Does crash risk increase when emergency vehicles are driving with lights and sirens?

Ambulance and helicopter response time. Association with patient outcome and illness severity: Protocol of a systematic literature review and meta-analysis

BACKGROUND

Response time for emergency medical service units is a key performance indicator. Studies have shown reduced response time association with improved outcome for specific critical conditions. To achieve short response time, emergency vehicles utilize lights and sirens, and crews are allowed to be non-compliant with traffic rules, posing a risk for accident. The purpose of the systematic review and meta-analysis is to provide an overview of the current body of evidence regarding the association, if any, between ambulance and helicopter response time and major complications and mortality in patients conveyed by ambulance and/or helicopter. Our secondary aim will be to enhance knowledge in the field of criteria-based dispatch to provide decision makers with evidence to optimize dispatch of limited resources.

RESEARCH QUESTIONS

What is the association between overall emergency medical services unit response time and patient outcomes, major complications, and time-critical conditions? What is the internal and external validity of the included literature?

METHODS

We plan the systematic review and meta-analysis to be in accordance with the Cochrane Handbook and Joanna Briggs Institute Manual for Systematic Reviews. The methodology will include formulating the review questions using a Population, Exposure, and Outcome framework. Every study design is eligible, including qualitative, quantitative, and mixed-methods designs. We will include all articles in English, Scandinavian, German, French and Portuguese in this systematic review.

RESULTS

We will publish results from the systematic review and meta-analysis in a peer-reviewed journal and we will present the results at scientific conferences and meetings. Results will also be available at www.ahrtemis.dk.

CONCLUSION

We will base our conclusions on the findings of the review and meta-analysis.

False Alarm Effects in Early Warnings for Emergency Vehicles: Exploring Drivers' Move-Over Behavior

OBJECTIVE

This study investigated drivers' move-over behavior when receiving an Emergency Vehicle Approaching (EVA) warning. Furthermore, the possible effects of false alarms, driver experience, and modality on move-over behavior were explored.

BACKGROUND

EVA warnings are one solution to encourage drivers to move over for emergency vehicles in a safe and timely manner. EVA warnings are distributed based on the predicted path of the emergency vehicle causing a risk of false alarms. Previous EVA studies have suggested a difference between inexperienced and experienced drivers' move-over behavior.

METHOD

A driving simulator study was conducted with 110 participants, whereof 54 inexperienced and 56 experienced drivers. They were approached by an emergency vehicle three times. A control group received no EVA warnings, whereas the experimental groups received either true or false warnings, auditory or visual, 15 seconds before the emergency vehicle overtook them.

RESULTS

Drivers who received EVA warnings moved over more quickly for the emergency vehicle compared to the control group. Drivers moved over more quickly for each emergency vehicle interaction. False alarms impaired move-over behavior. No difference in driver behavior based on driver experience or modality was observed.

CONCLUSION

EVA warnings positively affect drivers' move-over behavior. However, false alarms can decrease drivers' future willingness to comply with the warning.

APPLICATION

The findings regarding measurements of delay can be used to optimize the design of future EVA systems. Moreover, this research should be used to further understand the effect of false alarms in in-car warnings.

Medical fitness to drive, emergency service vehicles and crash risk

BACKGROUND

Emergency service vehicle (ESV) drivers are an important part of the health, fire and police services. ESV driving is associated with increased crash risk, but little guidance exists in the literature on relevant medical conditions among drivers and their potential for adding to higher crash risks.

AIMS

We undertook a narrative review to examine the role of medical and other conditions in crash risk of ESV drivers.

METHOD

A literature search was conducted using the ScienceDirect and Transport Research International Documentation (TRID) databases. There was no time frame for the search, and results were restricted to review and research articles.

RESULTS

Of 570 papers identified, 13 remained after screening and full-text review. A range of factors have been shown to have an impact on increased crash risk, including the nature of the task, physical features of the equipment, training, experience, environmental conditions and secondary tasks. There was scant information on medical conditions other than alcohol use disorders.

CONCLUSIONS

Given issues of speed, vehicle and environment, it would seem prudent to mandate levels of medical fitness to drive similar to and sometimes exceeding (i.e. colour blindness for traffic signals and alerts, hearing impairment as first responders) those for group 2 drivers with extra stipulations relating to specific service needs such as enhanced visual (such as colour blindness and contrast sensitivity) and auditory function. Further research is needed on the prevalence and emergence of relevant medical conditions among ESV drivers, with due consideration of their application to the driving tasks in each service.

Data mining approach to explore emergency vehicle crash patterns: A comparative study of crash severity in emergency and non-emergency response modes

Emergency vehicle crashes, involving police vehicles, ambulances, and fire trucks, pose a serious traffic safety concern causing severe injury and deaths to first responders and other road users. However, limited research is available focusing on the contributing factors and their interactions related to these crashes. This research aims to address this gap by 1) identifying patterns of emergency vehicle crashes based on severity levels in both emergency and non-emergency modes and 2) comparing the associations by response modes for the related fatal, nonfatal injury, and no-injury crashes. Two national crash databases, Fatality Analysis Reporting System (FARS) and Crash Report Sampling System (CRSS), were utilized for police-reported emergency vehicle crashes from January 2016 to February 2020. Association rule mining (ARM) was employed to reveal the association between factors that strongly contributed to these crashes. The generated rules were validated using the lift increase criterion (LIC). The results showed the complex nature of risk factors influencing the severity of emergency vehicle crashes. The fatal consequences of speeding with no seatbelt usage were evident for emergency mode, whereas none of these risky driving attributes was observed for non-emergency mode. In addition, the analysis identified the risk of fatal emergency vehicle crashes involving pedestrians in dark-lighted conditions in both response modes. Regarding nonfatal injury severity, angle collisions were more likely to occur at urban intersections during emergencies, while rear-end crashes were more frequent on segments with a posted speed limit of 40-45 mph during non-emergency incidents. The outcomes also revealed that the no-injury crashes involving fire trucks exhibited different patterns depending on the response mode. The findings of this study can guide in making effective strategies to improve safe driving behavior of first responders. The identified associations provide insights into the factors that can be controlled to ensure safe operation of emergency vehicles on the road.

A Retrospective, Single-Agency Analysis of Ambulance Crashes during a 3-Year Period: Association with EMS Driver Characteristics and a Telematics-Measured Safe Driving Score

BACKGROUND

Driver demographics and aggressive driving behavior are established risk factors for traffic accidents, yet their role in ambulance crashes remains poorly studied. We reviewed all ambulance crashes that occurred in our emergency medical services (EMS) agency during a 3-year period, and examined incidence rates (IR) by driver characteristics and telematics-measured driver behavior.

METHODS

This retrospective study was conducted in a U.S. EMS agency that operates 75 Type III ambulances and requires personnel to document all ambulance collisions, regardless of severity. Crashes reported between September 2017 and August 2020 were reviewed, and established criteria were used to classify injury and vehicle damage severity. Serious crashes were defined as events with any injury and/or functional or disabling damage. A vehicle telematics system installed fleet-wide in 2017 continuously captures driver-specific data, including miles driven and indicators related to speeding, harsh cornering and braking, and seatbelt use. A composite score characterizes compliance with safe driving behaviors (1 = low compliance to 5 = high compliance). Crash IR per 100,000 miles, IR ratios (IRR), and Poisson regression were used in analysis. Driver sex, age, agency tenure, miles driven, and safe driving score were examined.

RESULTS

Clinicians reported 214 crashes and the IR of any crash and serious crash were 2.1 and 0.63 per 100,000 miles, respectively. Injuries occurred in 8% of crashes and were all of low acuity. About one third of crashes produced functional (21%) or disabling (8%) vehicle damage, and the ambulance required towing in 10%. In a multivariate model, female sex (IRR = 1.50, 95%CI = 1.13-1.97), age 18-24 (IRR = 1.67, 95%CI = 1.06-2.66), and being in the lowest quartile of safe driving score (IRR = 1.51, 95%CI = 1.14-2.02) were EMS driver factors independently associated with an increased risk of any collision.

CONCLUSION

Most ambulance crashes are minor events, but the proportion that result in injury and/or functional or disabling vehicle damage may be as high as one-third. Poor driver compliance with objectively measured safe driving behaviors may increase risk for collisions independent of driver sex and age. The EMS industry would benefit from additional studies that examine the full spectrum of ambulance crashes and expand understanding of EMS driver-related risk factors.

Applying systems thinking to improve the safety of work-related drivers: A systematic review of the literature

INTRODUCTION

Light vehicles (<4.5 tons) driven for work purposes represent a significant proportion of the registered motor vehicles on our roads. Drivers of these vehicles have significant exposure to the dangers of the road transport environment. To optimize safety for these workers, it is critical to understand the factors contributing to risk of being involved in an incident. This information can then be used to inform the review and revision of existing risk controls and the development of targeted prevention activities.

METHOD

The aim of the study was to undertake a systematic review of the literature to identify the factors associated with work-related driving incidents. The factors identified in the review were represented within an adapted version of Rasmussen's risk management framework (Rasmussen, 1997). Fifty studies were analyzed following data screening and review of full text. The highest proportion of risk factors were categorized at the lower levels of the system, including the 'Drivers and Other Road Users' level (n = 20, 44.4%) and the 'Equipment, Environment, and Meteorological Surroundings' level (n = 19, 42.2%). There were no risk factors identified at the 'Regulatory and Government Bodies' levels of the framework, confirming the narrow investigative scope of past research and the need to acknowledge a broader range of factors within and across higher levels of the system.

CONCLUSIONS

The findings of this study inform the direction of future research and design of targeted prevention activities capable of creating system change for the safety of work-related drivers.

Traffic safety knowledge gain of ambulance drivers after simulator-based training

BACKGROUND

Compared to other road users, ambulance drivers are at a higher accident risk while driving with warning lights and sirens. No standard exists for training or education for emergency medical service employees driving ambulances. Training programs should positively influence knowledge. However, knowledge gain can be influenced by several different factors. This study developed a knowledge test for ambulance drivers to determine influencing factors on knowledge and its gain by simulator-based training.

METHODS

Two parallel knowledge test forms with 20 questions each were designed in several steps and tested on up to 174 participants. Questionnaires were used to study associated and influencing factors, such as objective experience, subjective attitudes, personality, motivation and demographic data.

RESULTS

Test construction showed good overall parallelism of the two tests as well as reliability and sensitivity. There was no correlation between subjective and objective knowledge gain, but participants with higher subjective knowledge gain showed a higher variation in objective knowledge. Younger age, higher qualification, higher number of license classes, fewer traffic violations, and more traffic safety trainings were positively associated with knowledge, whereas less yearly driving mileage, more traffic safety trainings, and higher risk sensitivity positively influenced knowledge gain through the training.

CONCLUSION

Knowledge and its gain through training are very low. Reasons for the lack of predictive power of some variables, such as motivation, personality and attitudes, are discussed. This study presents a new tool for testing knowledge on driving with warning lights and sirens. It shows the need for objective testing and for further research in this special area.

Driving Speeds in Urgent and Non-Urgent Ambulance Missions during Normal and Reduced Winter Speed Limit Periods—A Descriptive Study

Objective: Most traffic research on emergency medical services (EMS) focuses on investigating the time saved with emergency response driving. Evidence regarding driving speed during non-urgent ambulance missions is lacking. In contrast, this descriptive study compared registered driving speeds to the road speed limit in urgent A-missions and non-urgent D-missions. Specifically, the study examined driving speeds during normal speed limits, periods of reduced winter speed limits, and speeding during non-urgent D-missions. Methods: Urgent A-missions and non-urgent D-missions were included. Registered ambulance locations and speed data from Pirkanmaa Hospital District, Finland between 1 January 2018 and 31 December 2018 were used. Ambulance locations were linked to OpenStreetMap digital road network data. The registered driving speed distribution was reported as quartiles by the effective road speed limit. Furthermore, the results during the normal speed limit and reduced winter speed limit periods were reported separately. Driving speeds in non-urgent missions were compared with current Finnish traffic violation legislation. Results: As expected, the urgent A-missions exceeded the speed limits during both the normal speed limit and reduced winter speed limit periods. On the smallest streets with speed limits of 30 km/h, the driving speeds in urgent missions were lower than the speed limit. The driving speeds in non-urgent D-missions were broadly similar throughout the whole year on high-speed roads, and mostly on lower speed limit roads. However, within the 30 km/h speed limits, the mean speed in non-urgent missions appeared to increase during the winter. One-fifth of the registered non-urgent D-missions were speeding. Conclusions: Speeding is common in urgent A-missions and non-urgent D-missions throughout the year. Stricter guidelines for EMS are needed to increase driving safety.

Driving the ambulance: an essential component of emergency medical services: an integrative review

Background

The transport of patients from one location to another is a fundamental part of emergency medical services. However, little interest has been shown in the actual driving of the ambulance. Therefore, this review aimed to investigate how the driving of the ambulance affects the patient and the medical care provided in an emergency medical situation.

Methods

A systematic integrative review using both quantitative and qualitative designs based on 17 scientific papers published between 2011 and 2020 was conducted.

Results

Ambulance driving, both the actual speed, driving pattern, navigation, and communication between the driver and the patient, influenced both the patient’s medical condition and the possibility of providing adequate care during the transport. The driving itself had an impact on prehospital time spent on the road, safety, comfort, and medical issues. The driver’s health and ability to manage stress caused by traffic, time pressure, sirens, and disturbing moments also significantly influenced ambulance transport safety.

Conclusions

The driving of the ambulance had a potential effect on patient health, wellbeing, and safety. Therefore, driving should be considered an essential part of the medical care offered within emergency medical services, requiring specific skills and competence in both medicine, stress management, and risk approaches in addition to the technical skills of driving a vehicle. Further studies on the driving, environmental, and safety aspects of being transported in an ambulance are needed from a patient’s perspective.

Online Newspaper Reports on Ambulance Accidents in Austria, Germany, and Switzerland: Retrospective Cross-sectional Review

Background

Ambulance accidents are an unfortunate indirect result of ambulance emergency calls, which create hazardous environments for personnel, patients, and bystanders. However, in European German-speaking countries, factors contributing to ambulance accidents have not been optimally researched and analyzed.

Objective

The objective of this study was to extract, analyze, and compare data from online newspaper articles on ambulance accidents for Austria, Germany, and Switzerland. We hope to highlight future strategies to offset the deficit in research data and official registers for prevention of ambulance and emergency vehicle accidents.

Methods

Ambulance accident data were collected from Austrian, German, and Swiss free web-based daily newspapers, as listed in Wikipedia, for the period between January 2014 and January 2019. All included newspapers were searched for articles reporting ambulance accidents using German terms representing “ambulance” and “ambulance accident.” Characteristics of the accidents were compiled and analyzed. Only ground ambulance accidents were covered.

Results

In Germany, a total of 597 ambulance accidents were recorded, corresponding to 0.719 (95% CI 0.663-0.779) per 100,000 inhabitants; 453 of these accidents left 1170 people injured, corresponding to 1.409 (95% CI 1.330-1.492) per 100,000 inhabitants, and 28 of these accidents caused 31 fatalities, corresponding to 0.037 (95% CI 0.025-0.053) per 100,000 inhabitants. In Austria, a total of 62 ambulance accidents were recorded, corresponding to 0.698 (95% CI 0.535-0.894) per 100,000 inhabitants; 47 of these accidents left 115 people injured, corresponding to 1.294 (95% CI 1.068-1.553) per 100,000 inhabitants, and 6 of these accidents caused 7 fatalities, corresponding to 0.079 (95% CI 0.032-0.162) per 100,000 inhabitants. In Switzerland, a total of 25 ambulance accidents were recorded, corresponding to 0.293 (95% CI 0.189-0.432) per 100,000 inhabitants; 11 of these accidents left 18 people injured, corresponding to 0.211(95% CI 0.113-0.308) per 100,000 inhabitants. There were no fatalities. In each of the three countries, the majority of the accidents involved another car (77%-81%). In Germany and Switzerland, most accidents occurred at an intersection. In Germany, Austria, and Switzerland, 38.7%, 26%, and 4%, respectively, of ambulance accidents occurred at intersections for which the ambulance had a red light (P<.001). In all three countries, most of the casualties were staff and not uncommonly a third party. Most accidents took place on weekdays and during the daytime. Ambulance accidents were evenly distributed across the four seasons. The direction of travel was reported in 28%-37% of the accidents and the patient was in the ambulance approximately 50% of the time in all countries. The cause of the ambulance accidents was reported to be the ambulance itself in 125 (48.1% of accidents where the cause was reported), 22 (42%), and 8 (40%) accidents in Germany, Austria, and Switzerland, respectively (P=.02), and another vehicle in 118 (45.4%), 29 (56%), and 9 (45%) accidents, respectively (P<.001). A total of 292 accidents occurred while blue lights and sirens were used, which caused 3 deaths and 577 injuries.

Conclusions

This study draws attention to much needed auxiliary sources of data that may allow for creation of a contemporary registry of all ambulance accidents in Austria, Germany, and Switzerland. To improve risk management and set European standards, it should be mandatory to collect standardized goal-directed and representative information using various sources (including the wide range presented by the press and social media), which should then be made available for audit, analysis, and research.

Perceived occupational stressors among emergency medical service providers: a qualitative study

Introduction

Emergency medical services (EMS) providers are at continuous exposure to occupational stressors which negatively affect their health and professional practice. This study explored perceived occupational stressors among EMS providers.

Methods

This qualitative study was conducted from December 2019 to April 2020 using conventional content analysis. Sixteen EMS providers were purposively selected from EMS stations in Hamadan, Iran. Semi-structured interviews (with length of 45–60 min) were held for data collection. Data were analyzed through Graneheim and Lundman’s conventional content analysis approach.

Findings

Data analysis resulted in the development of two themes, namely critical conditions of EMS provision, and personal and professional conflicts. The six categories of these two themes were complexity of patients’ clinical conditions, interruption of EMS provision, health hazards, interpersonal problems, interprofessional interactions, and legal conflicts.

Conclusion

Besides the stress associated with emergency patient care, EMS providers face many different occupational stressors. EMS managers can use the findings of the present study to develop strategies for reducing occupational stress among EMS providers and thereby, improve their health and care quality.

Evaluating the effects of a simulator-based training on knowledge, attitudes and driving profiles of German ambulance drivers

INTRODUCTION

Accident risk is increased for emergency responders driving with warning lights and sirens compared to other road users' driving. Currently no standards for education of ambulance drivers exist. Research shows that high order understanding trainings focusing on insight to avoid critical driving situations might be more helpful than trainings focusing on car handling. The present controlled intervention study evaluates a one-day simulator-based high order training program specifically designed for ambulance drivers.

METHODS

In a longitudinal design with three measurement times multiple methods were used to evaluate the training holistically targeting the levels of reaction to training, learning, behavior and results of training. Questionnaire, knowledge test and driving profile data were analyzed with repeated measures analysis of variance controlling for age and sex. Data of two intervention groups and one control-waiting group was collected between 2014 and 2017 in two German federal states.

RESULTS

183 German paramedics (age: M = 33.1, SD = 9.4, 21.9 % female) participated in the study. 147 participants (80.3 %) completed post-training tests, and 30 participants (16.4 %) completed follow-up measurements six months after training. Participants' reaction to training was positive directly after the training, and dropped slightly over time. Intervention group participants gained traffic-relevant knowledge compared to control group participants. Risk sensitivity of regular driving situations was the only attitude variable positively affected by training. This effect was not sustained six months after training. Training led to a decrease of average and maximum speed in short- as well as long-term measurements but did not affect drivers' acceleration. Although speed was lower in post-tests, emergency response times did not differ.

CONCLUSION

The simulator-based training for paramedics has small but notable effects on drivers' knowledge, attitudes and real driving behavior. Although only very few measured variables showed positive training effects, no negative training effects were found. Speed was reduced in the long term which underlines the importance of such a training. More research is needed to determine effects on different types of participants and to elicit framework conditions for training integration in formal education.

Seat belt use in the ambulance patient compartment by emergency medical services professionals is low regardless of patient presence, seating position, or patient acuity

BACKGROUND

Inconsistent use of seat belts in an ambulance may increase the risk of injury for emergency medical services (EMS) professionals and their patients. Our objectives were to: (1) describe the prevalence of seat belt usage based on patient acuity and seat location, and (2) assess the association between EMS-related characteristics and consistent use of a seat belt.

METHODS

We administered a cross-sectional electronic questionnaire to a random sample of 20,000 nationally-certified EMS professionals, measuring seat belt use in each seating location of an ambulance during transport of stable, critical, or no patients. We included practicing, non-military, emergency medical technicians or higher who reported working in ambulances. We used multivariable logistic regression models to estimate the odds of consistent (≥50% of the time) use of seat belts for the rear-facing jump seat and right-sided crew bench during transport of stable and critical patients.

RESULTS

A total of 1431 respondents were included in the analysis. Patient compartment seat belt use varied with the highest use in forward-facing seats when no patient was being transported (59.8%) and lowest use in the left-side "CPR" seat with a critical patient (9.4%). Only 40.2% of respondents reported an agency policy regarding seat belt use while riding in the patient compartment. In all multivariable logistic regression models, advanced life support level certification and fewer years of experience were associated with decreased odds of consistent seat belt use. An agency seat belt policy was strongly associated with increased odds of seat belt use in the patient compartment.

CONCLUSIONS

Seat belt use was low and varied by seating location and patient acuity in the patient compartment of an ambulance. Practical Applications: EMS organizations should consider primary prevention approaches of provider education, improved ambulance designs, enactment and enforcement of policies to improve seat belt compliance and provider safety.