Making ambulances that don’t kill people
The UK is about to call time on a scattergun approach to vehicle design in the emergency healthcare services, says David Cottrell
When ambulance driver Andy Carter pulled out of his Merseyside depot one summer afternoon in the early 1980s and hung a sharp right on to the main road, he may not have lost control but he did lose his passenger seat – along with the paramedic in it.
“We didn’t have air-conditioning in those days, so we had the sliding doors open,” says Carter, now an emergency care practitioner. “My colleague was sitting next to me in the front and as I turned the corner he went flying, chair and all.”
His workmate suffered only bruised pride but the mishap was anything but isolated in an industry that has, until recently, been out of step with contemporary design thinking.
Worldwide, 27 paramedics have died in ambulances since 1991. In the UK, stretcher collapse accounted for 50 injuries in 2003. Ergonomic risk factors including heavy lifting, stooped working posture and whole-body vibration – while performing clinical tasks such as oxygen administration and heart monitoring in the restricted space of a vehicle often moving at high speed – have all contributed to fatigue and musculoskeletal injury or back pain among paramedics. Ambulances, in short, can be bad for your health.
This is a problem the world over. In Florida, vehicles now have state-of-the-art safety belts onboard. Ambulance staff are secured in five-point harnesses with their shoulders in retractors, allowing them to slide forward to treat the patient and access medical supplies.
Sometimes, the urgency of the ambulance’s journey can make it risky. In the 1970s, a study of 430 journeys found that in 6% of cases the ride disturbed the patient’s cardiovascular system. In a tiny number of cases, that disturbance proved fatal or led to cardiac arrest. The situation has improved significantly but the basic vehicle design has not changed greatly since the 1970s.
To help prevent medical accidents in the NHS, the UK instigated the Design for Patient Safety initiative. Funded by the Department of Health, it suggests ways design can improve everyday working practices.
In 2001 the National Patient Safety Agency (NPSA) was formed to turn ideas into action, and has recently collaborated with the Helen Hamlyn Centre at the Royal College of Art to define how the ambulance service should work in 2010. “We’ve taken it right back to the source data and evidence available, and we’re trying to take a national approach,” says Joan Russell of the NPSA.
The project aims to encourage standardisation of ambulances and their equipment across England and Wales. At the moment, NHS ambulance trusts produce their own vehicle specifications and there are over 40 variations.
Roger Coleman, professor of inclusive design at the Helen Hamlyn Centre, says that historically the NHS has not been a risk-aware organisation. “There was a big inquiry in the wake of the Bristol heart babies case [when around 100 babies died at the Bristol Royal Infirmary between 1988 and 1995]. It triggered a drive to address issues of patient safety and led to the creation of the NPSA.
“Originally the NHS was nursing-based, now it is highly complex and technologically driven. But it hasn’t applied the same safety principles found in industries such as aviation, which set up systems for capturing things that went wrong. The NHS tended to say, ‘Whose fault is it?’ Blame culture got in the way of open reporting.
“It’s more like the car industry. How long is it since they’ve had compulsory seat belts? In terms of how long cars have been around, not long at all. The NHS was created in 1945, but the drive for safety has only really kicked off in the last 20 years.”
Assisted by Coleman’s team, the NPSA has published two reports into A&E ambulance design. They found that rear ambulance occupants were more likely to be killed in accidents than those in the front – especially if they were unrestrained – and patient safety was put at risk by regional variations in interior layout and the location of equipment.
Nine design challenges, ranging from safe and effective entry and exit to better patient comfort, have been identified. Among the recommendations were: adjustable paramedic seating; integrated drop-down equipment; a clutter-free treatment area; modified suspension to reduce vibration; and better interior lighting to soften the vehicle’s clinical nature.
A ‘three-stage design direction’ aims to standardise over the next five years, modularise within 10 years and encourage innovation to meet the NHS’s ever evolving demands.
The NPSA’s reports envisage a set of three core vehicles that are based upon a typical Renault UVG Premia used by several ambulance services in the UK. At AMBEX 2007, an annual conference for the emergency healthcare industry, new and improved ambulance models from Ford, Honda, Land Rover, LDV, MacNeillie, UVM, Volkswagen and Volvo were displayed. Clearly there are issues over compatibility and compliance.
The NPSA ambulance design report envisages a small set of standardised but adaptable vehicles that can handle rapid response and major incidents as well as scheduled treatment and patient transport. This could make ambulances cheaper and easier to buy. Equipment, too, should be bought on the basis of agreed national criteria.
“Ambulances are improving but the most common inconvenience is kit,” says Carter, a member of the North West Ambulance Service’s Vehicle Design and Equipment Group. “We carry Life Pack 12 defibrillators that can be cumbersome. We’re restricted in where we can put them because they’re so big. The market has smaller, lighter alternatives, but trusts are tied down to contracts. On the other hand, we now use a wheelchair that can be strapped in the ambulance.
“We used to have a carry chair and had to stoop a lot. It sounds like a small difference, but it’s been a big improvement. It has saved a lot of back injuries, and the crew say it’s given them an extra 10 years in the job! But there’s a need to standardise equipment. It has to come with the vehicle.”
Today, only one in 10 call outs involves an old-style 999 emergency and 50% of journeys may not need to end at A&E. So the NPSA will continue to evaluate the ambulance. “It’s an ongoing project with several outline design options,” says Russell. The agency is exploring a model for moving urgent treatment out of hospitals and into patients’ homes. The ambulance of the future might prove to be a ‘SmartPod’ providing a range of on-site services and capable of rushing to major incidents when needed.
“The NHS hasn’t had the same understanding of design as a strategic tool as other industries,” says Coleman. “Research will get us closer to creating a level playing field for performance requirements and a knowledge base to inform the industry, but it is a 10-year exercise. We’re just starting to work out how to address it but people know they need to change, and there’s a lot of will to do it.”
'Just using a wheelchair that can be strapped in the ambulance has saved a lot of back injuries. Some of the crew say it’s given them an extra 10 years in the job'
The ambulance of the future
Diagnostic care
South East Coast Ambulance Service has been studying the use of an acoustic monitor that can help crew identify the kind of stroke a patient has suffered.
Colour scheme
The UK Ambulance Service has been replacing its traditional white ambulances with new vehicles painted a much more visible green and yellow.
Casualty figures
Research suggests that around half the patients taken to hospital by ambulance in the UK don’t need to go to A&E. With trained paramedics on board, these patients could be treated elsewhere.
Supersize interiors
In Winnipeg, Canada, a new ambulance has been designed to carry severely obese patients. Unchanged outside, inside there’s a double-width stretcher, winch-loading and larger medical equipment.
Black box
In the US, ambulances have been trialled with black boxes that record speed, monitor the driver’s behaviour and warn the crew if they are about to do something that exceeds pre-set safety parameters.
Audible warning
A new Localizer siren uses the way the brain responds to sound to increase safety. By using more frequencies, it helps motorists quickly establish where the vehicle is coming from.
Article first published in Design Council Magazine, Issue 3, Winter 2007