minimum training standards for 

Emergency Medical Services (EMS) Ambulance Operators including legal 

aspects, operator qualifications and testing, history of EMS vehicle operations, 

vehicle types/equipment, safety, physical forces, mechanics, pre-run, operations, 

post-run, and special circumstances. This training guide promotes the safe and 
43

efficient delivery of the ambulance, equipment, crew, passengers and patients, 

during all phases of the delivery of EMS involving the ambulance; at all times 

exercising the highest degree of care for the safety of the public. This standard

may be applied to the driving of other EMS vehicles that do not necessarily 

provide patient transportation. This guide shall be used as the basis for all 

programs relevant to the training of the emergency medical services operators. 

This standard does not purport to address all of the safety concerns, if any, 

associated with its use. It is the responsibility of the user of this standard to 

establish appropriate safety and health practices and determine the applicability 

of regulatory limitations prior to use. 

ASTM International. Standard Practice for Human Engineering Design for 

Marine Systems, Equipment, and Facilities. F1166-07, 2007.

*ABSTRACT: SCOPE: This practice provides ergonomic design criteria from a 

human-machine perspective for the design and construction of martime vessels 

and structures and for equipments, systems, and subsystems contained therein, 

including vendor-purchased hardware and software. The focus of these design 

criteria is on the design and evaluation of human-machine interfaces, including 

the interfaces between humans on the one side and controls and displays, 

physical environments, structures, consoles, panels and workstations, layout and 

arrangement of ship spaces, maintenance workplaces, labels and signage, 

alarms, computer screens, material handling, valves, and other specific 

equipments on the other. The criteria contained within this practice shall be 

applied to the design and construction of all hardware and software within a ship 

or maritime structure that the human crew members come in contact in any 

manner for operation, habitability, and maintenance purposes. Unless otherwise 

stated in specific provisions of a ship or maritime structure design contract or 

specification, this practice is to be used to design maritime vessels, structures, 

equipment, systems, and subsystems to fit the full potential user population 

range of 5 th % females to 95 th % males. 

British Standards Institution. Medical Vehicles and Their Equipment - Road 

Ambulances. BS EN 1789:2007, 2007.

*ABSTRACT: SCOPE: This European Standard specifies requirements for the 

design, testing, performance and equipping of road ambulances used for the 

transport and care of patients. It contains requirements for the patient’s 

compartment. This European Standard does not cover the requirements for 

approval and registration of the vehicle and the training of the staff which is the 

responsibility of the authority/authorities in the country where the ambulance is to 

be registered. This European Standard is applicable to road ambulances capable 

of transporting at least one person on a stretcher. Requirements are specified for 

categories of road ambulances based in increasing order of the level of treatment 

that can be carried out. These are the patient transport ambulance (types A1 A2), 

the emergency ambulance (type B) and the mobile intensive care unit (type C). 

This European Standard gives general requirements for Medical devices carried 
44

in road ambulances and used therein and outside hospitals and clinics in 

situations where the ambient conditions can differ from normal indoor conditions.

Ministry of Health and Long-Term Care (Ontario, Canada). Ontario 

Provincial Land Ambulance & Emergency Response Vehicle Standard. 

Version 4.0, March 21, 2008.

*ABSTRACT: SCOPE OF THE STANDARD: This Standard describes the 

minimum acceptable requirements for land ambulances for use by an operator of 

a land ambulance service. Annex A of this standard describes the minimum 

acceptable requirements for emergency response vehicles intended for use in 

ambulance services in the Province of Ontario. Annex B of this standard 

describes the minimum acceptable requirements for the transfer of a Patient 

Compartment Module to another chassis intended for use in ambulance services 

in the Province of Ontario. Annex C of the standard is the Compliance Checklist 

for a new ambulance. Annex D of this standard is the Compliance Checklist for a 

remounted ambulance. Every operator of a land ambulance service shall be 

responsible for fully complying, or ensuring full compliance, with every provision 

of this Standard.

National Academy of Sciences - National Research Council, Washington, 

DC Division of Medical Sciences. Medical Requirements for Ambulance 

Design and Equipment. Emergency Health Series. PHS-Pub-1071-C-3, 1970.

*ABSTRACT: A vehicle must meet certain specific requirements to be classified 

as an ambulance if it is to satisfy the demands of the physician in terms of 

emergence care for which properly trained ambulance attendants can be held 

responsible. Developed by professional and lay experts for use by automotive 

designers and manufacturing, this publication would be useful resource material 

for a teacher in a technical institute or instructors of emergency squad personnel. 

Requirements are provided for: (1) The Ambulance, including requirements for 

general vehicular design and specific requirements for the driver and patient 

areas, (2) Security and Rescue Equipment, (3) Emergency Care Equipment and 

Supplies, which include litters, airway care, ventilation, oxygenation, external 

cardiac compression, immobilization of fractures, prevention and treatment of 

shock, wound dressings, emergency childbirth and transportation of newborn 

infants, poisoning, and special equipment, (4) Communication and 

Documentation, which includes a 2-way radio, telemetry equipment, and 

recording devices and (5) Transportation by Air. 

National Fire Protection Association. Proposed Draft of NFPA 1917 

Standard of Automotive Ambulances. NFPA1917, 2013.

*ABSTRACT: SCOPE: This standard establishes the minimum requirements for 

new automotive emergency medical services (EMS) ground vehicles used for 

out-of-hospital medical care and patient transport. Ther term ‘new’ as applied in 

this standard is intended to refer to the original construction of an ambulance 

using all new materials and parts. PUPOSE: The purpose of this document is to 

specify minimum requirements, performance parameters, and essential criteria 
45

for the design of ground ambulances. APPLICATION: This standard shall apply 

equally to vehicles intended for use in both emergency and non-emergency 

operations. This standard shall not apply to the following: (1) Refurbished and remounted vehicles; (2) Vehicles that are used for transport of more than two 

stretcher-bound patients at the same time; (3) Mass casualty vehicles; (4) Military 

field ambulances; (5) Vehicles intended for use as fire apparatus as specified in 

NFPA 1901 and NFPA 1906. 

National Highway Traffic Safety Administration, Washington, D.C. 

Ambulance Design Criteria. 1973.

*ABSTRACT: Indexed design and performance criteria for ambulances, 

developed by the National Academy of Engineering at the request of the National 

Highway Traffic Safety Administration, are presented. Part I of the report 

provides historical and technical background, and describes the need for 

standardization of ambulance design and performance. The purpose and scope 

of the study are discussed in terms of vehicles, vehicle elements, and vehicle 

characteristics. From the specific criteria detailed in Part II of the report, several 

recommendations selected for their special significance, are highlighted. These 

relate to the design of the patient compartment; standardization of ambulance 

manufacture; principal environmental requirements for medical care; 

communications requirements; national standardization of external identification; 

omission of windows in the patient compartment to enhance privacy and 

efficiency; adequate acceleration capability; and application of Federal Motor 

Vehicle Safety Standards appropriate for the kind of chassis employed. Vehicle 

characteristics for which standards could not be recommended due to lack of 

adequate objective data include: color and intensity of identification lights; riding 

quality and stability; noise and vibration; and vehicle braking system. A 

bibliography and a brief description of applicable Federal Motor Vehicle Safety 

Standards are appended.

Society of Automotive Engineers International. Surface Vehicle 

Recommended Practice: Occupant Restraint and Equipment Mounting 

Integrity – Frontal Impact System-Level Ambulance Patient Compartment. 

SAE J2917, 2010.

*ABSTRACT: SCOPE: This SAE Recommended Practice describes the test 

procedures for conducting frontal impact occupant restraint and equipment 

mounting integrity tests for ambulance patient compartment applications. Its 

purpose is to describe crash pulse characteristics and establish recommended 

test procedures that will standardize restraint system and equipment mounting 

testing for ambulances. Descriptions of the test set-up, test instrumentation, 

photographic/video coverage, and the test fixtures are included.

Society of Automotive Engineers International. Surface Vehicle 

Recommended Practice: Occupant Restraint and Equipment Mounting 

Integrity -- Side Impact System-Level Ambulance Patient Compartment.

SAE J2956, 2010.
46

*ABSTRACT: This SAE Recommended Practice describes the test procedures 

for conducting side impact occupant restraint and equipment mounting integrity 

tests for ambulance patient compartment applications. Its purpose is to describe 

crash pulse characteristics and establish recommended test procedures that will 

standardize restraint system and equipment mounting testing for ambulances. 

Descriptions of the test set-up, test instrumentation, photographic/video 

coverage, and the test fixtures are included.

Standards Australia and Standards New Zealand. Australian/New Zealand 

Standards: Ambulance Restraint Systems. AS/NZS 4535, 1999.

*ABSTRACT: SCOPE: This Standard applies to motor vehicles designed as, or 

modified and converted into, ambulances for the transportation of occupants and 

equipment. The Standard specifies the requirements for restraining equipment 

and occupants sharing the same interior space. It may not be possible under all 

conditions to restrain occupants in the ideal configuration. OBJECTIVE: The 

objective of this Standard is to decrease the impact hazard to occupants during 

an accident whilst being transported in an ambulance.

U.S. General Services Administration. Federal Specification for the Star-ofLife Ambulance. KKK-A-1822F, 2007.

*ABSTRACT: PURPOSE: The purpose of this document is to describe 

ambulances that are authorized to display the “Star of Life” symbol. It establishes 

minimum specifications, performance parameters and essential criteria for the 

design of ambulances and to provide a practical degree of standardization. The 

object is to provide ambulances that are nationally recognized, properly 

constructed, easily maintained, and, when professionally staffed and provisioned, 

will function reliably in pre-hospital or other mobile emergency medical service.
47

4. ACRONYMS

AMBEX National United Kingdom Ambulance Conference

AMD Ambulance Manufacturers Division 

AMR American Medical Response

ASA Ambulance Service Association (United Kingdom)

ATD Anthropomorphic Test Dummy

CDC Center for Disease Control 

CDS Clinical Decision Support

CEN European Committee on Standardization

CPR Cardiopulmonary Resuscitation 

DOJ United States Department of Justice

EKG Electrocardiograph

EMS Emergency Medical Services

EMT Emergency Medical Technician 

ESV Enhanced Safety of Vehicles 

FARS Fatality Analysis Reporting System 

FMCSA Federal Motor Carrier Safety Administration

FMVSS Federal Motor Vehicle Safety Standards

GES General Estimates System 

GSA General Services Administration 

ICU Intensive Care Unit 

IFSTA International Fire Service Training Association 

ISO STD International Organization of Standardization 

JEMS JEMS: Journal of Emergency Medical Services 

MIP MIP: Mixed Integer Programming 

NEISS National Electronic Injury Surveillance System 

NFPA National Fire Protection Association 

NHS National Health Service 

NHTSA National Highway Traffic Safety Administration

NIJ National Institute of Justice 

NIOSH National Institute of Occupational Safety and Health 

NPSA National Patient Safety Agency (United Kingdom) 

NREMT National Registry of Emergency Medical Technicians 

NRLS National Reporting and Learning Service (United Kingdom) 

PaSA Purchasing and Supply Agency (United Kingdom) 

SAE Society of Automotive Engineers 

SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity 

Act: A Legacy for Users 

STD Standard

SUMMA 112 Medical Emergency Services of the Madrid, Spain Regional 

Government 
48

USFA United States Fire Administration

WPFD Winter Park Fire Department

VTFD Violet Township Fire Department

Acknowledgements

The US Department of Homeland Security Science and Technology Directorate

(DHS S&T) Human Factors/Behavioral Sciences Division sponsored the 

production of this material under Interagency Agreement HSHQDC-11-X-00049

with the National Institute of Standards and Technology (NIST). The work 

described was funded by the United States Government and is not subject to 

copyright.

The authors of this report would like to thank Jennifer Marshall of NIST Office of 

Law Enforcement (OLES) and Jennifer Moore, Carlotta Boone, Allison Jacobs

and Thomas Aten from BMT Designers & Planners for their help in compiling this 

report.

Disclaimer

Certain commercial equipment, instruments, or materials are identified in this 

paper to facilitate understanding. Such identification does not imply 

recommendation or endorsement by the National Institute of Standards and 

Technology, nor does it imply that the materials or equipment identified are 

necessarily the best available for the purpose.