Improved Restraint Usage for Infant and Pediatric Patients in Ground Ambulances
IMPROVED RESTRAINT USAGE FOR INFANT AND PEDIATRIC
PATIENTS IN GROUND AMBULANCES THROUGH EDUCATION AND
POLICY DEVELOPMENT
Position Statement of AAMS
Approved by AAMS Standards Committee: September 2007
Approved by AAMS Board of Directors: October 2007
BACKGROUND
EMS Transport Services throughout the years have typically transported pediatric patients (approximate
ages: 1 – 8 years) using stretcher belts only and infant patients (approximate ages: birth – 1 year) by
placing parents or caregivers in the stretcher belts and allowing the parent or caregiver to hold the
pediatric patient in their arms. Through the years, crash results have shown that these patients are not
properly restrained resulting in further injury and even death due to inappropriate restraining techniques.
There are no specific federal guidelines on the use of proper restraints on infant and pediatric patients in
ground ambulances. Without federal guidelines, EMS services are free to transport patients as they deem
appropriate. Often this puts the infant and pediatric patient as well as other occupants of the ground
ambulance at risk for death or serious injury.
Although research of ambulance crashes is limited, the principles of patient restraint can still be used to
develop useful and effective education and policies in the field. In a paper, “Crash Protection for
Children in Ambulances”, by Marilyn J. Bull, MD, et al. it states “EMSC acknowledges the special
circumstances of ambulance transport and the gap that exists between occupant restraint practices in
ambulances vs. other highway vehicles.” This paper covers Restraint Considerations in Ambulances,
Research Methods and Results, and Crash Test Data and Recommendations using certain type of
restraints in ambulances.
This paper published in 2001 has become a “golden rule” among EMS services. Since 2001 several new
innovations and restraint systems have been developed and marketed which assist in reducing the
likelihood of further injury to infant and pediatric patients. These new innovations and restraint systems
on the market have had limited crash testing since there are no federal guidelines for their use. Some of
these systems have been crash tested and advertised as such by the manufacturer.
There have been major advances in EMS transport safety research, infrastructure and practice over the
past five years. In a report entitled Ambulance Crash-Related Injuries Among Emergency Medical
Services Workers – United States, 1991 – 2002, published in the Journal of the American Medical
Association, 2 April 2003, the Centers for Disease Control and Prevention (CDC) recommends that:
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EMS workers use patient compartment vehicle occupant restraints whenever possible;
drivers and front-seat passengers use the occupant restraints provided;
ambulances be equipped with patient stretchers that include upper body restraints;
EMS workers who operate ambulances are qualified and trained appropriately;
ambulance manufacturers should develop occupant protection systems designed to reduce the
deaths and serious injuries of EMS workers and patients in ambulance patient compartments;
these systems should allow EMS workers the mobility to access the patients and equipment.
Since there are no federal guidelines, EMS services have adopted their own “Best Practice” rules which
may or may not protect the patient in a crash. There is uncertainty as to what is safe and unsafe occupant
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Improved Restraint Usage for Infant and Pediatric Patients in Ground Ambulances
protection practice. There is also no uniformity in defining what age constitutes a pediatric patient. All
states require the front seat occupants to be restrained appropriately, but most states do not require
patients of any age to be restrained in ambulances.
Child Passenger Safety for Emergency Medical Services program, developed by Sedley A. Tomlinson,
NREMT-B, I/C, Certified Child Passenger Safety Technician, addresses EMS staff education issues such
as where to place a infant or pediatric patient in an ambulance, the best practice options to restrain these
patients, and the need for education and policy development for EMS services. The “Best Practice”
options according to limited available research and the availability of some of the newer restraint systems
and techniques are discussed.
POSITION STATEMENT
The Association of Air Medical Services position developed by the Critical Care Ground Special Interest
Group believes that safe transporting of infant and pediatric patients should be of utmost importance to
EMS agencies. These agencies should provide their staff with proper child passenger safety education,
policy development and enforcement, and the restraint systems available to provide the safest transport
possible:
RATIONALE
Primary Recommendations from Evidenced Based Best Practice:
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Utilizing crash tested convertible car seats, with 5-point harnesses belted to stretchers utilizing the
forward and rear facing belt paths with stretcher seat belts when feasible to transport infant and pediatric
patients. If needed, blanket or towel rolls may be used around the patient’s head to provide stabilization
of the head. (ex. Evenflo Titan V or Cosco Scenara)
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Utilizing a car bed, with a 3-point harness, modified with four “securing loop straps” on the
restraint for patients up to 20 lbs or to the manufacturer’s specifications. Securing the car bed on a
stretcher with the head of the stretcher at a 45 degree angle with the car bed fitting snugly against the back
of the stretcher and using a stretcher seat belt on the forward and aft securing loop straps keeping the
patients head towards the patient compartment side door to allow for easier patient access. If needed,
blanket or towel rolls may be used around the patient’s head to provide stabilization of the head. (ex.
Cosco Dream Ride SE Car Bed)
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Utilizing a restraint device that has a 5-point harness for securing the patient and secures to the
stretcher at each leg and at the mid-torso for pediatric patients weighing between 10 – 40 lbs, adjusting all
straps to size, and securing it to the stretcher per the manufacturer’s instructions. If needed, blanket or
towel rolls may be used around the patient’s head to provide stabilization of the head. (ex. Ferno PediMate)
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Utilizing a restraint device that attaches to an isolette tray at four points and secures the patient in
a 3-point harness and velcro abdominal strap for infant patients and securing it to an isolette per the
manufacturer’s instructions paying special attention to using the 3-point harness and abdominal strap.
The addition of soft Velcro straps may be added for lateral security and blanket or towel rolls may be
used around the patient’s head to provide stabilization of the head. (ex. International BioMed Papoose)
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Remaining current on available restraint devices to ensure the safe transport of infant and
pediatric patients.
Secondary Recommendations from Evidenced Based Best Practice:
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Utilizing other restraint devices that have been used effectively and securely when transporting
infant and pediatric patients may be considered a “Best Practice” method and is left to the discretion of
the EMS service. (ex. Ferno Medkids Pedi-Sleeve, Ferno Pedi-Pal Child Transport Seat, Ferno Baby
Pod)
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Improved Restraint Usage for Infant and Pediatric Patients in Ground Ambulances
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Utilizing a restraint the secures patients at several points, like a backboard with spider straps, for
infant patients is in practice with many EMS services. Special note should be taken when using this
device: the patient can be securely fastened into the device, but there are no current recommendations on
how to secure this system in the isolette which could lead to possible injury to patients in a crash. This
restraint system is equipped with head blocks to support the head while using this restraint during
transport. (ex. Ferno Medkids Baby Board)
Not Recommended:
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A restraint that inflates, secures to the stretcher at one belt path, and secures the patient in a 3point harness due to it having only one belt path to secure to the stretcher. Manufacturers are currently
enhancing these types of restraint systems to have two belt paths to secure to the stretcher; but until this
modification has been made and evaluated it should not be considered for transport. (ex. Emergency
Products & Research Responder (EP&R) Inflatable Seat)
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Never placing a child restraint system on a side facing bench or bucket seat, in a rear facing
captain’s chair unless the captain’s chair contains the integrated child restraint and the pediatric patient
meets the weight and height guidelines for the integrated child restraint, or in any position that contains an
airbag.
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Never placing an infant or child in parent’s or caregiver’s arms and securing parent or caregiver
in either the front or the back of an ambulance.
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Transporting more than one infant per isolette. There is no current technique or device to
properly secure two infants in one isolette.
REFERENCES
1.
Bull, Marilyn J., M.D., Weber, Kathleen, Talty, Judith, Manary, Miriam. Crash
Protection for Children in Ambulances, Recommendations and Procedures (Published
in the Association for the Advancement of Automotive Medicine, 45th Annual
Proceedings, pp. 353-367. Barrington, IL, AAAM, 2001).
2.
Tomlinson, Sedley A., NREMT-B, I/C, CCPST, Child Passenger Safety for
Emergency Medical Services (Lecture for Air Medical Transport Conference, Austin,
TX, AMTC 2005).
3.
Arkansas Children's Hospital, Angel One Policy and Procedures Manual, Little Rock,
AR, Policy G-9, Utilization of Vehicle Safety Restraints for Patients in Aircraft and
Ambulances.
4.
SL Proudfoot, NT Ramano, MS, TG Bobick, PhD, PH Moore, Division of Safety
Research, National Institute for Occupational Safety and Health, CDC, Ambulance
Crash-Related Injuries Among Emergency Medical Services Workers - United States,
1991-2002, JAMA, Volume 289 (13), 2 April 2003, p 1628-1629.
5.
James S. Seidel, MD, PhD, Jacqueline Greenlaw, Use of Restraints in Ambulances:
A State Survey, Pediatric Emergency Care, Vol. 14, No. 3, p 221 – 223, 1998.
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