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Joint Statement on Lights & Siren
Vehicle Operations on Emergency Medical
Services (EMS) Responses
Douglas F. Kupas, Matt Zavadsky, Brooke
Burton, Shawn Baird, Jeff J. Clawson, Chip Decker, Peter Dworsky, Bruce Evans, Dave Finger, Jeffrey M.
Goodloe, Brian LaCroix, Gary G. Ludwig, Michael McEvoy, David K. Tan, Kyle L. Thornton, Kevin Smith, Bryan R. Wilson
The National
Association of EMS Physicians and the then National Association of State EMS Directors
created a position statement on emergency medical vehicle use of lights
and siren in 1994 (1). This document updates
and replaces this previous statement and is now a joint position
statement with the Academy of International Mobile
Healthcare Integration, American Ambulance Association, American College of
Emergency Physicians, Center for
Patient Safety, International Academies of Emergency Dispatch, International
Association of EMS Chiefs,
International Association of Fire Chiefs, National Association of EMS
Physicians, National Association of Emergency
Medical Technicians, National Association of State EMS Officials, National EMS
Management Association, National
EMS Quality Alliance,
National Volunteer Fire Council and Paramedic Chiefs
of Canada.
In 2009, there
were 1,579 ambulance crash injuries (2), and most EMS vehicle crashes occur
when driving with lights and siren
(L&S) (3). When compared with
other similar-sized vehicles, ambulance crashes are more often at intersections, more often at traffic signals, and more
often with multiple injuries, including 84% involving three
or more people (4).
From 1996 to
2012, there were 137 civilian fatalities and 228 civilian injuries resulting
from fire service vehicle incidents and 64 civilian
fatalities and 217 civilian injuries
resulting from ambulance incidents. According
to the
U.S. Fire
Administration (USFA), 179 firefighters died as the result of vehicle crashes
from 2004 to 2013 (5). The National
EMS Memorial Service reports that approximately 97 EMS practitioners were
killed in ambulance collisions from 1993 to 2010 in the United
States (6).
Traffic-related
fatality rates for law enforcement officers, firefighters, and EMS
practitioners are estimated to be 2.5
to 4.8 times higher than the national average among all occupations (7). In a recent survey of 675 EMS practitioners, 7.7% reported being
involved in an EMS vehicle crash, with 100% of those occurring in clear weather and while using L&S. 80%
reported a broadside strike as the type of MVC (8). Additionally, one survey found estimates of approximately four
“wake effect” collisions (defined as collisions caused by, but not involving
the L&S operating emergency vehicle) for every crash involving an emergency vehicle
(9).
For EMS, the
purpose of using L&S is to improve patient outcomes by decreasing the time
to care at the scene or to arrival
at a hospital for additional care, but only a small percentage of medical
emergencies have better outcomes from
L&S use. Over a dozen studies show that the average time saved with L&S
response or transport ranges from 42
seconds to 3.8 minutes. Alternatively, L&S response increases the chance of
an EMS vehicle crash by 50% and
almost triples the chance of crash during patient transport (11). Emergency
vehicle crashes cause delays to care
and injuries to patients, EMS practitioners, and the public. These crashes also increase emergency vehicle resource use
through the need for additional vehicle responses, have long-lasting effects on the reputation of an emergency
organization, and increases stress and anxiety among emergency services
personnel.
Despite these
alarming statistics, L&S continue to be used in 74% of EMS responses, and
21.6% of EMS transports, with a wide
variation in L&S use among agencies and among census districts in the
United States (10).
Although L&S
response is currently common to medical calls, few (6.9%) of these result in a
potentially lifesaving intervention
by emergency practitioners (12). Some agencies have used an evidence-based or quality improvement approach to reduce
their use of L&S during responses to medical calls to 20-33%, without any discernable harmful effect on
patient outcome. Additionally, many EMS agencies transport very few patients to the hospital
with L&S.
Emergency
medical dispatch (EMD) protocols have been proven to safely and effectively
categorize requests for medical
response by types of call and level of medical acuity and urgency. Emergency
response agencies have successfully
used these EMD categorizations to prioritize the calls that justify a L&S
response. Physician medical
oversight, formal quality improvement programs, and collaboration with
responding emergency services agencies
to understand outcomes is essential to effective,
safe, consistent, and high-quality EMD.
The sponsoring organizations of this statement believe that the
following principles should guide L&S use
during emergency vehicle response to medical calls and initiatives to
safely decrease the use of L&S when appropriate:
· The primary
mission of the EMS system is to provide out-of-hospital health care, saving
lives and improving patient outcomes,
when possible, while promoting safety and health in communities. In selected time-sensitive medical
conditions, the difference in response time with L&S may improve the patient’s outcome.
· EMS vehicle
operations using L&S pose a significant risk to both EMS practitioners and
the public. Therefore, during
response to emergencies or transport of patients by EMS, L&S should only be
used for situations where the time
saved by L&S operations is anticipated to be clinically important to a patient’s outcome. They should not be used
when returning to station or posting on stand-by assignments.
· Communication
centers should use EMD programs developed, maintained, and approved by national standard-setting organizations with
structured call triage and call categorization to identify subsets of calls based upon response resources needed
and medical urgency of the call. Active physician medical oversight is critical in developing
response configurations and modes for these EMD protocols. These programs should be closely monitored by a
formal quality assurance (QA) program for accurate use and response outcomes, with such QA programs being in
collaboration with the EMS agency physician
medical director.
· Responding
emergency agencies should use response based EMD categories and other local
policies to further identify and
operationalize the situations where L&S response or transport are
clinically justified. Response
agencies should use these dispatch categories to prioritize expected L&S
response modes. The EMS agency
physician medical director and QA programs must be engaged in developing these agency operational policies/guidelines.
· Emergency
response agency leaderships, including physician medical oversight and QA
personnel should monitor the rates of
use, appropriateness, EMD protocol compliance, and medical outcomes related
to L&S use during
response and patient transport.
· Emergency
response assignments based upon approved protocols should be developed at the local/department/agency level. A thorough
community risk assessment, including risk reduction analysis, should be conducted, and used in conjunction with
local physician medical oversight to develop
and establish safe response policies.
· All emergency
vehicle operators should successfully complete a robust initial emergency
vehicle driver training program, and
all operators should have required regular continuing education on emergency vehicle driving and appropriate L&S use.
· Municipal
government leaders should be aware of the increased risk of crashes associated
with L&S response to the public,
emergency responders, and patients. Service agreements with emergency medical response agencies can mitigate
this risk by using tiered response time expectations based upon EMD categorization of calls. Quality
care metrics, rather than time metrics, should drive these contract
agreements.
· Emergency vehicle
crashes and near misses should trigger clinical and operational QA reviews.
States and provinces should monitor
and report on emergency medical vehicle crashes for better understanding of the use and risks of
these warning devices.
· EMS and fire
agency leaders should work to understand public perceptions and expectations
regarding L&S use. These leaders
should work toward improving public education about the risks of L&S use to create safer expectations of the public
and government officials.
In most
settings, L&S response or transport saves less than a few minutes during an
emergency medical response, and there
are few time-sensitive medical emergencies where an immediate intervention or treatment in those minutes is lifesaving.
These time-sensitive emergencies can usually be identified through utilization of high-quality dispatcher
call prioritization using approved EMD protocols. For many medical calls, a prompt response by EMS practitioners
without L&S provides high-quality patient care without the risk of L&S-related crashes. EMS care is part
of the much broader spectrum of acute health care, and efficiencies in the emergency department, operative, and
hospital phases of care can compensate for any minutes lost with non-L&S response or transport.
Academy of
International Mobile Healthcare Integration
American Ambulance Association
American College of Emergency Physicians Center for Patient
Safety
International Academies of Emergency Dispatch
International Association of EMS Chiefs
International
Association of Fire Chiefs National Association of EMS Physicians
National
Association of Emergency Medical Technicians
National Association of State EMS Officials
¡National
EMS Management Association National EMS Quality Alliance
National Volunteer
Fire Council
References:
1.
Use of warning lights and siren
in emergency medical vehicle response and patient transport. Prehosp and Disaster Med. 1994;9(2):133-136.
2. Grant CC, Merrifield B. Analysis of ambulance
crash data. The Fire Protection Research
Foundation. 2011. Quincy,
MA.
3. Kahn CA, Pirallo RG, Kuhn EM. Characteristics of fatal ambulance
crashes in the United States: an 11-year retrospective analysis. Prehosp Emerg Care. 2001;5(3):261-269.
4.
Ray AF, Kupas DF. Comparison of
crashes involving ambulances with those of similar-sized vehicles. Prehosp Emerg Care. 2005;9(4):412-415.
5. U.S. Fire Administration. Firefighter fatalities
in the United States in 2013. 2014. Emmitsburg, MD.
6.
Maguire BJ. Transportation-related injuries
and fatalities among emergency medical
technicians and paramedics.
Prehosp Disaster Med. 2011;26(5): 346-352.
7.
Maguire BJ, Hunting KL, Smith GS, Levick NR. Occupational fatalities in emergency medical
services: A hidden crisis.
Ann Emerg Med, 2002;40: 625-632.
8. Drucker C, Gerberich SG, Manser MP, Alexander BH, Church TR, Ryan AD, Becic E. Factors associated with civilian drivers
involved in crashes
with emergency vehicles.
Accident Analysis & Prevention. 2013; 55:116-23.
9. Clawson JJ, Martin RL, Cady GA, Maio RF. The wake effect: emergency
vehicle-related collisions. Prehosp
Disaster Med. 1997;
12 (4):274-277.
10. Kupas DF. Lights and siren use by emergency medical services: Above
all, do no harm. National Highway Traffic Safety
Administration. 2017. Available online at https://www.ems.gov/pdf/Lights_and_Sirens_Use_by_EMS_May_2017.pdf
11.
Watanabe BL, Patterson GS,
Kempema JM, Magailanes O, Brown LH. Is use of warning lights and sirens
associated with increased risk of
ambulance crashes? A contemporary analysis using national EMS information
system (NEMSIS) data. Ann
Emerg Med. 2019;74(1):101-109.
12.
Jarvis JL, Hamilton V, Taigman
M, Brown LH. Using red lights and sirens for emergency ambulance response: How often are
potentially life-saving interventions performed? Prehosp Emerg Care. 2021; 25(4): 549-555.
11 de febrero, la @onuoficial celebra el día internacional de la mujer y la niña en la ciencia.
