Lights and sirens: Who's the boss?
Emergency Vehicle Operators (EVOs) rely on dispatchers to give them information to help them make safe driving decisions. Who creates the context in which the decisions are made? Administrators, managers, medical directors, legislators, and the general public all have a role. There is an obvious blending of internal and external driving forces. Think about response times.
Contractual obligations create magic numbers like X% of calls will have a response time less than Y.0 minutes. These obligations are often driven by political, not medical, considerations, which may result in legislatively determined compliance standards. Lights and sirens use shortens response and transport intervals 1.7 to 3.6 minutes. Transport times are shortened by 0.7 minutes to 3.8 minutes. These findings exist in rural, urban, and suburban sites. Rather than think about times, shouldn’t those who develop and those who commit to contractual relationships base their goals on clinical outcomes? The focused application of prehospital care has resulted in remarkable improvements in the treatment of acute myocardial infarction, stroke, and trauma. The precedent has been established that correlates the mode of transport and pre-determined destination with favorable outcome based on specific clinical conditions. Unfortunately the general public may look at fast ambulance speeds in the same manner they once looked at antibiotics. Antibiotics really won’t help my virus, but I want something. Instead of creating resistant organisms, we put our personnel in harm’s way, waste our resources, and propagate mindless expectations. These expectations can be counter-balanced by performance measures.
EMD programs should be used to reduce the use of lights and sirens. One suggested benchmark is to reduce lights and sirens response to 911 calls to less than 50%. Remember transport with EWS activation is a high risk medical intervention. Medical direction and oversight are required to determine when lights and sirens are used properly or omitted improperly. This is particularly pertinent with respect to scene to hospital transports. A suggested benchmark is less than 5%. The same caveats apply.
How can we consider emergency driving a high risk medical intervention and not require significant, formal initial, and continuing education specific to driving? EVOC, CEVO, and the new EVOS are examples of extant programs. Who should provide the training? There is no substitute for real world experience, but instructors should be credentialed. A good driver is not a priori a good instructor. How often does a person become an FTO because of tenure and a good personnel file? Monitors must be in place to track driving behaviors to validate the effectiveness of instruction and the need for remediation. The driving history of EVOs should be screened, reviewed, and monitored.
There are multiple technologies available to monitor driving behaviors. Telematics are popular because of the detailed information they provide on individual drivers which may be grouped to recognize trends. Real time feedback to drivers who violate performance standards is critical. It may be accomplished technologically via audible and visual prompts. Another critical component is direct observation with immediate feedback to reinforce good behaviors and create opportunities for remediation or discipline. A standardized, systematic approach must be used. Observers must be trained and use identical instruments to record their observations. Personnel believe that managers at any level talk to them about things that management perceives as important. Direct observation allows interactions on a routine basis that validate the significance of safe driving. The use of lights and sirens should be reviewed as any other high risk procedure. For example, it is common to review cricothyrotomy as part of regular QI audits. Do we ignore other aspects of clinical performance and look only at specific high risk ones? No, we don’t. The same applies to lights and sirens. Minimizing the use of lights and sirens is just one factor that improves our quality of care. We won’t achieve this improvement unless all driving behaviors are viewed as essential to our culture of safety
*Kupas, DF, “Lights and Sirens Use by Emergency Medical Services: Above All Do No Harm.”, submitted by Maryn Consulting, Inc., for NHTSA Contract DTNH22-14-F-00578, May 2017.
*Markel Specialty is a business division of Markel Service, Incorporated, the underwriting manager for the Markel affiliated insurance companies.