Designing future ambulance

transport for patient safety:

Research undertaken
Contents

Executive summary 2
1. Introduction 4
2. Literature review 6
3. Method 16
4. Results 23
5. Discussion 40
6. Conclusion 43
7. References 44

Research team/authors
Helen Hamlyn Research Centre, Royal College of Art, London

Prof Roger Coleman Principal Investigator

Prof Dale Harrow Co-Investigator
Owen Evans Senior Research Associate
Merih Kunur Senior Research Associate
Sally Halls Research Associate
Daniel Kafka MA designer

Healthcare Ergonomics and Patient Safety Unit,

University of Loughborough

Dr Sue Hignett Principal Investigator

Emma Crumpton Research Fellow
Anna Jones Research Associate


Executive summary
BACKGROUND
In March 2005, the NPSA prioritisation panel strongly supported
a project on ambulance design to be taken forward in the coming
year, in response to concerns relating to the design of vehicles
and equipment that impact on patient safety. In June 2005, the
Department of Health (DH) set out a vision for the provision of
future ambulance services by 2010. This included providing an
increasing range of quality mobile healthcare services for patients
with urgent and emergency care needs (e.g. ‘see and treat’). The
overarching aims are that patients will receive improved care by
consistently receiving the right response, first time, in time, and
that more patients will be treated in the community, resulting in
more effective and efficient use of NHS resources. It seems likely
that these changes will require different vehicles and equipment
for ambulance services.
METHOD
Three types of data were collected: archival incident reports,
research literature and empirical data from workshops. The
archival data were collected from three sources about reported
incidents relating to ambulance, ambulance equipment design
and use, and patient and staff safety. The research literature
review was used to not only set out the background context but
also to develop the conceptual framework for the analysis of
the workshop data. Empirical data were collected from four user
workshops.

AIM
This first scoping study aims to investigate the developing models
of service provision and the short and long term requirements
of vehicles and equipment that will be needed to address
the concerns of patient and staff safety in the future in the
Ambulance Service.


RESULTS DISCUSSION AND CONCLUSION
A dataset of 1,352 incidents was received from the National Each of the nine design challenges were reviewed to look at the
Reporting and Learning System (NRLS) database and 1,259 individual datasets (literature, incident reports and workshop
were retrieved from the Manufacturer and User facility Device themes). There was found to be a divergence between the
Experience (MAUDE) database. Ten ambulance trusts responded NRLS data and the incidents reported by the individual trusts for
to a request for information (from the 32 trusts contacted). some of the design challenges, for example securing people and
The incidents were scrutinised individually and initially coded to equipment in transit, and equipment. There are a number of
provide a framework for discussion at the workshops. After the possible causes for this divergence, including the design of the
analysis of the workshop data, the incident reports were reviewed NRLS interface and subsequent data input (this is recognised and
and coded into the nine design challenges. expected by the NPSA), through to local reporting cultures and
screening by trusts before sending incident data to the project
The data from the workbooks at the strategic workshop were
team. Issues that were raised in the workshops were not always
analysed thematically to identify six core areas of service provision.
reported in the incident reports. The sparsity of the literature
These areas of service provision were used as the discussion
relating to many of the design challenges is of concern. Particular
framework at the manufacturer and operational workshops. The
areas needing further research are communication, hygiene and
data from the operational workshops were coded in two stages
the patient experience. For future research in this area we would
to allow for iterative analysis and further exploration of codes and
recommend that the literature search is widened to domains
themes. The coding by Roger Coleman/Merih Kunur resulted in
other than ambulance, for example primary, secondary and
two distinct design outputs for (1) design issues and (2) problems/
community care, and possibly other emergency services, e.g. fire
features. These codes were then scrutinised by Emma Crumpton,
and police.
resulting in the 31 codes. At this stage a detailed secondary
coding was conducted within the codes to identify nine higher
level codes and address duplication between codes (Emma
Crumpton/Sally Halls). These design challenges were further
checked against the primary coding by Sally Halls to confirm
inclusiveness.


1. Introduction
1.1 DRIVERS FOR CHANGE IN THE PROVISION OF
AMBULANCE SERVICES
In March 2005, the NPSA prioritisation panel strongly supported
a project on ambulance design to be taken forward in the coming
year in response to concerns relating to the design of vehicles and
equipment that impact on patient safety.
In June 2005, the DH set out a vision for the provision of future
ambulance services by 2010 (2005). This included providing an
increasing range of quality mobile healthcare services for patients
with urgent and emergency care needs (e.g. ‘see and treat’). The
overarching aims are that patients will receive improved care by
consistently receiving the right response, first time, in time, and
that more patients will be treated in the community, resulting in
more effective and efficient use of NHS resources. It seems likely
that these changes will require different vehicles and equipment for
ambulance services.
Previous research considered two aspects of patient safety in
ambulance design by looking at the clinical working environment
when either taking the patient to the ambulance or the
ambulance to the patient. Ferreira and Hignett (2005) looked
at the efficiency of the patient compartment design for both
frequency and safety-critical clinical tasks in the ambulance
(taking the patient to the ambulance). They found that the high
frequency tasks (e.g. oxygen administration and heart monitoring)
included 40% of high musculoskeletal risk postures for the
paramedics. Redden and Hignett (2003) looked at responder
bag design for providing clinical care and treatment away from
the ambulance. A user trial for a chest pain response was used
to test the design and use of the bags. They found that the lack
of standardisation introduced delays in treatment provision. An
ongoing research project on stretcher loading systems has elicited
the views of ambulance staff (managers and operational staff),
manufacturers and others on the importance of patient safety for
stretcher loading systems (Jones & Hignett, 2005). It was found
that patient and staff safety was the most important design issue,
ahead of manual handling, mechanical/electrical reliability, time
and infection control.

In 2002/03, the Ambulance Service provided over 4.8 million
emergency responses using 3,481 emergency ambulances
(Ambulance Service Association, 2006). Each accident and
emergency (A&E) ambulance costs in excess of £100,000 and has
a service life of approximately five years. The current situation
is that most NHS ambulance trusts produce their own vehicle
specification; resulting in over 40 different designs. This presents
an increased risk to patient safety as the location of equipment
and consumables, as well as interior layout, varies in each vehicle,
which impacts on safe systems of work and the efficiency of
clinical care.
Vehicles used by the Ambulance Services have to be licensed by
the Driver and Vehicle Licensing Agency (DVLA) and have to meet
a type approval requirement from the Vehicle Certification Agency
(Vehicle Certification Agency, 2004). As part of this approval,
the vehicles and equipment must comply with two specific
European/British Standards (British Standards Institution, 2000a &
b). These standards provide a baseline for safety in the design of
emergency vehicles, but mostly relate to: electrical requirements;
vehicle performance requirements; medical devices; fixation
of the equipment in the patient’s compartment; emergency
exits; minimum seating dimensions; braking requirements; glass
requirements; interior lighting; and sound (Vehicle Certification
Agency, 2005). Although patient safety is considered for crash
protection (e.g. stretcher seat belt design), there are no guidelines
to assist vehicle designers and ambulance fleet managers with
clinical or workforce safety issues. As the range of services,
equipment, drugs etc. is likely to increase over the next five years,
it is timely that the NPSA and Ambulance Service Association
(ASA) have supported a design project to address these issues.
1.1.1 Aim
This first scoping study aims to investigate the developing models
of service provision and the short and longer term requirements
of vehicles and equipment that will be needed to address
the concerns of patient and staff safety in the future in the
Ambulance Service.

1.1.2 Objectives
The objectives were:
1. To review international literature on ambulance service
delivery systems and vehicle/equipment design;
2. To review the NRLS database for patient safety incidents
relating to ambulance services;
3. To hold a strategic stakeholders meeting to discuss future
provision of ambulance services;
4. To hold two operational stakeholder meetings to investigate
problems and possible solutions;
5. To present models/scenarios of future ambulance transport
at the national ASA conference (AMBEX 2006) to a second
series of stakeholder meetings to provide a basis for an
adaptation strategy for existing vehicles and equipment;
6. To communicate the findings through a final report
submitted to the NPSA and ASA in order to provide a future
vision for a safe system of emergency transport.


2. Literature review
An extensive literature search was carried out using the following 2.2 ACCESS/EGRESS (LOADING/UNLOADING)
sources:
Two higher quality papers were found relating to access and
• Medline (1960–2005);
egress issues. The first (Petzäll, 1995) looked at the dimensions of
• EMBASE;
the entrances of cars used in a taxi service for disabled people. A
• CINAHL;
mock-up car was used with methods including video, observation
• Ergonomics Abstract;
and interviews. It was found that much the same dimensions
• personal collections;
were required for people confined to wheelchairs and ambulant
• grey literature.
disabled people, and ideal measurements were specified.
The key words ‘ambulance’ and ‘ambulance design’
The second paper (Boocock et al., 2000) called for redesign to
were used and the results are presented below. The
minimise the physical effort involved in loading and unloading
review is narrative rather than systematic, and so the inclusion/
stretchers. This paper examined the interface between the
exclusion criteria err towards inclusiveness for treatment and care
ambulance crew and the equipment from an ergonomic
in ambulances, at home and in non-healthcare premises.
perspective, in particular loading the trolley cot into the
The review is presented as brief descriptions of relevant papers ambulance. Biomechanical analyses of simulated tasks led to the
given under the nine design challenges which were derived main recommendations relating to optimising operator posture
from the workshop data, incorporating the literature and the and strength capabilities. Long term recommendations included
incident reports (see chapter 3, Method). More detail is given
the need for redesigned, lower vehicles to minimise physical effort
where papers are of a higher quality. Higher quality, for the
in loading and unloading trolley cots.
purpose of this review, is deemed to be those papers that are
not simply professional opinion, that is, some intervention has Other papers were found to include elements pertaining
been described. However the quality of the intervention and to access and egress, but are listed under the other
methodology has not been critically appraised. design challenges.

2.1 NINE DESIGN CHALLENGES A previous detailed project, funded by Engineering and Physical
Sciences Research Council (EPSRC) project grant no. GR/S56078/01,
The nine design challenges were as follows: looked at ambulance loading systems in detail. The findings are
1. access/egress (loading/unloading); summarised in the following section.
2. space/layout;
3. securing people and equipment in transit; 2.2.1 EPSRC project grant no. GR/S56078/01
4. communication;
5. security, violence and aggression; Loading/unloading of patients is generally achieved using a
6. hygiene; mobility device such as a stretcher (emergency cot) that is loaded
7. equipment; into the patient compartment of the vehicle.
8. vehicle engineering; There are three main types of loading systems: easi-loader, ramp
9. patient experience (safety, comfort and dignity). and winch, and tail lift. The easi-loader is the most commonly
found system internationally but in the European Union (EU) usage
has significantly decreased since 2000 following the introduction
of new EU standards (British Standards Institution 2000a & b). In
2003 the Medical Devices Agency (Medical Devices Agency, 2003)
reported a number of adverse incidents with easi-loader stretchers,


with over 50 relating to stretcher collapse and others including The human:machine interface was investigated using task
limb entrapment, mechanism jamming, component failure, analysis methods in the field and postural analysis methods in
unstable load, operator ergonomic mismatch and receiving the laboratory as shown in figure 1. The field-based methods
tray incompatibility. included critical incident technique (CIT), link analysis (LA) and
There has been relatively little international research looking at hierarchical task analysis (HTA). The laboratory-based methods
emergency care services (Levick & Mener, 2006) but this project included rapid entire body assessment (REBA), the NIOSH lifting
adds valuable data to a growing body of literature (Kluth & equation, kinematic analysis (KA) and vibrational analysis (VA).
Strasser, 2006) by analysing the human:machine interface and
performance using a range of task analysis and postural analysis Over 300 hours of field data were collected during 12-hour shifts
tools. The data have been used to develop recommendations to with frontline A&E crews at the three participating ambulance
both improve the safety of current systems and specify the key trusts (East Midlands, East Anglia and Two Shires). Data were
design features for future systems. collected for loading and unloading patients from nine stations
selected by geographical location (rural, urban and intermediate
Figure 1. EPSRC project methodology stations) at different times over nine months to observe the
three systems in a range of environments and climates. These
CIT data were analysed using LA and HTA. During shift breaks, staff
were interviewed about critical incidents. Video-recording during
observations was not permitted due to ethical constraints.
Field LA Taxonomy
Laboratory-based postural data were collected using multi-
directional filming and analysed with REBA and NIOSH. Force
HTA measurements (for KA) were taken with all systems for a stretcher
load of 75kg using a force handle designed to be as similar as
possible in geometry to the existing stretcher handles. Equations
Ranking to give were derived to calculate the force exerted by the ambulance
recommendations for: workers for each phase. The British Standards Institution
• technical specifications;
• safe systems of work. recommendations for force limits in design and use of ambulance
stretchers were used as a comparator for the results (British
Standards Institution, 2000b).
KA
The data from the Critical Incidents Techniques (CIT), LA and
HTA were analysed independently before triangulation. The
REBA empirical data from the interviews were entered into NVivo
Postural for detailed analysis. Primary coding of the 10 CITs elicited five
Laboratory
analysis
first level generic codes across all three systems: system failure,
NIOSH
environment, patient-related, equipment, and coping strategies
and adaptation. These codes were used as the framework
VA taxonomy. A more detailed thematic analysis of the full interview
data produced 53 codes. These were separated into the three
systems and then further analysed to produce the first taxonomies
for the individual three stretcher loading systems. An HTA was


developed for each observed loading and unloading task (170
datasets). These were combined into 23 generic task summaries
indicating the type of issue and where it occurred. There were
many more issues observed with the tail lift than with the easi-
loader and ramp and winch.
LA was used to highlight task complexity and redefine the layout
of the stretcher loading system. The LA data were mapped
individually for each loading and unloading task of the stretcher
loading system. The 170 datasets were then summarised into
18 generic tasks. These data were then analysed to determine
the average number of links per task. The relative links for each
system were analysed. The tail lift was a more complex task for
both loading and unloading a stretcher, with an average of 19.3
links for loading compared with 11.6 and 10.5 for the easi-
loader and hydraulic ramp respectively and 9.7 for unloading
compared with 7.4 and 3.9 for the hydraulic ramp and easi-
loader respectively. Finally the LA and HTA data were added to the
taxonomy for each system with 16 design issues identified.
KA models were developed for each phase of the task using free
body diagrams. Equations were derived to calculate the force
exerted by the paramedics to produce the observed movement
for loading/unloading stretchers. The tail lift produced forces
(peaks around 100–200N) significantly less than the ramp and
winch (300–400N) and easi-loader (600N for one operator)
systems. Force limits (British Standards Institution, 2002) were
exceeded in all the easi-loader and ramp loading and leading
measurements in some part of the system operation, suggesting
that they present a risk of injury.
VA data were collected using an accelerometer in three locations
on the stretcher (head, chest and pelvis). The readings were
passed through a charge amplifier into a SigLab box and analysed
in MATLAB to produce acceleration time curves, converted to
frequency-time domain. The vibration level for the ramp and
winch was considerably higher than the other two systems but all
were within the comfort level of a healthy person. No data were
collected to model the experience for an ‘unhealthy’ person.

A total of 662 postures were analysed to give the average REBA
postural analysis score for each system. The easi-loader stretcher
had the highest REBA score (8.1) followed by the tail lift (5.8) and
the ramp and winch (5.7). An analysis of variance (ANOVA) post
hoc test was carried out to examine the difference in REBA scores
between the different systems. It was found that the easi-loader
scored significantly higher than all of the other systems (p<0.05).
The risk level using the easi-loader was high, with an action
category of three (action is necessary soon). For the other systems
the risk level was medium with an action category of two (action is
necessary). NIOSH was used to validate the REBA analysis. Sixteen
postures were analysed using both analysis tools, and a Friedman
test concluded that there was no significant difference in the results
(Lenton, 2005).
To assist with the development of design guidelines, a further
stage was added. Sixteen design issues were identified in the
summary taxonomy. To define management priorities, a list of
14 design issues (table 1) from the comparative findings were
used in a national ranking exercise (through the ASA and AMBEX)
with ambulance staff and manufacturers. Two issues were
omitted from the questionnaire (stretcher/control location and
obstacles) as they related to the stretcher design/use rather than
the loading system.
The ranking positions for the remaining 14 factors are shown
in table 1. It was found that ‘patient and operator safety’ and
‘manual handling’ were ranked as the most important issues for
loading and unloading patients. This was followed by system
design with respect to mechanical/electrical reliability. Three
factors received a very close ranking: time to operate, carry chair
access and vehicle layout. The tail lift was found to perform best
for patient and operator safety. There were manual handling risks
in all the systems, with more problems identified for the ramp
and winch and the easi-loader systems. The easi-loader stretcher
created the most problems for patient and operator safety.
From the KA, three design changes were recommended to reduce:
(1) stretcher mass; (2) maximum force application to stretcher
handle to less than 25°; and (3) wheel friction. The VA results
identified the ramp and winch system as the poorest performer.
Table 1. Design features The postural analysis found that the:
• tail lift had significantly lower forces for the lower
Average Ranking
Factor back (KA);
ranking position
• tail lift and ramp and winch had significantly lower risk than the
easi-loader (REBA).
Patient and operator safety 1.7 1
The vibrational analysis found that the:
Manual handling 3 2 • ramp and winch system had a significantly higher level than the
other systems.
Mechanical/electrical reliability 4.9 3
It was concluded that the tail lift is the best option currently
Time to operate 5.4 4= available but that there is scope for further future design
improvements as all systems still have risks. The tail lift operation
Carry chair access 5.4 4= needs to be simplified and the stretcher mass and wheel friction
need to be reduced.
Vehicle layout 5.7 6
2.3 SPACE/LAYOUT
Task complication 6.1 7
Several papers were found, including two higher quality papers
Weather/environment 8.0 8 about layout and general equipment issues and the effects of layout
on operator posture.
Clearance 8.1 9
Ferreira and Hignett (Ferreira & Hignett, 2005) reported on a review
of the layout of the patient compartment in a UK ambulance.
Effect of camber 8.3 10
The methods used included link analysis and postural analysis.
Security 8.8 11=
Paramedics were observed over 16 shifts. The results showed that
24% of a typical shift was spent treating patients in the patient
Infection control 8.8 11= compartment. An average of 29% of this was in a stationary
ambulance with the rest in transit. The most frequently occurring
Equipment misuse 9.0 13 clinical tasks were checking blood oxygen saturation, oxygen
administration, and monitoring the heart and blood pressure.
Need for sensors 11.0 14 The paramedics preferred to sit alongside the patient, so reach
distances were increased because the ambulance was designed
with the paramedic sitting at the head end for access to equipment
and consumables. High frequency tasks included 40% of postures
The HTA, LA and CIT analysis found that the:
requiring corrective measures. The study concluded that future
• tail lift performed best for patient and operator safety and
design should be based on ergonomic analysis of clinical activities.
had lowest manual handling risks.
Doormaal et al. (Doormaal et al., 1995) produced a more
equipment-based high quality paper, finding that harmful postures
are a feature of working in an ambulance. Tasks were assessed
using the Ovako Working posture Analysis System (OWAS) and


the Work and Health questionnaire. A biomechanical model was
applied to several specifically strenuous simulated conditions. The
results showed that 16–29% of a work shift was spent in a
harmful posture.
The recommendations included issues around the equipment in
ambulance cars, training of ambulance assistants and adaptations of
working procedures, including the position of the attendant to the
side and not at the head of the patient.
Other papers were found to support the importance of working
space and layout issues, although they are of a lower quality
according to the criteria for this review. Munk (Munk, 1996)
reported a professional opinion paper commenting on crew
comfort, including design features and working space. He
commented that people were happier and took better care of
their units when the equipment was new and working. Allen
(Allen, 1997) discussed the creation of crew space using design
ideas. Safar et al. (Safar et al., 1971) reported a professional
opinion based on 14 years’ experience with ambulance design
and equipment and listed vehicle features in order of importance,
starting with portable and stationary life support, working space,
riding quality, vehicle performance and cost.
2.4 SECURING PEOPLE AND EQUIPMENT
IN TRANSIT
Three high quality papers were found and all concur that the use of
seat belts is a problem, particularly for children. This poses a general
safety risk for both staff and patients.
Larmon et al. (Larmon et al.,1993) reported a cross-sectional
descriptive survey with 900 pre-hospital care providers. The results
showed that safety belt use was highest in the front (median 100%)
and lowest in the back (median 0%). The reasons given were that
seat belt use inhibited patient care (68%), restricted movement,
was inconvenient and was perceived to lower efficacy. Education
is needed about the importance of using a seat belt, enumerating
patient care activities that can be performed while wearing a belt
and design of a functional restraint system for the rear compartment.
10
Ferreira and Hignett (Ferreira & Hignett, 2005) found that the
position of the seat in the back of the ambulance affected seat belt
use, relating to the reach distance as reported in section 2.3.
Bull et al. (Bull et al., 2001) aimed to determine the most effective
and reliable means of restraining children on an ambulance cot. A
series of crash tests (with dummies) were carried out. A new cot
and fastener system significantly improved restraint performance
over older systems tested. Children weighing up to 18kg, who fit in
a convertible child restraint or a car bed and can tolerate a semi-
upright position, can be restrained in a convertible child restraint
secured with two belts to an ambulance cot. Infants, who must
lie flat, can be restrained in a car bed modified for two belts and
secured to a cot. In each case, the cot backrest must be elevated
and cot and anchor system must be crashworthy. None of the
harness configurations tested proved to be satisfactory, but an
effective system could be developed by following accepted restraint
design principles.
Becker et al. (Becker et al., 2003) reported an assessment of the
impact of emergency vehicle occupant seating position, restraint
use and vehicle response status on injuries and fatalities. Multi-way
frequency and ordinal logistic regression analyses were performed
on two large national databases. Restrained ambulance occupants
involved in a crash were significantly less likely to be killed or
seriously injured than unrestrained occupants. Ambulance rear
occupants were significantly more likely to be killed than front seat
occupants. They suggested that ambulance crew members riding in
the back should be restrained wherever possible. Family members
accompanying patients should ride in the front.
2.5 COMMUNICATION
One higher quality study was found (Wastell & Newman, 1996),
suggesting that a new system is not only dependent on the design
features, but also on the management of its implementation.
Wastell and Newman (Wastell & Newman, 1996) reported a
comparative analysis of two projects involving the computerisation
of ambulance control room operations in London and Manchester.
The outcomes were strikingly different in London, where severe
operational problems led to abandonment, and in Manchester,
where the new system led to both improved service levels and
decreased stress (lower blood pressure and subjective anxiety). This
was attributed to two sets of factors: technical and managerial.
London had weak management and poor industrial relations,
whereas in Manchester the management was reported to be strong
and the staff communication good.
2.6 SECURITY, VIOLENCE AND AGGRESSION
Two papers were found that suggest violence and aggression from
patients is a problem (Tintinalli & McCoy 1993; Corbett et al. 1998).
One further higher quality paper (Alves & Bissell, 2003) looked at
more general security issues.
Tintinalli (Tintinalli & McCoy, 1993) reported a study to estimate the
frequency of violence directed toward pre-hospital providers using a
convenience sample survey and descriptive review of ambulance call
reports. Results showed that 50% of respondents report having a
protocol for the management of violent patients and 67% reported
injury due to violence in the last year. The potential for injury to
pre-hospital providers is probably widespread. All systems should
have protocols for managing violent patients and for restraint
applications. Education, self defence and assessment of the scene
for violence may be indicated.
Corbett (Corbett et al. 1998) reported a survey with 490
respondents addressing experiences of pre-hospital violence.
Respondents reported a median of three episodes. He concluded
that emergency medical services (EMS) providers encounter a
substantial amount of violence and injury due to assault on the job
and suggested education and operational protocols.
Alves and Bissell (Alves & Bissell, 2003) reported an observational
study looking at whether ambulances may be targeted for terrorism
purposes. Security-related behaviours were observed for 151
ambulance arrivals. The results showed that 90% of ambulances
were left unattended and 84% unlocked. Emergency services
agencies should take steps to train their personnel to secure
ambulances.
2.7 HYGIENE
One higher quality paper was found relating to hygiene issues,
specifically about compliance with procedures. Additionally, two
letters supporting concerns about hygiene were retrieved.
Eustis et al. (Eustis et al., 1994) evaluated compliance with
recommendations for disposal of sharps and the use of personal
protective equipment in the pre-hospital environment in a single
blinded observational study of 297 ambulance runs. The results
showed that 37% of emergency medical workers disposed of
sharps correctly and most complied with the use of gloves, but
goggles, masks and gowns were under-used. There is a need to
develop standardised and more practical recommendations for the
pre-hospital environment.
Mitterer (Mitterer, 2000) suggested that the motivation through job
satisfaction could come from cleaning the ambulance. Hall (Hall,
2006) described a new vapourised hydrogen peroxide system in the
Irish ambulance service used in an effort to prevent infections such
as methicillin-resistant Staphylococcus aureus (MRSA).
2.8 EQUIPMENT
Several papers about equipment issues were found and have been
grouped as general equipment (2.8.1) and stretchers (2.8.2).
2.8.1 General equipment
The following higher quality papers look at general equipment use
and support a case for standardisation.
Fisher (Fisher, 2002) assessed the usability of portable electronic
equipment using field interviews. The results can be used to
enhance usability efficiency and acceptability of emergency
medical devices. He suggested that product manufacturers may
find it valuable to conduct usability tests that compare two devices
offering the same functionality, and to hold time and motion studies
of emergency medical equipment as it is used in the field to identify
ways in which products could be made more usable and effective.
Porter et al. (Porter et al., 2000) reported a study assessing
which items of equipment were carried as standard in front line
11
ambulances in the UK via a postal survey of chief executives. They
concluded that there was general agreement about basic levels
of ambulance equipment, but there remained significant areas of
apparent disagreement and poor provision. In particular, it was
recommended that the nasopharangeal airway, non re-breathing
(Hudson) mask and traction splint should be uniformly available,
and that consideration should be given to provision of alternatives
to the endotracheal tube in advanced airway management.
Lower quality studies provide some support for the findings of the
higher quality ones, for example Woollam (Woollam, 1982) gave
an opinion on ambulance equipment in five categories: patient
transport, patient comfort, dressings and splints, crew equipment
and resuscitation. The American College of Emergency Physicians
(ACEP, 2001) outlined new equipment guidelines from ACEP and
the American College of Surgeons, with the two organisations
working together for standardisation.
2.8.2 Stretchers
By far the greatest proportion of papers on equipment were about
stretchers and issues around stretcher use. The following higher
quality papers concur that stretcher-based tasks are hazardous and
that some design change is needed to rectify the situation. Some
of the older papers listed here suggest training-based solutions to
the problems with stretchers, but it is known that this is not a viable
long term solution and that the design must be addressed (Hignett
et al., 2003). Barnekow-Bergkvist et al. (Barnekow-Bergkvist et al.,
2004) aimed to identify which physical performance tests could best
explain the development of fatigue during a simulated ambulance
work task (carrying a stretcher). Tests included cardiorespiratory
capacity, muscular strength and endurance, and coordination. The
results show that maximum oxygen consumption (VO2 max) and
isometric back endurance were the most important predictors of
developing fatigue. The high physical strain during carrying the
loaded stretcher implies the importance of investigating whether
improved performance matching occupational demands could
increase the development of fatigue during strenuous tasks.
Furber et al. (Furber et al.,1997) examined 477 employee
compensation claims and found that the incident rate for patient
12
handling injuries to ambulance officers for 1992 to 1994 was
10.6 per year. The majority of injuries were to the back, with
41% occurring whilst some mechanical aid was being used,
most commonly a stretcher. They conclude that the current use
of mechanical aids should be investigated and the employee
compensation claim (ECC) forms restructured for monitoring
injury prevention.
Lavender et al. (Lavender et al., 2000a) analysed the biomechanical
stresses placed on the body based on simulations of frequently
performed tasks. The relative risk of low back disorders was
quantified using a trunk motion model. The hazardous tasks
performed included pulling a victim from bed to stretcher, the initial
descent of stairs using a stretcher, and lifting a victim on a back
board from the floor. The data indicated where engineering changes
to equipment regularly used by ambulance personnel would have
the greatest impact in reducing the risk of musculoskeletal injury.
Kluth and Strasser (Kluth & Strasser, 2006) reported a comparative
ergonomic study. Three combinations of stretchers with
incorporated transporters from brand name manufacturers were
tested with respect to their ergonomic quality. The methods
were work analysis of four standardised carry tests, measured
strain on circulatory system (beats per minute) and static and
dynamic components of muscle strain of six muscle groups
(electromyography). The rapid carrying led to increased strain on
the circulatory system. The evaluation made several suggestions
as to how the design of ambulance stretchers could be improved,
including changes in weight, shape, handle position and the
mechanism of height adjustment.
Stevenson (Stevenson, 1995) described a mechanical analysis of
lifting heavy patients or neonatal retrieval units using the stretcher,
and placing the loaded stretcher onto the ambulance to determine
the loads sustained under typical circumstances. The methods used
were direct observation and mechanical analysis. The results suggest
that lifting one end of the stretcher at a time from a low level is a
feasible way of reducing force requirements in many circumstances.
An intermediate height setting is desirable.
Lavender et al. (2000b) reported a postural analysis of paramedics
performing frequent tasks using interviews and surveys. Trunk
postures and hand forces were measured during simulated tasks
(bed-to-stretcher, ambulance stretcher-to-trolley, carrying chair/back
or board/stretcher down stairs). The recommendations include
advice to stand, not kneel on the bed, to use an interface board,
and for the leader to face forward.
Henderson and Raine (Henderson & Raine, 1998) described a
review of a lab shaker table and ambulance road test performance
of suspension with pneumatic damping. The suspension system
was found to offer compact low cost isolation with lower natural
frequencies than achieved in earlier mechanical systems.
Letendre and Robinson (Letendre & Robinson, 2000) evaluated
aspects of the main stretcher and patient compartment of the
ambulance that contribute to the risk of musculoskeletal injuries
for paramedics. The methods were a questionnaire, simulations of
composite tasks on a moving ambulance and focus groups. The
study resulted in further analysis of two potential solutions: (1) the
use of a mechanical lift and assist on the main stretcher; and (2)
jump kit design to reduce width and weight, provide a backpack
style shoulder strap, and investigate alternative placement within
the back of the ambulance.
The following lower quality studies provide some support for
findings of the higher quality ones. Forget et al. (Forget et al., 1976)
described the advantages of using a carriage stretcher mounted on
to a rail that can be used as a loading ramp. Guha (Guha, 1989)
described a two-wheeled stretcher in developing countries that is
used to transport over all types of ground and in very small spaces;
it features a metal guard over two wheels, friction belts and an
ergonomic tie bar system.
Specific equipment is also commented upon. Letendre and
Robinson (Letendre & Robinson, 2000) looked at the jump kit and
Gajendragadkar et al. (Gajendragadkar et al., 2000) looked at
mattresses. They describe a randomised block study of four mattress
combinations using mannequins and an ambulance travelling on
fixed routes. They concluded that a gel mattress used alone, or
with a foam mattress, resulted in the least attenuation of vibration,
but vibration in ambulance transport was not attenuated by any
mattress combinations; this may be relevant with low birth
weight neonates.
13
2.9 VEHICLE ENGINEERING
Many papers commented about vehicle engineering, mostly giving
descriptions of a new vehicle or piece of equipment. The following
list is derived from lower quality papers (Baker, 1969; Doughtery,
1990; Rolandelli, 1981; Lucia, 1992; Regan, 1993; Reeder, 1994;
Scott et al., 1994; Mossink & Munnik, 1995; Seymour, 1997;
Kolasa, 1998; Heightman, 1999; Gayle, 2000; Page, 2000;
American Lafrance, 2001; Overton, 2001; Erich, 2002; Demers,
2003; Weiss, 2003; Weiss et al., 2003; Whitehead, 2004; Vance et
al., 2005):
• Description of process to design a neonatal specific ambulance.
• Ambulance manufacturers listening to the people using the
vehicles – benefits of new design features.
• Description of design flaws from medics and emergency
medical technicians (EMT).
• Design features for safety.
• How to specify a new ambulance.
• Description of action group to develop a paramedic
ambulance which would conform to European Committee for
Standardisation (CEN) standards and evaluation of front line
service.
• Ambulances for children.
• Mercedes sprinters description.
• Modification of ambulance for bariatric patients.
• Fiat Ducato ambulance description.
• Use of red lights and siren (RLS) increases the risk of the
ambulance becoming involved in a crash and the severity
of that crash. Scheduled preventative maintenance and a
comprehensive safe driving program decreases risk factors, and
RLS responses should be reduced.
• Description of a mobile nursery van for the transport of sick
infants.
• Description of new Ford e-350.
• Development of interior design proposals for ambulances,
measuring physical/environmental factors and simulation of
vehicle behaviour, giving a draft of an overview of design
recommendations desires and boundary conditions. Suggests
that because ambulance services have freedom to design their
own ambulances and because the task situation differs from
14
service to service, development of a single design makes no
sense.
• New specifications for ambulances and fleet managers.
• Description of problems of performing cardiopulmonary
resuscitation (CPR) in a moving vehicle and ideas for solutions
including a centrally mounted stretcher.
• Demers ambulance design.
• Latest innovations in emergency vehicle lights and sirens.
• New type 2 ambulance.
• Design comments and solutions for crew comfort and how this
affects employee morale and job performance – particularly
chair design and comfort.
• New designs of sirens and lights.
• Letter commenting on road safety and blue lights and sirens
– not always necessary.
• Description of ambulance design features for children.
• Experience with ambulance design and equipment over 14
years – vehicle features in order of importance: portable and
stationary life support, working space, riding quality, vehicle
performance, and cost.
Higher quality papers dealt with other areas, including a paper
describing a consensus on design characteristics. This, with some
of the personal professional opinions expressed in the lower quality
papers above, supports a good case for some design features.
Hassan and Barnett (Hassan & Barnett, 2002) used a Delphi
questionnaire design to develop consensus opinion with senior
expert staff on future design characteristics of EMS in the UK. These
were significantly different from the present EMS model.
Ambulance crashes were examined by Kahn et al. (Kahn et al.,
2001) with a retrospective analysis of all fatal ambulance crashes
on United States (US) public roads, revealing that most occurred
during emergency use and at intersections. Rear compartment
occupants were more likely to be injured than those in the front. It
was recommended that crash and injury reduction programs should
address improved intersection control, screening to identify high
risk drivers, appropriate restraint use and design modifications to
the rear compartment of the ambulance. This paper also refers to
restraint and informs the section on securing people and equipment
in transit.
The effects of noise and vibration were considered by Prasad 2.10 PATIENT EXPERIENCE (SAFETY, COMFORT
et al. (Prasad et al., 1994) in a study looking at the influence of AND DIGNITY)
ambulance noise and vibration on auscultation of blood pressure.
Forty nine personnel obtained blood pressures using a model in Only one lower quality paper was exclusively about patient
a quiet environment and in a moving vehicle. The results showed experiences in ambulances. Middleman (Middleman, 2004)
that blood pressure readings in the moving ambulance differed commented on the importance of getting the right type of transport
significantly from those obtained in a quiet environment, which may for the patient. However the issue is implicit in many other papers
be due to road noise and ambulance motion. for instance:
• patients with severe trauma are better in private transport
Seats and the effects of sitting for long periods were considered (Demetriades et al., 1996);
by two higher quality papers. Morneau and Stothart (Morneau • geographical information systems are used to get to rural
& Stothart 1999a & b) carried out a survey of EMS personnel to communities (Snooks et al., 2004);
determine whether the amount of time sitting in an ambulance, • ambulance diversions are common and increasing, and delay
back injuries and discomfort had increased since the implementation emergency care (Redelmeier et al., 1990);
of ‘roaming’. They also evaluated the physical characteristics of • Young et al. (Young et al., 2003) highlight the need for public
seats and space. The results showed that exposure to a static education on proper use of 911.
position for an extended period and vehicular vibration resulted in
increased back pain and that current seats did not provide adequate
safeguards. They recommended that the significant health and
safety issues should be corrected to allow paramedics to carry out
their critical functions without jeopardising their own safety.
Satellite navigation systems were examined by McGregor et al.
(McGregor et al., 2005). Two geographical information systems
(GIS) approaches were compared to determine whether recent
standards of emergency care access were being met. The two ways
used were ‘as the crow flies’ or a more sophisticated estimation
of travel time using digitally referenced road network data. Both
revealed standards were not being met and that the network
technique was more accurate.
A more clinical concern was the storage of drugs and the
environment within the ambulance. Gill et al. (Gill et al., 2004)
reported an evaluation of the effects of temperature variation on
stability of common cardiac drugs. A temperature recording device
was placed in the compartment with drugs to record and store
temperatures at 15 minute intervals with a control. The results
showed that common cardiac drugs can withstand temperature
variations for 45 days, but this is not necessarily the case for
other drugs.

15
3. Method
3.1 OVERVIEW for the analysis of the workshop data. Empirical data were collected
from four user workshops. The first workshop focused on issues at
Three data types were collected: archival incident reports, research
a strategic level, the second on manufacturer’s issues and the final
literature and empirical data from user workshops. The archival
two on operational issues.
data were collected from three sources about reported incidents
relating to ambulance and ambulance equipment design and use. The integration of the data types and flow of the collection/
The research literature review was used to not only set out the analysis are shown in figure 2.
background context but also to develop the conceptual framework

Figure 2. Overview of project

Incident report data

NRLS NHS trusts MAUDE

(coded by SH) (coded by EC) (coded by AJ)

5 DESIGN THEMES
Project aims
WORKSHOPS (data entered by RC/MK)
and objectives
(primary coding by EC)

Literature review 9 DESIGN THEMES 9 DESIGN CHALLENGES

(summarised and (secondary coding by SH) Supported by:
coded by EC/AJ) (validation at AMBEX) 1) empirical data from workshops;
2) incidental reports
(NRLS, ASA, MAUDE);
3) literature review.

Design performance requirements

‘Towards a national ambulance fleet’
(developed by RC/OE/MK)
16
3.2 DATA MANAGEMENT, DISPLAY
AND ANALYSIS
It is important to have a robust audit trail showing how data
were collected and then managed with respect to the analysis
to support the iterative process of data collection and analysis in
qualitative research.
Qualitative data projects generally use a three-stage process for
data management by firstly organising, reducing or describing
the data (table 2). This was achieved in the summaries of the
workshop. Stage two started the analysis by classifying as
achieved in the iterative thematic analysis. Finally, stage three
involved interpretation and conclusion drawing. To test the
interpretation, more detailed visualisations were produced and
taken to AMBEX. As the qualitative process is iterative, these
steps are cyclical rather than linear.
Table 2. Data management steps (modified from Miles &
Huberman, 1994)
Data are reduced in anticipatory ways as
conceptual frameworks are chosen and
Step one: cases and questions are refined. Data are
data reduction summarised, coded and broken down into
themes, clusters or categories.
Summarising and packaging the data.
Data display describes diagrammatically
pictorial or visual forms in order to show
what those data imply to give an organised,
Step two:
compressed assembly of information that
data display
permits conclusion drawing and/or action
taking.
Repackaging and aggregating the data.
Conclusion drawing and verification using
Step three:
different tactics, e.g. analytic induction.
conclusion
drawing/ Developing and testing propositions to
verification construct an explanatory framework.
3.2.1 Addressing validity and reliability
Internal validity addresses issues of credibility and authenticity in
the research. At an operational level, this was established through
the audit trail and the analytic induction process of testing theory.
External validity looks at issues of generalisability and transferability.
The detail given with respect to the context, researcher bias,
sampling strategy and history of the research question can all
help to establish the conditions whereby the findings could be
transferred to another setting.
Respondent validation, also known as member checking, is when
the interpretation of the researcher is presented back to the
subjects as part of the conclusion drawing and verification process
(Walker, 1989). This is a different process to accuracy checking of
data, where an interview transcript is returned to the interviewee.
Mays and Pope (Mays & Pope, 1995) suggested that member
checking could be used to add to both the internal (authenticity
check) and external (transferability of findings) validity.
Triangulation is another method that can be used to establish
both internal and external validity. It refers to the use of
more than one data source, method or investigator, and the
convergence of these to add credibility to a study. There are
concerns that if the philosophical (ontological) positions have not
been defined, the combination of different analyses would look
as if they had been stuck ‘together like children’s building blocks
in order to create a single edifice’ (Coffey & Atkinson, 1996),
resulting in a comparison between optimal and inferior methods
and data.
Reliability addresses the issues of auditability or quality control.
This could be the consistency with which instances are assigned
to the same code in analysis, or on a broader level to the process
itself. There is a problem with the ability to replicate both
qualitative and quantitative research, since for any study looking
at human actions within a social context there will be change, for
example: the people involved or the social situation.
17
3.3 INCIDENT REPORTS
Archival documents were retrieved from three sources to explore
documented problems with ambulance design
and use.
The three systems were:
• NRLS (maintained by the NPSA, UK);
• MAUDE (USA);
• NHS ambulance trusts.
Due the different methods of data collection for all three systems,
it was not possible to draw any conclusions about the frequency
of incidents. Data were primarily used to develop the conceptual
framework for the workshop data analysis and provide examples
of ambulance/equipment problems for the design challenges.
3.3.1 NRLS
A dataset of reports from the NRLS at the NPSA was requested
for the period November 2003 (start of NRLS) to November 2005
for the care setting ‘ambulance service’.
The total dataset for this period was 400,000 reports. The data are
usually coded by the NHS trusts before submission to the NPSA
(see figure 3). The only exception to this is the code for ‘other’. This
code is scrutinised by a data engineer at the NPSA and recoded if
appropriate (Cook, 2005).
18
Figure 3. NRLS Disclaimer Statement
NRLS Reports Disclaimer Statement
The incidents summarised in this report have been drawn from the
NPSA National Reporting and Learning System (NRLS). The NRLS
supports the goal of the NPSA to make patient care safer. The NRLS
is a confidential reporting system. The incidents are reported through
a variety of routes, by individual NHS staff, including through
the local trust risk management systems and web based e-forms
(including an open access e-form). The individual reports are not
investigated or verified by the NPSA. Since these incidents are self-
reported they are not necessarily representative of the NHS across
England and Wales and therefore need interpreting with care.
Permission must be obtained from the NPSA before the information
contained within the report is published or passed on to a third party
outside the NPSA. For help with interpretation please contact the
statistics team on statisticsteam@npsa.nhs.uk.
3.3.2 MAUDE
The MAUDE database collects voluntary reports of adverse
incidents in the US between 1997 and 2005. The database
was formed by the Center for Devices and Radiological Health
(CDRH) and provides an online search of medical devices which
have malfunctioned or caused injury and death. Consumers
experiencing equipment malfunction can report the incidents
directly to the CDRH.
The database was searched to identify incidents occurring
between 2004 and 2005 relating to ambulance equipment. Three
search terms were used; ‘ambulance’, ‘paramedic’ and ‘EMT’.
A total of 1259 reports were retrieved. These were screened
for relevance to ambulance and ambulance equipment design.
Sixteen reports were duplicated across the three search terms,
giving a final result of 95 reports (table 3).
Table 3. MAUDE incidents 3.4 WORKSHOPS
No. of relevant
Search term No. of reports The four workshops collected data using a similar methodological
reports
approach to Clarkson et al. (Clarkson et al., 2004) and aimed to
Ambulance 500 74 deepen understanding of the problems (current and future) for
ambulance transport by learning from workers’ and patients’
Paramedic 500 14
experiences (both positive and negative), identifying obstacles,
EMT 259 7 prioritising the resulting issues, and identifying areas relevant to
future design of vehicles and equipment (figure 5). Data were
TOTAL 1259 95 collected using field notes and workbooks to capture issues and
problems in an open-ended way. Some common elements were
3.3.3 Individual NHS ambulance trust addressed at all workshops (for example, patient safety). The
incident reports exercises varied between workshops to ensure a range of results
and the data were analysed thematically (Hignett, 2005).
The National Health, Safety & Risk Coordinator from the ASA sent
an email to all NHS ambulance trusts (n=32) on 7 February 2006 Figure 5. Overview of workshops
(see figure 4.) Replies were received from 10 trusts. Sampling strategy
(1) Spreading the net: purposive sampling at strategic workshop
Figure 4. Invitation to NHS ambulance trusts to supply (2) Following up leads: industrial and operational workshops
incident information (3) Analysis sampling: to test interpretation at AMBEX (questionnaire)

In relation to the Ambulance Design Project, the researchers at

Data collection and analysis/reduction (1)
Loughborough University and the Royal College of Arts require data Strategic workshop
on patient and staff accidents/untoward events that have taken Industrial workshop
place within or entering/exiting ambulances. This information will be Operational workshops 1 & 2
extremely valuable in informing the project and for future design. Whilst TRIANGULATION OF DATA BETWEEN WORKSHOPS
they have access to the NPSA NRLS, I suspect far more information
is held within trusts’ databases which would prove useful. I would
be grateful if you could provide anonymised data for a 3 year period Data collection and analysis/reduction (2)
November 2002 – November 2005, or minimum 2 years Nov 03–05. Thematic analysis (primary and secondary)
Design requirements
Key information
• summary of the incident i.e. what the incident was and where
within the vehicle it took place;
Data display & conclusion drawing
• whether it involved equipment etc if possible; Validation of design requirements at AMBEX 2006 (member checking)
• what type of vehicle it was (A&E or PTS at least);
• if there was any injury; and
• whether it affected staff or patient.
Evolution Revolution
Preferred format would be Excel spreadsheet, separating patient Retrofit existing vehicles System of service delivery
incidents from staff incidents. Please let me know if you have any Incremental change with existing New vehicle options
products/equipment Vehicle types
queries on what is required. If possible, could you send the data to me Move to standardisation SANDPIT
by Friday 24 February.

19
The data management steps from table 2 are shown in figure 5,
with the three sampling strategies to:
1. spread the net to capture as wide a range of participants and
views as possible;
2. follow up leads, including an additional workshop with
manufacturers (industrial);
3. analysis sampling to test the emerging interpretation and
theory with a modified form of member checking.
The detail from the workshop data collection is given in sections
3.4.1–3.4.3 and the analysis in section 4.2. The validation stage is
described in sections 3.5 and 4.3.
3.4.1 Strategic workshop (16 January 2006)
For the strategic level workshop, the publication ‘Taking
Healthcare to the Patient’ (Department of Health, 2005) was
circulated to all attendees before the meeting.
Aim
The workshop aimed to explore what ambulance vehicles and
equipment will be needed in the future by deepening the
understanding of current and future problems, identifying
obstacles, prioritising resulting issues for the operational
workshops and identifying areas for future design (revolution).
Objectives:
• exploring the big issues;
• mobile healthcare services;
• vehicle typologies;
• design opportunities.
18 participants:
• policy makers;
• chief executives;
• clinical directors;
• operational directors/managers;
• fleet managers;
• patient representatives.
Expert advisors from the Ambulance Transport Advisory Group
(ATAG), NPSA, ASA, Purchasing and Supply Agency (PASA) and
Health and Safety Executive (HSE) were also in attendance.
20
3.4.2 Industry workshop (9 March 2006)
Objectives:
• securing industry ‘buy-in’;
• understanding industry capabilities and dynamics;
• exploring opportunities for change and innovation.
18 participants represented body builders (7), chassis (4),
equipment (4) and car manufacturers (3).
3.4.3 Operational workshops (9 March 2006 and
6 April 2006)
At both operational workshops the design requirements of
the vehicle and associated equipment, storage, information
management and recording equipment were explored, as
were the possible variants in care provision at A&E sites and in
the community.
Topics:
1) What are the current problems in the different types of
transport. For example, patient safety, staff safety, delivery of
care and transportation.
2) How could future ambulances be designed to address these
problems. For example, possibility of separation of functions
into (a) knowledge, with example of emergency care
practitioners; (b) equipment, vehicles dedicated to moving
equipment to support care at home or extricate complex
patients; and (c) transportation to hospital.
Objectives:
• understanding operational realities;
• identifying design opportunities;
• improving emergency care delivery.
Design issues in four key areas:
• loading and unloading patients;
• treating patients (in situ and on the move);
• transporting patients and equipment;
• vehicle turn-around.
Fifty five participants attended, including 25% operational staff Figure 6. Participants in the operational workshops
and 7% patient representatives (figure 6) from:
Patient
London (9 March 2006)
representatives Fleet managers
7% 15%
Nine ambulance trusts
Three acute/primary care trusts
Patient representatives Advisory
Advisory agencies
agencies
Operational
• Vehicle Certification Agency
16%
managers
• Health Protection Agency 15%
• NHS Security Management Service
• Health and Safety Laboratory
• Healthcare Commission
Acute/PCT Safety & risk
trusts 13% managers (including
Loughborough (6 April 2006)
infection control)
Eleven ambulance trusts
9%
Two acute trusts Operational staff
Patient representatives 25%
St John Ambulance
Advisory agencies
3.5 DESIGN CHALLENGE VALIDATION
• Unison National Ambulance Sector
• Vehicle Certification Agency To validate the design challenges, the data were returned to
participants via a plenary lecture and exhibition at AMBEX 2006.

3.5.1 Aims
• To inform the ambulance community about the project.
• To report on the results for the design requirements of the
EVOLUTION component.
• To invite participation for validation of the design
requirements using a ranking questionnaire.

3.5.2 Question set

1. Space and layout including access to equipment and both
sides of the patient, space to accommodate paramedics and
relatives and to move around.
2. Securing people and equipment in transit, including quality
of static and dynamic seat belts for all staff, patients and
children.

21
 3. Communication, including inside the ambulance; and 3.5.3 Data collection
between ambulance and hospital; and ambulance and
Eight of the nine themes were explained in detail. Theme 1
ambulance control.
(access/egress) was omitted due to the previous EPSRC project
4. Security, violence and aggression including unattended
(see section 2.2.1). A ranking questionnaire was used to
vehicle, paramedics working alone and central locking/drugs.
collect data.
5. Hygiene including seams/crannies in equipment, steam
cleaning, better access to gloves/aprons and improved
disposal.
6. Equipment, including storage and standardisation;
maintenance, availability, fit for purpose/patient, portability,
accessibility, secure and compatible.
7. Vehicle engineering, including temperature, noise, lighting,
ventilation and power supply.
8. Patient experience, including clinical issues (response times,
treatment on site) and non-clinical issues (accompanying
relatives, dignity, intimidating environment).

22
4. Results
4.1 INCIDENT REPORTS Figure 7. NRLS: Reported degree of harm

Incident report data were collected from three sources: NRLS,

100%
MAUDE and individual ambulance trusts.
90%
90%
4.1.1 NRLS
A dataset of 1,352 was received, representing less than 1% of 80%
74%
the NRLS reports. The data were analysed for:
• degree of harm; 70%
• reported speciality;
• reported category. 60%

Degree of harm 50%

The degree of harm from this subset of reports was low. Figure 7 40%
shows that 74% of the incidents involved no harm to the patient
(rising to 90% for medical devices and equipment), with only 4% 30%
of reports resulting in severe harm or death.
20%
15%

10% 7%
4% 5%
2% 2% 2% 1%
0%
Death Low Moderate No harm Severe

All

Medical devices

23
Reported speciality were scrutinised and recoded using revised categories (table 4),
but without reference to the original category. This resulted in
Figure 8 shows the reported speciality. It can be seen that reports
23% of reports (as before), with equipment issues accounting for
coded as patient transport services (PTS) account for 75% of the
17% and vehicle issues accounting for 6% of the reports. These
reports. On closer scrutiny it became apparent that the code PTS
subsets were further analysed to identify the detailed contributory
was probably used as a descriptor for all ambulance transport, not
factors as shown in table 5.
as the term PTS is used in the ambulance service to differentiate
between A&E vehicles and PTS vehicles. It was concluded that the
reported speciality field could not be used to differentiate location Figure 9. NRLS: Reported category
of reports.
No information: 1%
Figure 8. NRLS: Reported speciality
Treatment, Access, admission, transfer,
procedure: 5% discharge (including missing
Anaesthetics: 0% patient): 19%
Medical specialities: 3% Self-harming: 0%
Diagnostics: 0% Clinical assessment
Learning A&E: 1% Patient (including diagnosis,
Mental health: 1% accident: 21%
disabilities: 0% scan, tests,
Not applicable: 1% assessment): 2%
Unknown: 4%
Obstetrics and Patient abuse
gynaecology: Consent,
(by staff or
1% communication
third party):
confidentiality: 7%
Surgical Other: 13% 1%
specialities: Disruptive
1% aggressive
PCT: 0%
behaviour: 1%

Documentation:
0%
Other:
1% Implementation
of care and
PTS: on-going
75% monitoring/
review: 1%
Medication: 7%
Reported category Infection control: 0%
Figure 9 shows the reported category, with reports for medical Infrastructure (including staffing,
devices and equipment accounting for 23% of the total dataset. Medical device/ facilities, environment): 11%
On closer scrutiny, many discrepancies were found with respect to equipment: 23%
the assigned categories. To standardise the data, the 1352 reports
24
Table 4. NRLS: Categories for recoding data

Category Category description Number Percentage

0 No information 8 1%

1 Referral (including wrong services) 300 22%

Equipment issues (including stretcher, carry chair and wheelchair design; FRED, MobiMed,
2 229 17%
Lifenet, telemetry transmission but not 02 and entinox cylinder design)

3 Vehicle design (including satellite navigation, tail lift, fixing and fittings) 79 6%

4 Violence and aggression 33 2%

Medication errors (including provision of gases; missing equipment; split masks

5 258 19%
(consumables))

6 Infection control 10 1%

7 Patient condition (including deterioration) 121 9%

8 Other (including non-ambulance incidents) 79 6%

9 Patient accident – slips, trips and falls 142 11%

10 Obese 11 1%

11 Patient accident – laceration 82 6%

25
Table 5. NRLS: Detailed analysis of medical devices/equipment and vehicle issues

Category description Number Percentage

Breakdown (including doors opening in transit) 16 5%

Carry chair 6 2%

CPR bag 1 0%

Diagnostic equipment, e.g. BM sticks (for blood glucose measurement), pulse oximeter, laryngoscope 16 5%

Heart monitor (including telemetry, FR2, electrocardiogram (ECG) leads) 89 28%

Interior e.g. seats/bags falling, unsecured, clamps, cupboards opening, windows not tinted 17 5%

Lifting aids – scoop stretcher, elk, spinal board 16 5%

Noise 2 1%

Other 2 1%

Computer (PC) failure 2 1%

Power failure (battery and vehicle) 20 6%

Pump, suction, balloon pump, bag/mask defects, syringe driver 38 12%

Radio failure 2 1%

Ramp failure 5 2%

Satellite navigation 3 1%

Siren 1 0%

Stretcher (including collapse, toppling) 37 12%

Tail lift failure 26 8%

Wheelchair (including missing straps) 4 4%

Ventilator 12 1%

26
By analysing the medical devices/equipment and vehicle subsets
(table 6) it becomes apparent that the reports relating to the
heart monitoring equipment, pumps and stretcher reports
account for 52% of the reports. If the design, operation and
reliability of these items could be improved there would be a
significant reduction in the number of reports.

Table 6. NRLS: Equipment and vehicle issues

Equipment issues (52%) Vehicle issues (48%)

Heart monitor, telemetry (28%) Loading failure: ramp, tail lift (10%)
Bag/mask defects, syringe driver, suction etc. (12%) Power failure, battery (6%)
Stretcher collapse (12%) Breakdown (5%)
Diagnostic equipment – pulse oximeter, laryngoscope (5%) Interior: seat/bags falling, clamps, cupboards opening (5%)
Lifting aids – scoop, elk, spinal board etc. (5%) Noise (1%)
Wheelchair defect (4%) Computer failure (1%)
Carry chair (2%) Satellite navigation failure (1%)
Ventilator (1%) Radio failure (1%)

4.1.2 MAUDE
From 1259 reports, 111 were relevant to ambulance equipment.
Sixteen reports were duplicated throughout the three search
terms and these were discarded, leaving 95 reports.
The vast proportion of the equipment reported in the ambulance
equipment dataset related to stretchers and defibrillators.
Stretchers accounted for 44% of reports and defibrillators
accounted for 38%. The full list of equipment reported in MAUDE
is shown in table 7.

27
Table 7. MAUDE: Number of reports for each Table 8. MAUDE: Outcome of incidents
equipment type
Event type Number Percentage
Equipment Number Percentage
Not reported 9 10%
Intraosseous infusion pump 1 1%
Death 9 10%
Defibrillator 36 38%
Malfunction 31 33%
Medical gas ventilator 1 1%
Injury 34 36%
Suction liner 1 1%
Other 12 13%
Infusion pump 1 1%

Electrocardiograph electrodes 2 2%
Patient outcome

Suction unit 1 1% The reports were further analysed to determine the percentage of
incidents that resulted in intervention, hospitalisation and death.
Electrode cable 1 1% It was found that 36% of incidents resulted in intervention,
while 16% of incidents resulted in death. The analysis of patient
Safety catheter 2 2% outcome can be seen in table 9.

Eagle vent 3 3%
Table 9. MAUDE: Patient outcome
Cardiac monitor 2 2%
Patient outcome Number Percentage
Blood glucose monitor 1 1%
Not reported 28 30%
Stretcher 42 44%
Death 15 16%
Automatic external defibrillator 1 1%
Other 15 16%

Required
Event type 34 36%
intervention
The reports were analysed to determine the outcome of incidents,
revealing that 36% were injury related and 33% were the result Hospitalisation 3 3%
of equipment malfunction. The categories were determined by the
consumer and were therefore subject to their interpretation. The
full results of this analysis can be seen in table 8.

28
Summary
From analysis of these reports it is evident that defibrillators
and ambulance cots contributed to the majority of incidents in
the US between 2004 and 2005. The percentage of incidents
resulting in death was 16%, with cots and defibrillators
accounting for the majority of these incidents. Results showed
that 33% of incidents were attributable to equipment
malfunction. Therefore if this equipment were improved in
terms of design, functionality and reliability, the incidents
would decrease in frequency. The majority of stretcher
incidents resulted in injury requiring intervention, while the
majority of defibrillator incidents resulted in death. Stretchers
accounted for 44% of reports (compared with 12% in the UK)
and defibrillators for 38% (compared with 28% in the UK).
The total number of reports in the database is not available.
If this was provided it would be possible to work out the
percentage of ambulance related reports. The on-line search
facility only displays 500 results per search term and the
database is not categorised in terms of ambulance and
hospital equipment, which makes it difficult to ensure that all
reports are found.
4.1.3 Individual ambulance trusts
Ten NHS ambulance trusts responded to the national invitation
from the ASA from an invited 32 trusts. The reports were
presented at the workshops, and the validation questionnaire
at AMBEX. For further analysis, they were categorised into the
nine design challenges to check for inclusion. As they do not
form a representative sample, no further detail is included in
this report.
4.1.4 Validating the design challenges from
the incident report data
To check the inclusiveness of the nine design challenges, the
NRLS data were reviewed and re-categorised with the nine design
challenges identified from the workshop data. The inclusion/
exclusion criteria for this re-categorisation are as follows:
1. where a category was difficult to determine from the
available information, the incident was omitted;
2. category two (securing people and equipment in transit)
was not applied to all reports of accidents due to falling
or being struck by objects in the ambulance, unless it was
mentioned that the ambulance was moving;
3. incidents were only included in the further categorisation
if they occurred within, or in contact with, the
ambulance;
4. problems with communication could have been inferred
in several reports, but unless it was mentioned specifically
it was not categorised;
5. the access/egress category was used if the incident was
associated with the ramp, tailgate, steps, handrails etc. or
it occurred when entering or exiting the vehicle.
It can be seen in table 10 that the largest number of incident
reports related to equipment, followed by access/egress issues.
29
Table 10. Incident reports for design challenges 4.1.5 Strategic workshop
Recoded Incident report The data from the workbooks collected at the strategic workshop
Design challenge NRLS data from were entered into FileMaker Pro and analysed thematically. Six
data ambulance trusts
core areas of service provision were identified and discussed:
1. A
 ccess/egress (loading/ 1. Response:
5% 25%
unloading) a. admission, including response time;
2. Space/layout 1% 7% b. c ondition specific response, e.g. paediatric, bariatric;
c. communication and technology design to support
3. Securing people and information exchange.
2% 17%
equipment in transit 2. Diagnostics e.g. for minor injuries:
4. Communication 2% <1% a. blood analysis;
b. mobile x-ray;
5. S ecurity, violence c. breast screening.
2% 3%
and aggression
3. Treatment in the community:
6. Hygiene 1% 1% a. discharge on site by ambulance workers;
b. s upporting community clinicians e.g. doctors, dentists,
7. Equipment 28% 12% optometrists, cardiologists, pharmacists, midwives, nurses,
chiropodists;
8. Vehicle engineering <1% 12% c. chronic disease management support e.g. diabetes,
9. P atient experience respiratory care, cardiac disease;
(safety, comfort 5% <1% d. mobile treatment centres, e.g. minor surgery, minor
and dignity) injuries unit at events.
4. Support services:
10. O
 ther incidents
a. removal of clinical waste;
irrelevant to design
b. delivery of drugs;
challenges, for example
55% 21% c. clinical support services e.g. organ transport, blood
incident location was
not ambulance (e.g. delivery.
patient’s home) 5. Health promotion:
a. surveillance of vulnerable groups (e.g. elderly);
b. displays/exhibitions;
6. Non-emergency transport:
The design challenges did not map well onto the NRLS data due a. discharge;
to the different criteria for analysis. For example, the option to b. special needs, e.g. bariatric;
describe the contributory factors of an incident with respect to c. care groups (social transport).
space/layout is not offered as part of the NRLS input prompt so
this design challenge is poorly represented from the incident data.
It is suggested that incidents where the contributory factors may
be lack of space or inappropriate layout are more likely to be
reported as equipment problems.

30
The initial categorisation of topics at the strategic workshop manufacturers, and NHS processes e.g. indecision resulting in
resulted in three proposed vehicles types: changes to the design specification during manufacturing and
1. Large modular vehicle with a 2–3 hour response time for late ordering (last quarter of financial year).
diagnostics, treatment, minor surgery, health promotion etc.
A number of factors were identified that the manufacturers
2. Van to transport patients on stretchers/wheelchairs. Includes
felt could help to implement changes. These included better
transportation in sections (1) and (6) above.
communication with the NHS, more flexibility (but at the same
3. Rapid response, which could be achieved using a motorbike,
time feeling that a national specification would be helpful
small car etc.
with standardisation for fixing methods) and a longer-term
commitment from the NHS to support business continuity.
4.1.6 Industrial workshop
The manufacturers were asked to consider the time frame for 4.1.7 Operational workshops
changes, drivers and barriers to change, and what initiatives
The data from the operational workshops were coded in two
might help to implement change.
stages to allow for iterative analysis and further exploration
The time frame for change was split into three stages, up to two of codes and themes. The empirical data from the operational
years, two to five years and longer than five years. In the first workshops were coded in parallel by Roger Colman/Merih Kunur.
time period it was suggested that changes would include the The primary coding exercise by Roger Colman/Merih Kunur
use of alternative construction materials, increased privatisation resulted in two distinct design outputs for (1) design issues and
(especially for non-emergency transportation), a change in NHS (2) problems/features. These codes were then scrutinised by
buying behaviour due to the restructuring of ambulance trusts Emma Crumpton, resulting in the 31 codes.
(reduction from 32 to 12), and standardised fixing methods for
At this stage, a detailed secondary coding was conducted within
equipment within the ambulance.
the codes to identify nine higher level codes (table 11) and
The mid-time frame (2–5 years) was expected to include changes address duplication between codes (Emma Crumpton/Sally Halls).
in ambulance body designs, increased manufacturer collaboration For example, space in the higher level code of internal layout
(cross-European), more treatment in the community and an and access/egress was merged into a revised design challenge of
increased use of stair-climbing chairs and bariatric equipment. ‘working space and layout’. These design challenges were further
In the longer time frame it was anticipated that there would be checked against the primary coding (from Roger Colman/Merih
different styles of patient care (and therefore changes in vehicle/ Kunur) by Sally Halls to confirm inclusiveness.
equipment requirements), increased globalisation (especially
European partnerships) and more centralised design with vehicles
lasting longer.
The drivers for change included the DH (Department of Health,
2005), legislation (especially health and safety), politics (influence
from government), medical practices and patient weight/size.
The barriers included ‘old school thinking’ (resistance to change),
development costs and time, CEN (and Vehicle Certification
Agency) requirements, the relatively small size of the market,
changes in the purchasing structure due to the reduced
number of ambulance trusts, poor communication between
31
Table 11. Design themes/challenges
Code
1. Access/egress
2. W
 orking space and
layout
3. S ecuring people and
equipment in transit
4. Communication
5. S ecurity, violence and
aggression
6. Hygiene
7. E quipment usability
(including storage)
8. Vehicle engineering
9. Patient experience
32
Description and design issues
Manual handling
Speed
Safety (hand rails, edges)
Not included as has been covered in more detail in another project
How much space is needed for treatment e.g. three attendants?
Is it possible to achieve this space in a confined area or is an alternative design solution needed for a treatment
service?
Dynamic harness so that paramedic can be secured (possibly overhead) – however seat belts are not currently used
Better design for seated position (possibly alongside or at head end for critical care and/or monitoring)
Two-way (driver and patient compartment)
Communication between ambulance and hospital
Especially for panic button (two exit points)
Link displays (e.g. chip and pin, transfer to hospital)
Unattended vehicle
Working alone (isolation)
Drug security (theft)
Restraint of violent patients
Possibly modular design for improved turn-around
Cleaning of floor, straps, cupboards
Standardisation of mounting systems
Standardisation of location and storage of equipment
Access to storage: height, inside/outside
Standardisation of location of sharps and disposal
Standardisation of mobile equipment e.g. responder bags, weight
• Temperature
• Ventilation
• Noise
• Lighting
• Vibration
• Brakes
• Turning circle
• Security when unattended
Designed so that the vehicle supports the equipment (e.g. including power supply)
Less clinical environment for children
Response time (fast responder)
Different responses needed for treatment on site (inside-outside), fast transport
Transportation of carers/family (especially for vulnerable groups, children/elderly)
Power supply so that equipment works reliably (pump, syringe driver)
4.2 DESIGN CHALLENGES
The design challenges have been further reviewed and are
summarised in the first section of this publication Design for
patient safety, future ambulances.
The workshop comments were used to inform the design process
and are listed below under the nine design challenge headings in
verbatim format (participant’s own words). Comments have been
screened to minimise repetition. The proposed solutions were also
suggested by workshop participants.
4.2.1 Access/egress (loading/unloading)
Issues identified at the workshops included:
• need controlled entry and egress – speed may be needed;
• hospital road systems and patient loading/
unloading designs;
• need improved vehicle access device;
• tail lift design and operation;
• ease of use during power failure;
• loading and unloading platform – different heights;
• weight – combined bed and patient;
• moving equipment;
• restraint of staff and patients during the lift;
• time issues when operating side bars and foot plates – too
slow;
• carers find it difficult to negotiate access points;
• angle of ramp – width of ramp difficult for staff to assist
patient if nervous, staff unable to walk up either side of the
patient and no handles;
• type of surface;
• heavy, slow breaks, manual/electric;
• variation in wheelchairs – some too high, leads to tipping on
ramps, difficulty using winch;
• steps are wide apart and narrow and high;
• location of rails, colour, tactile and fit for purpose – handrails
at the top of the stair, becomes out of reach by the time they
reach the bottom step.
Suggested solutions included:
• needs to be simple (hydraulic lift);
• tail lifts good for complicated and heavy equipment;
• involve patients in design;
• need stretcher, chair and walking access;
• straps – handrails;
• tail lifts or ramps on all vehicles – remote control;
• slopes and ramps should have inclines consistent with
building regulations;
• ramps with a winch;
• powered ramps – robust;
• lowering of suspension;
• make steps wide and lower to ground to avoid slipping;
• floor fixed railings;
• longer hand rails.
4.2.2 Working space/layout
Issues identified at the workshops included:
• staff access to patient – some activities need up to three
attendants with access to patient;
• carer should be able to see and touch the patient;
• difficult to move around if more than one attendant;
• lack of head space;
• unable to store all equipment;
• defibrillators are too big (storage problems);
• reaching across patients and colleagues;
• trip hazards;
• not enough room in front of vehicle – bash knees on safety
helmets and torches;
• storage of patients’ personal effects;
• higher vehicles result in higher cupboards – difficult for
shorter staff;
• equipment stored on inside so when treating patient on
outside have to keep going in;
• stability/security of equipment, medical gases;
• equipment should be easily accessible and visible;
• equipment may need to go on patients body as no room
both sides or to carry;
• lack of space – equipment becomes missiles in accident.
33
Suggested solutions included: moving e.g. CPR
• all round access to patient by seat on track – patient in centre • when vehicle brakes sharply staff can be thrown
of vehicle; around saloon;
• adjustable seats, swivel lateral movement – three seats • restraint for children;
around stretcher; • restraint for patients and carers;
• fold down bench or flap on stretcher; • cannot secure patient’s own wheelchair;
• remote control chair; • bariatric patients do not fit seat belts;
• centrally mounted stretcher; • seat belt material, colour, hygiene fixing point;
• standardisation of equipment; • falling equipment if vehicle brakes;
• design smaller equipment; • loose equipment.
• storage above heads;
Suggested solutions included:
• more critical equipment built into roof area –
• restraint needs to be adjustable according to
pull down;
seating position;
• kangaroo pouch style locker that can be pulled down and
• harness of some sort for treating patients
pushed shut;
whilst moving;
• standardise all kit on walls, bulkheads etc.;
• secure overhead fixing for personal safety to allow more
• secure storage/fixing of mobile equipment and medical gases;
controlled movement whilst vehicle is in motion;
• no sharp edges;
• padded cupboards in ambulance as well as a restraint system;
• more cubby holes;
• sensors at front and rear will help driver not to bump;
• more storage;
• minimise standing by having essential equipment close at
• lockers that can be accessed from inside and outside;
hand;
• drop down from ceiling for electrodes and oxygen – easy to
• design of seats capable of carrying children and babies from
hand for primary equipment;
0–10 years;
• lock off location for little-used equipment;
• standardise mounting systems for cots;
• essential equipment, close at hand and visible;
• standardise incubator design;
• flexible systems to exchange equipment;
• design of cot and seat to ensure comfort and stability of
• electronic tagging to indicate used storage access to
patient;
equipment entered;
• padded seatbelts/straps (more comfortable);
• integrate equipment into walls, cupboard and bulkhead
• easy clean fabric;
creating smooth surfaces;
• secure mountings.
• lockers with integral electrical supply;
• bespoke trolley;
4.2.4 Communication
• on table above patient;
• movable equipment houses – hydraulic arms. Issues identified at the workshops included:
• facility to relay information about patients;
4.2.3 Securing people and equipment • policy and procedure get in way of clear communication;
in transit • role of patient’s carer unclear;
• built in communications required;
Issues identified at the workshops included: • being able to absorb crucial information whilst
• need restraint for staff carrying out treatment whilst vehicle is
under stress;
34
 • public announcement (PA) system to speak to crowd or direct Suggested solutions included:
other driver/pedestrian. • no nooks and crannies to trap dirt;
• infection control – interior that can be steam cleaned;
Suggested solutions included:
• modular design with access around fittings;
• writing down – whiteboard;
• curved moulded joints;
• need more information from control room – crew.
• smooth seam free surfaces able to withstand chlorine-
releasing agents;
4.2.5 Security, violence and aggression
• quick cleaning mopping.
Issues identified at the workshops included:
• restraint – violence and aggression by patients; 4.2.7 Equipment
• conveying patient in a single responder unit – secure
Issues identified at the workshops for trolley/
bulkhead door, may need help from driver;
stretcher design:
• vulnerable to allegations from patient;
• design is inadequate in terms of the diverse range
• being seen by other crew staff and communication
of patients;
– attendant isolated in rear of vehicle;
• compatibility;
• security of staff property;
• adjustment – restraint;
• secure vehicle against theft – still have access.
• locking and unlocking;
Suggested solutions included: • wobbly/noisy/hard/unstable – patients not feeling safe/
• reduce potential weapons; comfortable;
• reduce need to enter/exit past patients legs – kicking; • not wide enough or soft enough – is head supported?;
• two way communication – intercom, window; • too firm – poor for patients with pressure sores;
• link with central ambulance control (CAC); • mattress easy to tear;
• no fixed bulkhead; • very heavy when loaded;
• closed circuit television (CCTV) in saloon; • manoeuvrability – steering;
• central locking – drug cabinet; • fixed height;
• mobile phones; • problems with equipment weight and flexibility to move
• panic button; around;
• two exit points; • transfers to stretcher;
• make vehicle conspicuous and identifiable in all situations day • patient safety – patients that tend to roll.
and night;
Suggested solutions included:
• ensure vehicle can be heard and seen – LEOs facing in right
• universal trolleys between ambulance service and hospital
direction, not at the sky.
would mean fewer patient transfers;
• need to be as flexible as ones on the wards, adjustable up
4.2.6 Hygiene
and down;
Issues identified at the workshops included: • design stretcher to accommodate patient, ventilator, syringe
• interior design – no seams/nooks and crannies to facilitate driver etc.;
cleaning and disinfection; • trolley should fit any vehicle;
• floor water unable to run away;
• disposal – clinical and general, access to clean gloves and
easy disposal. 35
 • compatibility of equipment;
• should be one man task – minimal movement from • old and new equipment – changing and upgrading;
lock down; • lack of standardisation – no spare equipment or alternatives;
• wider mattress; • specification continually changing;
• cover metal work; • transfer of equipment – too heavy;
• floating stretcher top to reduce vibration levels and • ability to safely secure equipment;
G forces; • struggling to adjust or use equipment can frustrate or lose
• replaceable mattress – waterproof and sectioned; patients’ confidence;
• should be higher so they can be pushed by one person; • turnaround issues;
• should be height adjustable; • access to appropriate equipment for bariatric patients;
• built in overhead hoist; • need better equipment for moving and handling;
• fixed on rails; • long transfers have very little equipment;
• wedges; • transfer equipment bag – too generalised;
• wider stretcher; • increasing amount of equipment needed;
• bed should be foldable onto a chair; • equipment designed for hospitals not ambulances;
• multifunctional chair/stretcher – multipurpose top for patient • sirens currently on steering wheel;
comfort and manual handling, e.g. mattress with lifting • training, protocols, cost, replacement etc. all complicate
capacity, gel filled. equipment use.
Suggested solutions included:
Issues identified at the workshops for carry chair design: • service interval regimes, replacement, durability, spares;
• inadequate for loading patients due to the effort required to • link devices for one display – chip and pin to pass information
get chair up ramp; to hospital;
• uncomfortable – feeling of being unsafe and vulnerable; • standardisation of equipment;
• need strength to operate – staff risk; • universal trolleys between ambulance service and hospital
• very narrow – should be cleanable. would mean fewer patient transfers;
• equipment should be able to be connected easily to receive
Suggested solutions included:
various recordings;
• mechanical caterpillar design;
• need forward thinking and planning;
• design chairs which feel safer for the patient;
• universal fittings;
• motorise.
• needs to be light;
• coloured features – reassurance, comfortable design;
Workshop comments on general equipment issues and • specific equipment to improve turnaround – time, infection
standardisation: control, performance and other safety issues;
• equipment often dirty and stained; • ramps and winches – still have risk due to initial effort, need
• maintenance; better lifting aids;
• too many displays; • bag must be visible and accessible – appropriate contents,
• lack of manoeuvrability, lack of space; specific bags for specific problems;
• attendant needs to move around to access equipment • trolley with segmented areas for different equipment – on
– safety; wheels;

36
 • incorporate into design rather than add-ons; Suggested solutions included:
• design to suit environment; • invert or build into trolley;
• standardised simple systems; • improve electric circuit in vehicle;
• need automatic equipment for resuscitation; • pump alarm redesign – plug panel;
• motorise; • light weight silent run generator;
• reduce number of services. • keep electrical equipment to a minimum;
• vehicles running on sustainable fuel sources – greener;
4.2.8 Vehicle engineering • power saving devices designed into equipment;
• solar power;
Issues identified at the workshops included:
• more or appropriate use of power;
• access to power supply;
• work with manufacturers – robust technology;
• who is responsible for maintenance – time taken
• flexible panels;
to do it;
• more compact features, electronic access;
• pump and syringe driver need to ensure better
• power – turbo;
battery life;
• air suspension;
• electrical source from vehicle, producing enough power to
• traction control;
operate (inadequate power), fuel consumption;
• turning circle;
• large amount of electrical equipment – three or more
• vehicles to meet all needs;
batteries needed, increases weight;
• vehicle monitoring system – pay for fuel before filling;
• components e.g. brakes/suspension;
• use of demountable body;
• weight issues;
• design of vehicle bays – specific equipment to
• vibration;
assist turnaround;
• lighting;
• develop system to manage vehicles in emergency braking.
• vehicle should perform and handle yet be comfortable
and secure;
• time to repair body damage;
4.2.9 Patient experience (safety, comfort
• access within and to vehicle; and dignity)
• large turning circle; Issues identified at the workshops included:
• poor traction; • patient safety – clinical;
• certain vehicles limited to certain incidents; • treatment on site (power supply concerns and equipment);
• petrol damage to diesel vehicle; • response times – how long to get there or for ambulance to
• cleaning and stocking and vehicle checks take time from arrive;
when vehicle is available; • patient comfort;
• defects render whole vehicle off road; • relatives – patients want to be accompanied;
• turnaround of vehicle; • dignity – modesty of patients during procedures;
• automatic braking in emergency – misjudgement • intimidating environment – interior could be decorated to be
of driver. less intimidating.

37
4.3 VALIDATION OF DESIGN CHALLENGES Figure 10. Validation questionnaire: average response
(AMBEX QUESTIONNAIRE)
Very good, agree with interpretation
A total of 104 questionnaires were collected from the stand at
AMBEX 2006. Of these, 98 had been completed adequately. The 5
questionnaire asked participants to rank the interpretation of
each design challenge on a scale of one (very poor, disagree with
interpretation) to five (very good, agree with interpretation).
4
The average response results for each question are summarised
in figure 10. The respondents included 63% operational staff
(paramedics, medical technicians, fast responders, Urgent/Delta
and PTS crews). NHS staff completed 72% of the questionnaires.
3

0
1 2 3 4 5 6 7 8

Very poor, disagree with interpretation

38
Question set
1. Space and layout including access to equipment and both
sides of the patient, space to accommodate paramedics and
relatives and to move around.
2. Securing people and equipment in transit including quality
of static and dynamic seat belts for all staff, patients and
children.
3. Communication including inside the ambulance and between
ambulance and hospital; and ambulance and ambulance
control.
4. Security, violence and aggression including unattended
vehicle, paramedics working alone and central locking/drugs.
5. Hygiene including seams/crannies in equipment, steam
cleaning, better access to gloves/aprons and improved
disposal.
6. Equipment including storage and standardisation;
maintenance, availability, fit for purpose/patient, portability,
accessibility, secure and compatible.
7. Vehicle engineering including temperature, noise, lighting,
ventilation and power supply.
8. Patient experience including clinical issues (response times,
treatment on site) and non-clinical issues (accompanying
relatives, dignity, intimidating environment).

39
5. Discussion
This scoping study has used three data types to investigate the – these have been included in the equipment section. Papers
developing models of service provision and the types of vehicles relating to physiological and biomechanical stress on staff have not
and equipment that will be needed in the future in the ambulance been included in this review as they are beyond the scope of this
service. A literature review was used to inform the workshops project and/or did not directly relate to ambulance design.
and was then, after further literature had been collected and
The key issues identified from the workshops were control, speed,
summarised, triangulated with the other data. The limitations for
interfaces (e.g. road, visual), reliability, usability, weight capacity
the literature review included the scope of the search and the lack
and patient safety. It can be seen from the EPSRC project that
of a critical appraisal (other than a descriptive narrative with respect
most of these issues were identified in the comparison of the
to lower and higher quality papers).
three stretcher loading systems. The recommendation for current
The incident reports were gathered from three sources. Although ambulance design is for a tail lift.
similar time periods were used, there were discrepancies
between the datasets (including the data content, with MAUDE 5.2 SPACE/LAYOUT
focussing on equipment, whereas the NHS trust and NRLS data
The layout of the ambulance interior and the time spent
collected information about all incidents) that limited the possible
working in this confined environment, added to the fact that
comparisons and conclusions.
it is frequently moving, presents a risk to staff and patients.
The workshop data were iteratively coded and checked for Equipment, mobility devices and consumables all have the
inclusiveness by several members of the research team. Where potential to impact on the efficiency and safety of delivery of
differences were identified, the team discussed these and care and treatment. The incident reports from the trusts again
reached a consensus before proceeding. This audit trail adds to identified this as a higher contributory factor (7%) than the NRLS
the reliability of the research process. The validity of the design dataset (1%), with examples of both falling equipment and staff
challenges was tested at AMBEX 2006. It was not possible to falling against equipment. Two higher quality papers looked at
return the interpretation to all the workshop participants, so the layout of the patient compartment (Ferreira & Hignett, 2005)
the questionnaire provided a means of validating the findings. and the effects of layout on operator posture (Doormaal
The limitations of workshops included self-selection by the et al., 1995).
participants (both inclusion and exclusion) and the duration and
The key issues identified at the workshops were patient care/
scope of the discussions/data. The questionnaire method was
comfort, storage, size of equipment, access to equipment, space
limited by the number of respondents and the use of convenience
to move and security of equipment on a moving vehicle (e.g.
sampling (representativeness).
medical gases). The design challenge of space and layout is clearly
an issue that needs addressing, particularly with respect to work
5.1 ACCESS/EGRESS
systems, how ambulance personnel are working in ambulances
Access/egress was identified as a major issue by both the incident and what procedures are carried out in the confined space of
reports (in particular the direct reports from the trusts, 25%, an ambulance.
rather than the NRLS data, 1%) and workshops. Two higher
quality research papers were found relating to access/egress issues
with respect to the design of doorways and the physical effort of
loading/unloading (Petzäll, 1995; Boocock et al., 2000). A number
of papers were also retrieved relating to the design of mobility
equipment, for instance stretchers, carry chairs and wheelchairs

40
5.3 SECURING PEOPLE AND EQUIPMENT
IN TRANSIT
This challenge overlaps with the previous one with respect to
securing equipment. The NRLS data showed that 2% of incidents
were related to restraint, whereas the rate reported directly
from the trusts was 17%. Some of the reported incidents were
due to not wearing or removing seat belts (by patients, staff
and relatives), as well as staff treating patients in a moving
vehicle. Larmon et al. (Larmon et al., 1993) found that seat belt
compliance was greater in the front of the ambulance, with a
higher risk of mortality for rear compartment occupants
(Becker et al., 2003).
The key issues identified from the workshops included patient
care, safety, comfort and dignity, including children/babies, staff
safety, seatbelt design (including materials) and
equipment stowage.
Two studies indicated that the use of seatbelts might impede
patient care (Larmon et al., 1993; Ferreira & Hignett, 2005). The
provision of suitable restraints for all passengers was highlighted
by Bull et al. (Bull et al., 2001) and Levick (Levick, 2006), with a
need to provide suitable seating/restraints for babies and children
(none of those tested were found to be suitable). This literature
supports the findings from the incident reports and workshops
that seatbelt use, and restraint and safety of personnel, patients
and relatives, is a problem. The consequences of this challenge not
being adequately met are potentially fatal.
5.4 COMMUNICATION
Communication was not directly mentioned in many of the
incident reports, featuring in just 2% of NLRS data and in less
than 1% of the directly obtained data. The only research found
pertaining to communication looked at two projects computerising
ambulance control room operations (Wastell & Newman,
1996). The incident report data related mostly to equipment
failure, in particular heart rate monitor telemetry. The key issues
identified from the workshops related to both within ambulance
communication (between driver and patient compartments) and
from the ambulance to other places (e.g. hospital, ambulance
control). Although the workshop issues were comparatively few,
the consequences of the problems are potentially great in terms
of patient care. This issue is perhaps fundamental to the smooth
running of the service and should be addressed in terms of not
only design, but also work practices.
5.5 SECURITY, VIOLENCE AND AGGRESSION
The issue of violence and aggression towards staff has been
addressed more widely in nursing and medicine with the
introduction of training and operational protocols (British
Medical Association, 2006). The incident reports and NRLS data
suggested that 2–3% of incidents are associated with violence and
aggression. Two papers suggested that violence from patients is a
problem (Tintinalli & McCoy, 1993; Corbett et al. 1998).
The workshops identified concerns about the restraint of violent
patients, the potential isolation of staff and the risk of theft. The
concerns of general security of ambulance vehicles were also
identified by Alves and Bissell (Alves & Bissell, 2003) who found
that 90% of ambulances were left unattended and
84% unlocked.
This is an area of concern, and most ambulance trusts have
policies and procedures on violence and aggression. Design
solutions should be sought to support these policies, however
there is insufficient research to inform designers, as the literature
simply highlights that there is a problem.
41
5.6 HYGIENE
The issue of hygiene was raised repeatedly in the workshops.
Although in the first analysis hygiene was not a higher level
theme, it appeared as a sub theme in several others. The incident
report data from both the NLRS and trusts revealed that only 1%
of reports pertained to hygiene issues. Only one paper (Eustis
et al., 1994) was found reporting research on ambulance hygiene,
looking at the disposal of sharps, with just 37% of medical
workers complying with disposal procedures.
The key issues identified from the workshops were the design of
the vehicle with respect to surface joins, materials and cleaning
methods (including speed and ease).
5.7 EQUIPMENT
The data from both the NRLS (28%) and trusts (12%) found
a high level of reporting for equipment issues. The range of
equipment is large and many incidents related to stretchers. This
was supported by the emphasis in the literature, with higher
quality papers about stretchers and stretcher design (Barnekow-
Bergvist et al., 2004; Lavender et al., 2000a & b; Kluth & Strasser,
2006). Another study looked at the design of portable electronic
equipment (Fisher, 2002), including portable cardiac monitors.
The range of equipment in ambulances is large and it is suggested
that the interfaces between the equipment and the vehicle would
benefit from standardisation (Porter et al., 2000). As this is one
of the highest risk categories (as identified by the incident data) it
should be considered as a priority.
The key issues identified by the workshop data were compatibility
and standardisation, usability, security (stowage), patient safety,
comfort and dignity, reliability, portability, manoeuvrability,
adjustability and hygiene.
42
5.8 VEHICLE ENGINEERING
Problems in this design challenge range from seat comfort
(Morneau & Stothart, 1999a & b) to doors shutting on fingers.
The incident reports for this category are variable, with the NRLS
data indicating less than 1% and directly obtained data 12%.
Many of the incidents could be categorised under the access and
egress, vehicle engineering and equipment design challenges.
The literature review found a lot of lower quality descriptive
papers about individual design solutions. Two higher quality
papers reported the effects of vehicle engineering on clinical care
for noise and vibration (Prasad et al., 1994) and temperature (Gill
et al., 2004). The need for standardisation and compatibility with
equipment and working practices is important.
The key issues from the workshops were power supply,
maintenance, turn-around time and vehicle design (vibration,
traction, turning circle, brakes, suspension etc.).
5.9 PATIENT EXPERIENCE (SAFETY, COMFORT
AND DIGNITY)
The incident data for patient experience were low, at 5% from
the NRLS data and less than 1% from the trust data. Only one
lower quality paper was exclusively about patient experience
(Middleman, 2004) with respect to the provision of suitable
transport for patients. Other papers looked at the use of
emergency services (Young et al., 2003), navigation (Demetriades
et al., 1996) and routes/delays (Redelmeier et al. 1990). The
workshop comments included patient safety, response times,
power supplies, dignity, modesty and carers.
6. Conclusion
Each of the nine design challenges was reviewed to look at the The scarcity of the literature relating to many of the design
individual datasets (literature, incident reports and workshop challenges is of concern. Particular areas needing further research
themes). There was found to be a divergence between the are communication, hygiene and the patient experience. For
NRLS data and the incidents reported by the individual trusts for future research in this area, we recommend that the literature
some of the design challenges, for example securing people and search is widened to domains other than ambulance, for example
equipment in transit, and equipment. primary, secondary and community care, and possibly other
emergency services e.g. fire and police.
There are a number of possible causes for this divergence,
including the design of the NRLS interface (and subsequent data
input) through to local reporting cultures and screening by trusts
before sending incident data to the project team. Issues that
were raised in the workshops were not always reported in the
incident reports.

43
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