In 2008, the United States General Services Administration (GSA) announced that it would no longer revise and maintain its KKK Star-of-Life ambulance purchasing specification. Since 1974, the KKK specification has been used by federal agencies and organizations purchasing ambulances using federal grant monies. The government looked to the National Fire Protection Association (NFPA)-an organization with a long history of developing industry consensus standards, especially for public safety entities-to pick up the ball and develop a standard to replace the KKK specification. This turned out to be easier said than done.
The KKK specification, now in its sixth iteration (called KKK-A-1822F, published in August 2008), was originally designed as a purchasing specification (i.e., a template for writing ambulance bid solicitations) yet has been extensively cited and adopted by almost two-thirds of the states as a de facto ambulance safety standard. Although certainly not unsafe, KKK never included specific practices for designing, building, and testing ambulances.
ASTM International (formerly known as the American Society for Testing and Materials) is a safety organization and publishes an industry consensus standard, F2020-02a, which outlines standard ambulance design, manufacturing, and purchasing practices. The Ambulance Manufacturers Division (AMD) of the National Truck Equipment Association (NTEA) publishes manufacturing standards for ambulances (standard 001-025) that specify static load testing of the ambulance body, stretcher mounts, and onboard oxygen cylinder mounts/straps.
The Society of Automotive Engineers (SAE) publishes recommendations for testing passenger restraint systems and equipment mounts to protect against frontal and side-impact collisions. Sadly in the United States, ambulances have always been exempt from the federal motor vehicle safety standards (FMVSS), which serve to protect passenger lives and safety in most other vehicles on the highway.
To varying degrees, the KKK specification has evolved to include many AMD recommendations. Currently 25 AMD test standards appear in KKK. Others, such as ASTM, evolved to reflect the requirements of KKK. The challenge facing the NFPA 1917 committee was to develop a standard that not only incorporated purchasing specifications with design and testing standards but also reflected scientifically sound automotive safe engineering practices. This was further complicated by the proprietary nature of the many existing standards and a virtually nonexistent body of scientific evidence recommending best practices for the design and manufacture of a safer ambulance.
Patient Compartment Study
That’s not to say that no one is working to analyze the patient compartment in an effort to make it a safer environment for patients and EMS providers. The National Institute for Occupational Safety and Health (NIOSH) has been working with AMD to study passenger restraints and stretcher mounting devices for more than a decade. More recently, driven by concerns of multiple EMS advocacy groups, NIOSH has partnered with the National Institute of Standards and Technology (NIST) to redesign the layout of the ambulance patient compartment to make it safer while still allowing providers to care for a patient during transport. During NFPA 1917’s initial development, none of the NIOSH or NIST research had progressed to the point necessary for inclusion in a published standard.
The NFPA 1917 committee first met in June 2009, using NFPA 1901, Standard for Automotive Apparatus, as a template for its initial design of an ambulance standard. The committee considered creating a completely new standard to include crash restraint and safety technologies, but the dearth of sound crash testing studies virtually forced the committee to work with the existing KKK standard and do its best to reformat it in a like fashion to the NFPA 1901 layout, incorporating as much of AMD, ASTM, and SAE recommendations as feasible. The first draft of this monumental undertaking was published for public comment in October 2010. More than 1,700 comments were received, which, when categorized, represented 1,200 unique proposals for changes. A revised document was posted in June 2011 for which 46 comments were received. The final NFPA 1917 version was published in September 2012 and is intended to apply to ambulances contracted for purchase after January 1, 2013.
NFPA 1917 vs. KKK
When comparing NFPA 1917 to KKK-A1822-F, some of the most significant changes include a top speed regulated at 77 miles per hour (mph) (4.13.3); a requirement for tire pressure monitors (5.9.5); a carbon monoxide detector mounted in the patient compartment (220.127.116.11); requiring equipment weighing more than three pounds to be mounted in a bracket, mount, or stored in an enclosed compartment able to contain the equipment against a 10-G force applied from any direction (6.19.2); reflective striping covering 25 percent of the front and 50 percent of each side as well as a rear-facing chevron pattern similar to that required on fire apparatus (18.104.22.168); a seat belt warning system in the patient compartment that would indicate any unbelted passenger (6.26.10); load testing requirements for minimum alternator outputs under varying conditions (22.214.171.124); battery testing requirements (126.96.36.199); a do-not-move warning light near the driver indicating whenever any door or exterior compartment is open (7.12); generator test standards (188.8.131.52); new payload requirements for all vehicles; a statement of exceptions whenever an ambulance is not fully compliant with NFPA 1917 (4.17); and a requirement that the ambulance not be placed into service until all exceptions are remedied by the user (4.17.3).
NFPA 1917 also includes an annex, which, like all NFPA standards, exists to clarify, interpret, and offer guidance and suggestions on compliance. Items included in an annex are not specifically required by an NFPA standard. Suggestions beyond KKK included in the NFPA 1917 Annex are a recommendation for checkout lights wired to a shoreline so the ambulance batteries can be bypassed during rig checks (A.184.108.40.206) and adding a backup camera (A.7.13).
NFPA 1917’s publication in the fall of 2012 met with underwhelming response from the EMS industry. The National Association of State EMS Officials (NASEMSO), which had a representative on the NFPA 1917 Committee, announced plans to develop its own Model Rules for Ambulance Vehicle Design. NASEMSO also published a series of comparisons between NFPA 1917, ASTM, and KKK to facilitate its member states’ consideration in adopting NFPA 1917 (see www.nasemso.org under Committees/Projects, then Agency & Vehicle Licensure tabs). Finally, NASEMSO submitted two Temporary Interim Amendment (TIA) requests to the NFPA-one that would eliminate the 77-mph maximum speed and another that would delete the requirements for full compliance with NFPA 1917 for an ambulance to be delivered and placed in service. Both TIAs were ultimately approved by the NFPA.
Owing to the confusion and generally underwhelming response from end users, regulators, and ambulance manufacturers, NASEMSO asked the GSA to delay retiring the KKK specification for two years. On January 19, 2012, the GSA announced that it would maintain the KKK specification until October 1, 2015. This, according to the GSA, will allow the many states that have incorporated the Federal Star-of-Life Ambulance specification into law or regulation some temporary relief.
The Next Revision
In the meantime, NFPA 1917’s public comment period recently closed. The committee expects, in addition to input from organizations like NASEMSO, to have new and definitive crash test results from NIOSH and NIST that will help to improve the next edition of NFPA 1917, scheduled for publication in the fall of 2015.
Meanwhile, purchasers who are confused should recognize some inherent issues about the currently existing (and overlapping) standards. First, it is each state’s responsibility to regulate and certify ambulances for use. Purchasers should consult with their state regulators on the applicability of the current standards. Ambulances certified under KKK-A1822-F are not also NFPA 1917- compliant. It is possible to purchase an NFPA 1917-compliant ambulance that is also KKK-A1822-F certified if the purchaser orders all the NFPA options.
Many expect that the next revision of NFPA 1917 should resolve many of the concerns expressed by EMS stakeholders and ultimately not only serve as a replacement for the federal KKK specification but also improve the patient and provider safety in the patient compartment of future ambulances. It’s a sad reflection on the public safety industry that police cars and fire apparatus have evolved so much while ambulances look essentially the same and offer no greater protection for their rear passengers than they did 30 years ago.
MIKE McEVOY is the EMS coordinator for Saratoga County, New York, and the EMS editor for Fire Engineering. He is a paramedic supervisor for Clifton Park & Halfmoon Ambulance, a firefighter and chief medical officer for the West Crescent (NY) Fire Department, and the EMS director on the board of the New York State Association of Fire Chiefs. McEvoy has served as a principal member of the NFPA 1917 committee since its inception.
The challenge facing the NFPA 1917 committee was to develop a standard that not only incorporated purchasing specifications with design and testing standards but also reflected scientifically sound automotive safe engineering practices.