Since the late 1800s, there have been many different designs used to transport patients to an aid station, MASH tent, or hospital. Napoleon’s physican, Dominique-Jean Larrey was the first to create a “flying ambulance” carriage staffed with a doctor, a nurse, and two attendants to bring wounded soldiers to a field first-aid center.
Since that time, the standard of care has been to have patients transported to centralized treatment centers. The design priority of the mode of transportation was on function over style, or safety. The idea of standardization was almost two centuries away.
EMS as most of us know it began in 1966, with the publication of Accidental Death and Disability; The National Disease of Modern Society by the National Academy of Sciences.
The following year, the National Academy of Sciences published the Report of a Task Force on Ambulance Services which concluded that ambulance designers must understand the role and responsibility of ambulance providers during treatment and transport. This recommendation was included in the Highway Safety Act of 1966, which required states to have highway safety standards that adhered to national performance standards.
However, ambulance designs were slow to change. In the early 1970s, the US DOT estimated that there were 28,000 ambulances, most of which were purchased with federal funds, that were not adequately configured to treat patients during transport. DOT then asked the General Services Administration (GSA) to develop standard guidelines for ambulances, which in 1974 resulted in the first publication of the Federal Specification for Star-of-Life Ambulances (KKK-A-1822, also known as K-Specs).
In the absence of other standards, the K-Specs became adopted in whole or in part by most, but not all, states as the minimum standard for state licensure. Since 1974, the K-Specs have had interim change orders and major revisions. The current version is KKK-A-1822(F), with Change Order 8 (issued July 1, 2015).
The turn of the century saw a significant increase in the focus on ambulance safety, including:
- In 1980, testing standards developed by AMD were incorporated into the K-Specs
- In 2003, NIOSH completed front crash tests, working with the US and Canadian Army to test restraint systems to protect military personnel while performing their duties in moving vehicles (air and ground).
- In 2007 NIOSH partnered with the Ambulance Manufacturers Division of the National Truck Equipment Association (AMD-NTEA) and the General Services Administration (GSA) to revise the GSA ambulance purchase specification and the companion AMD-NTEA test standards. NIOSH also worked with AMD-NTEA to establish a new crash test methodology Technical Committee. The committee used NIOSH research to develop a cost-effective test procedure to evaluate how components (seats, cot, equipment mounts) in a patient compartment would withstand a 30 mph frontal impact. (This test procedure was published by the Society of Automotive Engineers (SAE) in May of 2010 as a recommended practice, and is being used within the industry to improve ambulance seating and restraints.)
In 2008, the International Association of Fire Chiefs (IAFC), working through the National Fire Protection Association (NFPA) Fire Apparatus Committee, approached the NFPA Standards Committee with a request to develop standards for ground ambulances with consideration given to both GSA KKK-A-1822 and NFPA 1901 (Standard for Automotive Fire Apparatus).
The Standards Committee approved the request and a new Technical Committee on Ambulances was formed to develop NFPA 1917: Standard for Automotive Ambulances.
The chair of the Committee was selected by the IAFC; with members appointed by NFPA in the following categories:
- Applied Research/Testing Laboratory
- Enforcing Authority
- Special Expert
NFPA set an initial limit of 30 members, with no represented group constituting more than 1/3 of the Committee. NFPA may adjust the total membership provided it does not affect the 1/3 provision.
As an ANSI Standards Developer, NFPA adhered to ANSI guidelines. These guidelines include a requirement that all meetings must be open to the public and provide at least two formal opportunities for comment.
Much of the development for NFPA 1917 took place in Work Groups where interested parties focused on a specific chapter (e.g. patient compartment) to fully review each standard. The Work Groups then reported their results to the Technical Committee on Ambulances for addition review and action. The resulting draft documents were then formally released for public comments.
Comments received were reviewed first by each respective Work Group and then by the Technical Committee on Ambulances. The final decision of the Committee was presented to Association Technical Meeting for action.
The 1st edition of NFPA 1917 was approved by both the NFPA Standards Council and ANSI in August 2012.
During the development process, concerns were emerging about the impact of NFPA 1917 upon the EMS industry and the number of fire apparatus references that were incorporated into the ambulance standards. At the same time, there was an increasing body of research about ambulance safety provided by NIOSH, NIST, and SAE.
In 2013, the Commission on Accreditation of Ambulance Services (CAAS) Board of Directors discussed the impact of NFPA 1917 (1913) and established a Steering Committee to perform a detailed review. Based upon the Steering Committee’s recommendation, the Board of Directors invited representatives from throughout the EMS industry to apply for appointment to the Ground Vehicle Standard (GVS) Action Committee.
While the GVS Action Committee was developing GVS 2015 (working title), on a parallel track the CAAS Board of Directors applied to be accredited by ANSI as a Standards Developer. As such, the process used to develop GVS adhered to the ANSI process, which required all meetings to the public and include two formal public comment periods.
The GVS Action Committee sought representation throughout the EMS industry and did not have pre-established categories for membership. The Board of Directors appointed 22 voting members (primary and alternate) representing eleven EMS groups or organizations (the voting members later decreased to 20 after the IAFC withdrew their involvement). There were an additional twelve non-voting members and subject matter experts representing 6 major governmental agencies/departments.
The Action Committee worked as a group to evaluate and discuss the K-Specs in detail. This was done over the course of more than 10 two-day meetings held in the greater Washington, DC, area in addition to two formal public comment periods.
As work began on 2nd edition of NFPA 1917, there were changes made in the membership of the Technical Committee on Ambulances due to turnover within represented organizations and original members who were no longer eligible due to business mergers that took place.
The Technical Committee on Ambulances reconvened in September 2013, held meetings in several locations around the country, and provided two public comment periods. The resulting revision, NFPA 1917 (2016), was presented to at the Association Technical Meeting in June 2015. It was approved by the NFPA Standards Council in August 2015, with a Technical Interim Amendment applying to several sections. NFPA 1917 (2016) was approved by ANSI and became effective in September 2015.
The CAAS Board of Directors also appointed a GVS Consensus Body who received and reviewed the recommendation from the GVS Action Committee. Membership in the Consensus Body again solicited throughout the EMS industry provided that there is no crossover to Action Committee members. There were eighteen members appointed to the Consensus Committee in the following categories (6 from each):
User Group: A representative from or member of the various types of ground ambulance service providers and consumers.
Producer Group: A representative from or member of industries that supply ambulance services as ambulances and equipment manufacturers and emergency medical service supply vendors.
General Interest Group: A representative from or member of industry associations or groups that have direct or indirect material interest in the development of standards but are not covered in the two previous categories.
No interest category shall constitute more than one-third of the overall consensus body membership to provide balance in the GVS Consensus Body in order to preserve an equal balance and ensure a lack of dominance.
CAAS was accredited by ANSI in October 2015, and published Ground Vehicle Standards version 1.0 in March 2016, with an effective date of July 1, 2016.
Both GVS and NFPA 1917 are schedule for a three year revision cycle.