Document ID: NHTSA-2010-0089-0001
Agency: nhtsa
Document Type: Rule
Title: Meetings: Draft Recommendations for Safely Transporting Children in Specific Situations in Emergency Ground Ambulances
Posted Date: 2010-07-19T04:00Z

[Federal Register: July 19, 2010 (Volume 75, Number 137)]
[Notices]               
[Page 41923-41926]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr19jy10-134]                         

[[Page 41923]]

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DEPARTMENT OF TRANSPORTATION

National Highway Traffic Safety Administration

[Docket No. NHTSA-2010-0089]

 
Public Meeting on Draft Recommendations for Safely Transporting 
Children in Specific Situations in Emergency Ground Ambulances

AGENCY: National Highway Traffic Safety Administration (NHTSA), 
Department of Transportation (DOT).

ACTION: Notice of Public Meeting.

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SUMMARY: The National Highway Traffic Safety Administration (NHTSA) 
will hold a Public Meeting to obtain comments on the attached Draft 
Recommendations for Safely Transporting Children in Specific Situations 
in Emergency Ground Ambulances. These recommendations were developed by 
a Working Group comprised of subject matter experts to provide guidance 
to local, State, and national emergency medical services (EMS) 
personnel and organizations to safely transport children from the scene 
of a crash or other incident in ground ambulances.

DATES: The Public Meeting will be held on August 5, 2010 from 1:30-4:30 
p.m. EST.

ADDRESSES: Location of meeting: Department of Transportation, 1200 New 
Jersey Avenue, SE., Washington, DC 20590. NHTSA recommends that all 
persons attending the Public Meeting arrive at least 45 minutes early 
in order to facilitate entry into the DOT building. If you wish to 
attend or speak at the Public Meeting on August 5, 2010, you must 
register by 5 p.m. ET on July 26, 2010 by following the instructions in 
the Procedural Matters section of this Notice. NHTSA will consider late 
registrants to the extent time and space allows, but NHTSA cannot 
ensure that late registrants will be able to speak at the meeting.
    If you are unable to attend the Public Meeting in person in 
Washington, DC, NHTSA will also conduct a live, Internet-based 
``Webinar'' of the meeting on August 5, 2010. For those interested in 
registering to participate in the Webinar, please send an e-mail 
message indicating this to sandy.sinclair@dot.gov by no later than 5 
p.m. ET, on July 26, 2010 with ``Webinar Attendance'' in the e-mail 
``Subject'' line.
    Instructions for written comments: If you are interested in 
submitting written comments on the draft recommendations, you may 
submit comments identified by DOT Docket ID Number NHTSA-2010-0089 by 
July 26, 2010 using one of the following methods:
     Federal eRulemaking Portal: Go to http://
www.regulations.gov. Follow the online instructions for submitting 
comments.
     Fax: 202-493-2251.
     Mail: Docket Management Facility, M-30, U.S. Department of 
Transportation, West Building, Ground Floor, Room W12-140, 1200 New 
Jersey Avenue, SE., Washington, DC 20590.
     Hand Delivery or Courier: West Building, Ground Floor, 
Room W12-140, 1200 New Jersey Avenue, SE., Washington, DC, between 9 
a.m. and 5 p.m., ET, Monday through Friday, except Federal holidays.

    Please Note: All comments received will be posted without change 
to http://www.regulations.gov, including any personal information 
provided. Please see the information provided under ``Privacy Act.''

    Privacy Act: Anyone is able to search the electronic form of all 
comments received into any of our dockets by the name of the individual 
submitting the comment (or signing the comment, if submitted on behalf 
of an association, business, labor union, etc.). You may review the 
complete User Notice and Privacy Notice for Regulations.gov at http://
www.regulations.gov/search/footer/privacyanduse.jsp.
    Docket: For access to the docket to read background documents or 
comments received, go to http://www.regulations.gov at any time or to 
West Building, Ground Floor, Room W12-140, 1200 New Jersey Avenue, SE., 
Washington, DC, between 9 a.m. and 5 p.m. ET, Monday through Friday, 
except Federal holidays.

FOR FURTHER INFORMATION CONTACT: Mr. Alexander Sinclair, Telephone: 
202-366-2723, Occupant Protection Division (NTI-112), Office of 
Impaired Driving and Occupant Protection, Research and Program 
Development, Traffic Injury Control, NHTSA, DOT, 1200 New Jersey 
Avenue, SE., Washington, DC 20590. E-mail: sandy.sinclair@dot.gov.

SUPPLEMENTARY INFORMATION:

I. Background

    Estimates suggest that ground emergency medical services (EMS) 
responds to approximately 30 million emergency calls each year.\1\ 
Approximately 6.2 million patient transport ambulance trips occur 
annually,\2\ of which approximately 10 percent of those patients are 
children.\3\ While data sources regarding ambulance crashes involving 
child ambulance occupants in the U.S. are limited, it is estimated that 
each year up to 1,000 ambulance crashes involve patients who are 
children. A review of local, national, and international media coverage 
of ambulance crashes involving injuries to children of all ages 
suggests such crashes are dangerous and can result in injuries ranging 
from minor to fatal. Injured children may be patients or passengers 
accompanying a parent or caregiver; they may be receiving transport 
from the scene of a crash or a medical emergency, or may be involved in 
an inter-facility transport.
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    \1\ Levick, NR. Emergency Medical Services: A Transportation 
Safety Emergency. Paper presented at: American Society of Safety 
Engineers Professional Development Conference; June 24-27, 2007; 
Orlando, Florida, USA. Available at: http://www.objectivesafety.net/
2007ASSE628Levick.pdf. Accessed December 9, 2008.
    \2\ Levick, NR. 2002. New Frontiers in optimizing ambulance 
transport safety and crashworthiness. The Paramedic. 2002;4:36-39.
    \3\ Winters, G and Brazelton, T. Safe Transport of Children. EMS 
Professionals. July-August 2003;13-21.
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    The issue of variation in emergency child transport guidelines was 
first identified in a 1998 publication which reported the results of a 
survey examining State requirements regarding the use of safety 
restraints for children in ambulances. The study revealed that 35 
States did not require patients of any age to be restrained in 
ambulances. Of those States requiring the use of child safety 
restraints, requirements varied between requiring that the child be 
placed in a child restraint system on an ambulance cot, in a child 
seat, or both.\4\ Depending upon the medical condition of the child 
(e.g., uninjured/not ill, and being transported with an injured parent 
or caregiver; injured/or ill but not requiring continuous and/or 
intensive medical monitoring; or injured/ill and requiring continuous 
and/or intensive medical monitoring), these three methods of 
transporting children in ground ambulances may not be the safest means 
of doing so.
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    \4\ Seidel J.S., Greenlaw J. Use of restraints in ambulances: A 
state survey. Pediatric Emergency Care. 1998;14(3):221-3.
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    The Health Resources and Services Administration (HRSA) of the U.S. 
Department of Health and Human Services (HHS) and the National Highway 
Traffic Safety Administration (NHTSA) of the U.S. Department of 
Transportation convened a national consensus committee in 1999 to 
review EMS child transportation safety practices following the 1998 
publication of the State survey and to develop guidelines for safely 
transporting children in ground ambulances. The HRSA/NHTSA committee, 
composed of

[[Page 41924]]

representatives from national EMS organizations, Federal agencies, and 
transportation safety engineers, developed a document entitled, The 
Do's and Dont's of Transporting Children in an Ambulance, which was 
published in December 1999.\5\ This document provides general guidance 
for EMS practitioners in the field on how to transport children safely 
in an ambulance.
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    \5\ Health Resources and Services Administration (HRSA) and 
National Highway Traffic Safety Administration (NHTSA). The Dos and 
Don'ts of Transporting Children in an Ambulance. December 1999. 
Available at: www.dhhs.state.nc.us/dhsr/EMS/pdf/nhtsa_
childtransport.pdf. Accessed January 21, 2009.
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    Since the publication of The Do's and Don'ts of Transporting 
Children in an Ambulance, protocols and practices currently utilized by 
EMS practitioners have remained inconsistent. States, localities, 
associations and EMS providers have developed legislation, guidelines 
or protocols regarding this issue. However, these guidelines and 
protocols vary across jurisdictions and often provide limited, or in 
some cases inappropriate, guidance.
    Currently, there are no Federal standards or standard protocols 
among EMS and child passenger safety professionals in the U.S. for how 
best to transport children safely in ground ambulances from the scene 
of a traffic crash or medical emergency to a hospital or other 
facility. The absence of consistent national standards and protocols 
regarding the transportation of children in ground ambulances 
complicates the work of EMS professionals and may result in the 
improper and unsafe restraint of highly vulnerable child passengers. As 
a result, EMS agencies, advocates and academicians have turned to NHTSA 
for leadership on this issue.

II. Draft Recommendations

    To address this issue, NHTSA initiated ``Solutions to Safely 
Transport Children in Emergency Vehicles'' in September 2008.\5\ The 
major objectives of the project were to: (1) Build consensus in the 
development of a uniform set of recommendations to safely and 
appropriately transport children (injured, ill, or not sick/uninjured) 
from the scene of a crash or other incident in a ground ambulances; (2) 
foster the creation of best practice recommendations after reviewing 
the practices currently being used to transport children in ground 
ambulances; and (3) provide consistent national recommendations that 
will be embraced by local, State and national EMS organizations, 
enabling them to reduce the frequency of inappropriate and potentially 
unsafe transportation of ill, injured or not sick/uninjured children in 
ground ambulances.
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    \5\ Operational support for the project was provided by Maryn 
Consulting Inc. under NHTSA contract DTNH22-08-C00085 by Maryn 
Consulting, Inc.
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    To achieve the objectives described above, NHTSA formed a Working 
Group of experts with the experience, background, and knowledge of the 
current practices for the emergency transportation of child passengers 
in ground ambulances. The members of the Working Group were drawn from 
many prominent national organizations and entities involved in the 
health care of children and the transportation of children and others 
in ground ambulances, including the International Association of 
Firefighters, the National Association of State EMS Officials, the 
American Academy of Pediatrics, the American College of Emergency 
Physicians (ACEP), the National Association of Emergency Medical 
Service Physicians (NAEMSP), the National Volunteer Fire Council, the 
National Association of Emergency Medical Technicians, the American 
Ambulance Association, the National Emergency Medical Services for 
Children's Resource Center (EMSC NRC), and the Emergency Nurses 
Association (ENA). Members from NHTSA, HRSA and other entities within 
HHS also participated in the discussions and deliberations of the 
Working Group. The Working Group met monthly via teleconference 
beginning in 2009 to develop the draft recommendations for the safe 
transportation of children in ground ambulances. In addition to holding 
the monthly teleconferences, the Working Group was also convened for a 
one-day meeting in Washington, DC on July 22, 2009.
    The ultimate goals of the draft recommendations developed by the 
Working Group are to: (1) Prevent forward motion/ejection of all 
children being transported in ground ambulances; (2) secure the torso 
ejection of all children being transported in ground ambulances; and 
(3) protect the head, neck and spine of all children transported in 
ground ambulances. By ensuring that these goals are met in all 
situations involving the transportation of children in ground 
ambulances from the scene of a traffic crash or medical emergency, the 
Working Group believes that the safety of such children will be greatly 
improved.
    The draft recommendations for the safe transportation of children 
in emergency ground ambulances are organized into five categories 
reflecting common situations:
    1. Child who is uninjured/not ill;
    2. Child who is ill and/or injured and whose condition does not 
require continuous and/or intensive medical monitoring and/or 
interventions;
    3. Child whose condition requires continuous and/or intensive 
medical monitoring and/or interventions;
    4. Child whose condition requires spinal immobilization and/or 
lying flat; and
    5. Child or children who require transport as part of a multiple 
patient transport (newborn with Mother, multiple children, etc.).
    The full text of the recommendations and the draft report will be 
placed in the Docket.

III. Participation in the Public Meeting

    The Public Meeting will be open to the public with advance 
registration for seating on a space-available basis. Individuals 
wishing to register to assure a seat in the public seating area should 
provide their name, affiliation (if any), telephone number and e-mail 
address to Mr. Alexander Sinclair using the contact information in the 
FOR FURTHER INFORMATION CONTACT section at the beginning of this notice 
no later than July 26, 2010. Should it be necessary to cancel the 
Public Meeting due to an emergency or some other reason, NHTSA will 
take all available means to notify registered participants by e-mail or 
telephone.
    The Public Meeting will be held at a site accessible to individuals 
with disabilities. Individuals who require accommodations such as sign 
language interpreters should contact Mr. Alexander Sinclair using the 
contact information in the FOR FURTHER INFORMATION CONTACT section no 
later than July 26, 2010. Any written materials NHTSA presents at the 
Public Meeting will be available electronically on the day of the 
Public Meeting to accommodate the needs of the visually impaired.
    Once NHTSA learns how many people have registered to speak at the 
Public Meeting, NHTSA will allocate an appropriate amount of time to 
each participant, allowing time for necessary breaks during the time 
allotted for the meeting. [Please note: NHTSA anticipates the Working 
Group will present some of the recommendations and respond to technical 
questions during the Public meeting.]
    For planning purposes, each speaker should anticipate speaking for 
no more than approximately ten (10) minutes, although NHTSA may need to 
adjust the time for each speaker depending upon the total number of 
speakers. To accommodate as many speakers as

[[Page 41925]]

possible, NHTSA prefers that speakers not use technological aids (e.g. 
audio-visuals, computer presentations, etc.). However, if you plan to 
do so, you must contact Mr. Sinclair by July 26, 2010 using the contact 
information in the FOR FURTHER INFORMATION CONTACT section of this 
notice. Speakers must also make arrangements to provide their 
presentations to NHTSA in advance of the Public Meeting to facilitate 
set up. During the week of August 2, 2010, NHTSA will post information 
on its Web site at http://www.nhtsa.gov indicating the amount of time 
allocated for each speaker and each speaker's approximate order on the 
agenda for the Public Meeting.

Jeffrey P. Michael,
Associate Administrator, Research and Program Development.

   Draft Recommendations for Safely Transporting Children in Specific
                Situations in Emergency Ground Ambulances
------------------------------------------------------------------------

------------------------------------------------------------------------
                               Situation 1
                 For a Child who is uninjured/not ill 6
------------------------------------------------------------------------
The Ideal.........................  Transport using a size-appropriate
                                     child restraint system that
                                     complies with FMVSS 213 in a
                                     vehicle other than a ground
                                     ambulance.
If the Ideal is not Practical or    1. Transport in a size-appropriate
 Achievable.                         child restraint system that
                                     complies with FMVSS 213
                                     appropriately installed in the
                                     front passenger seat (with air bags
                                     off) of the emergency ground
                                     ambulance; or
                                    2. Transport in the forward-facing
                                     EMS provider's seat (currently rare
                                     in the industry) in a size-
                                     appropriate child restraint system
                                     that complies with FMVSS 213 inside
                                     ambulance; 7 or
                                    3. Transport in the rear-facing EMS
                                     provider's seat in a size-
                                     appropriate child restraint system
                                     that complies with FMVSS 213
                                     (convertible or combination seat
                                     but not infant only seat, using a
                                     forward facing belt path) or in an
                                     integrated child restraint system
                                     seat (certified by manufacturer) to
                                     meet the injury criteria FMVSS 213;
                                     or
                                    4. Consider delay 8 of transport of
                                     the child with appropriate adult
                                     supervision until additional
                                     vehicles are available (patient is
                                     transported in EMS vehicle
                                     separately); or
                                    5. Per the judgment of EMS personnel
                                     on the scene (and in consultation
                                     with medical control, when
                                     possible), consider delay of
                                     transport (to the extent the
                                     patient's safety and medical
                                     condition are not in any way
                                     compromised), patient care
                                     continued on scene (monitoring)
                                     until an additional vehicle is
                                     available for transport.
------------------------------------------------------------------------
                               Situation 2
For a Child who is ill and/or injured and whose condition does not
 require continuous and/or intensive medical monitoring and/or
 interventions 9.
------------------------------------------------------------------------
The Ideal.........................  Transport child in a size-
                                     appropriate child restraint system
                                     that complies with the injury
                                     criteria of FMVSS 213--secured
                                     appropriately on cot.10
If the Ideal is not Practical or    1. Transport child in the EMS
 Achievable.                         provider's seat in a size-
                                     appropriate child restraint system
                                     that complies with the injury
                                     criteria of FMVSS 213 or an
                                     integrated seat in the EMS
                                     provider's seat that is certified
                                     by the manufacturer to meet the
                                     injury criteria of FMVSS 213; or
                                    2. Transport child on cot 11 using
                                     three horizontal restraints across
                                     the child's torso (chest, waist,
                                     and knees) and one vertical
                                     restraint across each of the
                                     child's shoulders.
------------------------------------------------------------------------
                               Situation 3
For a Child whose condition requires continuous and/or intensive medical
                   monitoring and/or interventions 12
------------------------------------------------------------------------
The Ideal.........................  Transport child in a size-
                                     appropriate child restraint system
                                     that complies with the injury
                                     criteria of FMVSS 213--secured
                                     appropriately on cot.13
If the Ideal is not Practical or    Secure the child to the cot 14; head
 Achievable.                         first, with three horizontal
                                     restraints across the torso (chest,
                                     waist, and knees) and one vertical
                                     restraint across each shoulder. If
                                     the child's condition requires
                                     medical interventions, which
                                     requires the removal of some
                                     restraints, the restraints should
                                     be re-secured as quickly as
                                     possible as soon as the
                                     interventions are completed and it
                                     is medically feasible to do so. In
                                     the best interest of the child and
                                     the EMS personnel, the vehicle
                                     operator is urged to consider
                                     stopping the ambulance during the
                                     interventions. If spinal
                                     immobilization of the child is
                                     required, please follow the
                                     recommendation in the following
                                     table.
------------------------------------------------------------------------
                               Situation 4
 For a Child whose condition requires spinal immobilization and/or lying
                                 flat 15
------------------------------------------------------------------------
The Ideal.........................  Secure the child to a size-
                                     appropriate spineboard and secure
                                     the spineboard to the cot,16 head
                                     first, with a tether at the foot
                                     (if possible) to prevent forward
                                     movement. Secure the spineboard to
                                     the cot 17 with three horizontal
                                     restraints across the torso (chest,
                                     waist, and knees) and a vertical
                                     restraint across each shoulder.
If the Ideal is not Practical or    Secure the child to a standard
 Achievable.                         spineboard with padding added, as
                                     needed, (to make the device fit the
                                     child) and secure the spineboard to
                                     the cot,18 head first, with a
                                     tether at the foot (if possible) to
                                     prevent forward movement. Secure
                                     the spineboard to the cot 19 with
                                     three horizontal restraints across
                                     the torso (chest, waist, and knees)
                                     and a vertical restraint across
                                     each shoulder.
------------------------------------------------------------------------
                               Situation 5
    For a Child or Children requiring transport as part of a multiple
   patient transport (newborn with Mother, multiple children, etc.) 20
------------------------------------------------------------------------
The Ideal.........................  If possible, for multiple patients,
                                     transport each as a single patient
                                     according to the guidance shown for
                                     Scenarios 1 through 4.

[[Page 41926]]

                                    For mother and newborn, transport
                                     the newborn in an approved size-
                                     appropriate child restraint system
                                     that complies with the injury
                                     criteria of FMVSS 213 in the rear
                                     facing EMS provider seat with a
                                     forward-facing belt path that
                                     prevents both lateral and forward
                                     movement (convertible or integrated
                                     child restraint system and not an
                                     infant only seat), leaving the cot
                                     21 for the mother.
If the Ideal is not Practical or    When available resources prevent
 Achievable.                         meeting the criteria shown for
                                     situations 1 through 4 for all
                                     child patients, including mother
                                     and newborn, transport using space
                                     available in a non-emergency mode,
                                     exercising extreme caution and
                                     driving at reduced (i.e., below
                                     legal maximum) speeds.
                                    If additional units may be needed
                                     based upon preliminary reports,
                                     backup units should be put on
                                     standby.
------------------------------------------------------------------------
Prepared under NHTSA Contract DTNH22-08-C00085, EMS Solutions for Safely
Transporting Children in Emergency Vehicles, with Maryn Consulting, Inc.
------------------------------------------------------------------------
6 Please consult Appendix C, General Considerations and Selecting Child
  Restraint Systems for Ground Ambulance Transport, for guidance on how
  to select equipment that may be used to meet the requirements of each
  of the recommendations. EMS providers are encouraged to check with
  equipment manufacturers for detailed information on the proper use and
  installation, results of crash testing, and possible limitations of
  any equipment that may be considered for use to fulfill the
  recommendations for the safe transportation of children in emergency
  ground ambulances.
7 There may be considerations of adding specific conditions for this
  use, e.g., crash tested seat meeting FMVSS 213 and adequate space in
  front of the seat.
8 The Working Group recommends that all EMS agencies plan, in advance,
  with other public health, public safety, and other partners for those
  situations where uninjured or not ill infants and children may be on
  the scene--as primary patients or not--so such events can be
  successfully mitigated and the uninjured infants and children can be
  transported as safely and as quickly as possible.
9 See Footnote 1.
10 11 All children transported on a cot shall be restrained to the cot
  with the 5-point cot restraint system that includes three horizontal
  restraints across the torso (chest, waist, and knees) and one vertical
  restraint across each shoulder.
12 See Footnote 1.
13 See Footnotes 5 and 6.
14 Ibid.
15 See Footnote 1.
16 See Footnotes 5 and 6.
17 Ibid.
18 Ibid.
19 Ibid.
20 The Working Group recommends that all EMS systems ``pre-plan'', i.e.,
  plan in advance for those situations where multiple infants and
  children may be on the scene--as primary patients or not--so such
  events can be successfully mitigated. Pre-planning for such events
  must also involve other public health, public safety and other
  partners to be most successful. An example of such an event is one
  that involves multiple patients, i.e., infants and/or children who
  need to be transported (to include labor with the mother and one or
  more newborns).
21 All children transported on a cot shall be restrained to the cot with
  the 5-point cot restraint system that includes three horizontal
  restraints across the torso (chest, waist, and knees) and one vertical
  restraint across each shoulder.

[FR Doc. 2010-17513 Filed 7-16-10; 8:45 am]
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