Mike McEvoy

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.

Varying Standards

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 bes

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