1. VERMONT CHILD PASSENGER SAFETY FOR EMS

2. EMERGENCY MEDICAL SERVICES FOR CHILDREN Ensuring all children and adolescents, no matter where they live, attend school or travel receive appropriate emergency medical care  HRSA (Health Resources and Services Administration's Maternal and Child Health Bureau) funded grant  State partnership grants are guided by 10 performance measure focusing on the prehospital and emergency department setting.

3.  Discuss issues related to occupant protection for non-critical pediatric patients in ambulances  Understand considerations for transporting children in ambulances  Preview the Safe Transport/ CPS for EMS training OBJECTIVES

4. VERMONT EMS Total Population 68815 treated and transported/89594 all responses = 77% transported all population Pediatrics 4585 treated and transported/5714 all responses = 80% transported pediatrics cases Pediatrics are represented in a little over 6% of responses 5714/89594

5. PEDIATRIC CALLS: TREATED AND TRANSPORTED TO A HIGHER LEVEL OF CARE (I.E. ED)

6. WHAT DEVICES ARE ON OUR AMBULANCES? 72 EMS transport services surveyed in 2015-2016 Required equipment “passenger restraint devices”

7. Device Category / DistrictCount by Category / District weight range Integrated8320-50 Pedi-Mate7510*40 Car Seat50varies Inflatable1420-40 Safeguard Transport1022-100 Vacuum Mattress / Splint10varies Pedi Seat510*40 Car Bed15*20 Other1 Grand Total249 WHAT DEVICES ARE ON OUR AMBULANCES? 72 EMS transport services surveyed in 2015-2016 Required equipment “passenger restraint devices”

8. 2015 VT EMS PROTOCOL 8.12

9. Child’s own car seat Ambulance service’s car seat Ambulance specific device We don’t transport peds ….. HOW DO PROVIDERS TRANSPORT A KID? What are some practices do EMS service employ to transport kids?

10. QUESTIONS & ISSUES Questions How best to transport children in ambulances from scene to hospital or another facility? Use of the child's safety seat (car seat) on a stretcher? Properly securing EMS equipment? What protocols for placement and restraint of injured, ill or uninjured children in emergency response vehicles?

11. QUESTIONS & ISSUES Questions How best to transport children in ambulances from scene to hospital or another facility? Use of the child's safety seat (car seat) on a stretcher? Properly securing EMS equipment? What protocols for placement and restraint of injured, ill or uninjured children in emergency response vehicles? Issues The absence of consistent standards and protocols complicates the work of EMS professionals. This may result in the improper restraint of highly vulnerable child passengers. Ambulances have various configurations and setups, this challenges developing a ‘standard’.

12. 1. Ambulance Transportation: Issues & Considerations 2. Child Restraint Basics 3. Conventional Child Safety Seats: Ambulance Use 4. Crash Tests: Convertible Child Restraint & Car Bed 5. Restraints Specifically Designed for Ambulance Use 6. Policy & Protocol for Pediatric Transportation CPS FOR EMS TRAINING OUTLINE

13.  4,500 crashes per year involving an ambulance  Occur on straight roads during good weather  Majority are frontal impacts  2,633 injured persons/ fatalities  Most serious / fatal injuries:  Rear compartment  Unrestrained or improperly restrained  At Intersections  During emergency use  About 10% crashes per year involve pedi patients (NHTSA) AMBULANCE CRASH CHARACTERISTICS

14.  Newton’s Law of Inertia  Object in motion continues at same speed until stopped by outside force (windshield, pavement)  Also applies to EMS providers and equipment  Needed restraining force roughly equals occupant’s weight times vehicle’s speed  Prevent ejection & slow down body  Contact body at strongest parts & spreads forces  Protect brain, spinal cord & internal organs CRASH DYNAMICS & HOW RESTRAINTS WORK

15. OVERALL PRINCIPLES  Seatbelt and restraint use for all occupants  Secure movable equipment  Driver screening and selection  Training for drivers, and providers  Policies to support and ensure safe transport

16. CRASH TEST: TRADITIONAL COT RESTRAINT

17. NHTSA Guidelines:  Replace after moderate / severe crash  Continue to use after minor crash. 5 criteria must all be met for continued use.  Always check with car seat manufacturer for their replacement guidelines CHILD SAFETY SEATS IN A CRASH

18.  Uninjured children should ride in passenger vehicle & in child restraint appropriate for height, weight, and age  If child is transported by ambulance, secure safely  Never transport child in adult’s lap or unrestrained  Check with manufacturer for instructions for use of conventional CSS installed in ambulance’s rear compartment. CHILD SAFETY SEATS: AMBULANCE USE

19. AMBULANCE CONSIDERATIONS For ambulance use, the saying should be modified to state: “Best” child restraint: 1.Fits the child 2.Fits securely a specific ambulance location (cot, captains chair in rear or forward facing orientation, or front passenger seat) 3.Fits a location that matches the medical needs of the child 4.Easy to use every time.

20. INSTALLATION LOCATIONS CONVENTIONAL CSS* IN AMBULANCES Car seat can only be placed in the front passenger seat if the air bag can be turned off! Never put a car seat on a side-facing bench or CPR seat. Car seats are not designed for side impact. Captain’s chairs must be able to lock in the Rear or Forward facing position, and the seat belt meets FMVSS 209 and locked. Car Seat must have 2 belt paths that allows it to be properly secured to the cot. * Child Safety Seat

21. Can not be use on cot Reasons:  In harness mode, seat has only one belt path & cannot be adequately secured  In booster mode, seat must be used with a vehicle lap/shoulder belt USING THE CHILD’S OWN CAR SEAT FOR SPINAL IMMOBILIZATION AND TRANSPORT This child has been immobilized in his combination car seat.

22. Part Four: Research on Convertible Seat & Car Bed Use on Ambulance Cot Background Crash Test Convertible CSS Recommendations: Convertible CSS Crash Test Car Bed Recommendations: Car Bed Harness Systems

23. Recommendations  Choose seat with 5-point internal harness  Position seat facing rear of ambulance  Adjust seat to full upright position  Elevate cot backrest to meet & fully support seat  Install with rear-facing & forward-facing belt paths  Attach belts to cot’s vertical posts to prevent sliding CONVERTIBLE CAR SEAT ON COT Not appropriate if child: Acutely ill or unable to maintain temperature Can’t be treated in semi- reclined position Requires intubation Meets or exceeds wt./ht. limits of CSS

24. Recommendations  For 5-20 lbs infants who must lie flat  Only use with two belt systems Fully elevate cot back Attach belts to cot where sliding minimized by vertical posts  Position baby’s head away from vehicle sidewall  Must have 2 sets of loops/ straps to secure both sides of car bed. CAR BED ON COT Not appropriate if child: – acutely ill or unable to maintain temperature – injuries can not be treated within car bed – spinal cord injury suspected – requires intubation – does not meet or exceeds wt./ht. limits of car bed

25. Adult cot-mounted harness systems do not provide adequate restraint for adult and pediatric Significant flaw is no belt attachment at level of patient’s shoulder In 71% of NHTSA investigated crashes, patients were not restrained by both a shoulder and lap restraint during transport. 44% of the time patients were ejected from cots. HARNESS SYSTEMS Pediatric dummy positioned in adult cot-mounted harness system Bull, 2001

26. Part Five: Restraints Specifically Designed for Ambulance U se FMVSS & Ambulance Specific Restraints Child Restraints Designed for Ambulances Considerations for Ambulance Restraint Use

27.  Instruction manuals for ambulance specific child restraints may be unclear or confusing  Contact manufacturer(s) before use to clarify installation procedures & requirements for use on cot or inside ambulance CONSIDERATIONS FOR AMBULANCE SPECIFIC RESTRAINT USE

28. Consider the following when selecting restraints:  Demographics of pediatric population served for scheduled or non- scheduled transport  Ease of installation and harness procedures when securing child in restraint  Ease of cleaning and storage CONSIDERATIONS FOR AMBULANCE SPECIFIC RESTRAINT USE

29. CHILD RESTRAINTS DESIGNED FOR AMBULANCE USE Safe Guard Transport by IMMI EP-96 The Rescu-Air: Air Filled Child Transport Seat Pedi-Pal by Ferno Pedi-Mate by Ferno Ambulance Child Restraint (ACR) by ParAid Medical

30.  Provide solution for transporting uninjured children who must ride in rear compartment  Improve ease of child restraint use for EMS  Some models may provide EMS occupant protection via a 3-point lap/shoulder belt when integrated child restraint not in use INTEGRATED CHILD RESTRAINTS IN AMBULANCES

31. Various types of products to immobilize children, but they are not necessarily meant to be used as a restraint device.  Baby Board by Ferno  Pedi Sleeve by Ferno  Pedi Pac by Ferno IMMOBILIZATION DEVICES

32. There are many different types of restraints available for ambulance transport. Factors to consider when selecting restraints:  Demographics of pediatric population served for scheduled or non- scheduled transport  Ease of installation and harness procedures when securing child  Ease of cleaning and storage  Training! RECAP

33. Part Six: Policy & Protocol Development for Pediatric Transportation

34. VT PEDIATRIC TRANSPORT PROTOCOL

35. Exclude unacceptable practices such as: Child on a parent’s lap CSS on side-facing jump seat CSS on ambulance bench seat CSS in airbag equipped seating position PEDIATRIC TRANSPORT POLICY COMPONENTS

36. PLANNING, TRAINING AND SAFETY  Policies to support and ensure safe transport  Training for drivers, and providers  Seatbelt and restraint use for all occupants  Secure movable equipment  Driver screening and selection

37.  VT’s EMS for Children Safe Transport and NH’s CPS for EMS trainings and resources  Advancing EMS Safety through Leadership and Partnership. http://www.ems.gov/safety-LP.htm. Accessed 10/16/2015.  Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances.  Child Passenger Safety program beseatsmart.org. RESOURCES

38.  Analyze, Investigate, Document: HNTSA Addresses Ground Ambulance Crashes Webinar. http://www.ems.gov/ems-focus.htm. Accessed 10/16/2015. http://www.ems.gov/ems-focus.htm  Advancing EMS Safety through Leadership and Partnership. http://www.ems.gov/safety-LP.htm. Accessed 10/16/2015.  Working Group Best-Practice Recommendations for the Safe Transportation of Children in Emergency Ground Ambulances. SOURCES

39. QUESTIONS? Stephanie Busch, CPST, NREMT EMS for Children Coordinator Vermont Department of Health -- DEPRIP Stephanie.busch@vermont.gov