Understanding NFPA's new ambulance rule

With NFPA taking over the new ambulance standard process, here's a look at what it means and how we got here

For about as long as there has been EMS in the United States, there has been the "Triple K" specifications for ambulances. The KKK-A-1822 specifications were first developed and published by the U.S. General Services Administration in the 1970s as the purchasing specifications for federal ambulances. 

At that same time, block grants were in vogue as a means for distributing federal money to communities, and those block grants required that vehicle purchases must comply with federally approved specifications. 

Very quickly, as things tended to happen in the early days of EMS, EMS agencies and local, state, and federal officials used the KKK-A-1822 for ambulance purchases under block grants as it was the only document available. And thus, KKK-A-1822 became the de facto ambulance standard in the United States.

15 ambulance changes

  • Load capacity will be 171 pounds per seated position.
  • A seatbelt monitoring system that senses when a seat is occupied and a seatbelt attached. Audible and visible warning devices will trigger for cab and patient compartments if the parking brake is released and the transmission is not in park.
  • Tire-pressure monitors.
  • Designate health care provider seating positions that are adjustable to within 6 inches of the cot.
  • AMD testing standards.
  • Speed governed for maximum speed of 77 mph.
  • Chevrons on rear doors in red and fluorescent yellow or green.
  • Underbody lighting that establishes lighting zones in which all areas of the truck must display certain warning lights.
  • Interior cabinets marked with maximum weight rating.
  • Items more than 3 pounds must be secured in a compartment or by device that withstands a 10-g force.
  • Carbon monoxide detector.
  • Mud flaps.
  • Additional hand rails at every point of ingress.
  • Certificate of compliance — exceptions to be corrected before placing in service.
  • "Do not move" light connected to doors, storage racks and deployed devices.

In recent years, two developments have prompted the search for a more applicable ambulance standard.

First was GSA's decision that it would no longer continue to maintain the specifications that were originally focused solely on a vehicle purchasing decision. Although GSA has revised and routinely extended the KKK specifications over the past 40-plus years, it never had the technical expertise in house to keep up with the rapidly evolving ambulance.

Second, there's the increasing number of patients and EMS providers that are being killed and injured in ambulance crashes each year.

Those mortality and morbidity numbers prompted the International Association of Fire Chiefs to begin working with the National Fire Protection Association in 2009 to develop a true standard for a safer ambulance. Their work culminated with the approval of NFPA 1917: Standard for Automotive Ambulances in August 2012.

What is NFPA 1917?
Developed with consideration of KKK-A-1822 and NFPA 1901: Standard for Automotive Fire Apparatus, NFPA 1917 defines the minimum requirements for the design, performance, and testing of new automotive ambulances.

The standard presents general requirements for ambulance design and performance, along with standalone chapters for ambulance components including chassis, patient compartment, low-voltage electrical systems and warning devices, and line voltage electrical systems. NFPA 1917 also specifies provisions for test methods.

Initially, this had to be viewed as a win for all parties involved. GSA would be relieved of its responsibility for maintaining a standard for which it was never fully intended and EMS providers and patients would get a safer ambulance. There were, as one would expect, other entities that did not have the same positive viewpoint initially.

NFPA was considered a good fit for developing the standard because of its long history of developing consensus or industry standards for the fire service. Non-fire EMS organizations, however, expressed fears that the fire service was taking over EMS and that the standard would require all ambulances to be painted red, have a water tank and be medium-duty ambulances.

Some of those same organizations expressed fears that they would not have a voice in the standard development, and that they could not afford the price of an ambulances meeting an NFPA standard. It is unclear how much more a 1917-compliant ambulance would cost.

Fears addressed
Many of those fears were assuaged when those non-fire EMS organizations saw NFPA's technical committee makeup. It included representatives from these groups.

During 2012, the National Association of State EMS Officials wanted more of a voice in the development and approval of NFPA 1917. NFPA and NASEMSO collaborated to develop several meetings, hosted by NASEMSO, to inform and educate NASEMSO members about how the NFPA standard development process worked and on the details of NFPA 1917. IAFC and NFPA were both actively present in these meetings.

NFPA responded to this unprecedented interest by NASEMSO and its membership by establishing a task group to take a closer look at NFPA 1917.

The task group, which included individuals recommended by NASEMSO, met over the course of two days in January 2013 and out of those sessions came an extensive list of public comments that were sent on to NFPA. Most of those comments were accepted and will be incorporated into the second edition of NFPA 1917, scheduled for 2016.

Enter CAAS
The Commission on the Accreditation of Ambulance Services convened a group of its own in March to create a new ground ambulance standard because it believed that NFPA 1917 wasn't developed using a consensus process. IAFC and the National Volunteer Fire Council were the only fire service organizations invited to the first meeting; CAAS didn't respond to an offer of assistance from the NFPA.

IAFC withdrew its support for the process after reviewing the goals of CAAS. IAFC felt strongly that the CAAS group did not have the technical expertise in vehicle design and safety and would be unable to produce a standard that addressed the safety for all ambulance occupants to the level specified in NFPA 1917.

NFPA and IAFC were troubled that CAAS is not accredited by American National Standards Institute as a standard-setting organization. ANSI is a private, nonprofit organization that oversees the development of voluntary consensus for products, services, processes, systems, and personnel in the United States.

The fear of IAFC and the NFPA technical committee was that CAAS's lack of familiarity with ANSI's policies would render it unable to ensure that any standard developed by CAAS, and the standard-setting process used, would meet the requirements for receiving ANSI approval.

CAAS's goal of creating a standard by January 2015 caused IAFC and NFPA concern as well. IAFC felt that such an aggressive target date was incompatible with producing the same quality of standard as that produced through the NFPA technical committee's work over five years.

IAFC felt that a rushed process, led by a panel lacking in professional diversity, would result in duplicated efforts, a weaker standard and confusion for fire and EMS leaders across the board.

The current edition of NFPA 1917 is the 2013 edition; the revision cycle for the 2016 edition will begin in mid-2015. GSA's KKK-A-1822 will be sunset — that is, not be revised or renewed — that same year.

Ultimately, when EMS personnel board an ambulance, they deserve to arrive to their destination safely. When a patient enters an ambulance, we owe it to them to keep them safe. The adoption and publication of NFPA 1917 is a significant development in helping all EMS agencies to obtain ambulances that meet both of those objectives.

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