Indian Ambulances Ushering In A New Era Of Quality Vehicles

Mandatory compliance with AIS-125 for all road ambulances will usher in a new era of quality road ambulances in the country.

As technology develops, the advances to patient transport principles and equipment provide safer, more comfortable transport options. Modifications designed to ease the physical workload of responders, safer ambulance restraints, telemedicine, and equipment geared toward specific patient populations are the areas where state-of-the-art technologies advance patient transport practices. Most of the early models indirectly consider the uncertainty related to both demands and travel times. Many of them also use the coverage to assess the system’s performances. More recently, researchers have continued to work on the static ambulance location problem with the aim of addressing more explicitly some of the issues related to the randomness.

To combat the public perception that quality of the ambulances is steadily on the decline, uncertainty over funding following bifurcation, an aging fleet of ambulances, and shortcomings in infrastructure, the government has also contributed to maintaining its ambulance services.

Indian scenario
Indian public healthcare system has in the last decade increased its investment into pre-hospital patient transport with over 20,000 ambulances being inducted in over 30 states/UTs under the National Health Mission. The private healthcare sector was also not far behind and has also augmented its investment in ambulance services. This transformative change in the public healthcare system of the country was accompanied with additional responsibility on healthcare providers of procuring quality ambulances at rational prices – a task which may appear simpler than it actually is because of the peculiarities of the operational and regulatory environment.

To delve deeper, it needs to be understood that all road ambulances are invariably a vehicle first and a medical care environment later. Hence, they primarily fall under the regulatory framework applicable to all vehicles plying on Indian roads viz. Central Motor Vehicle Rules (CMVR) and the Motor Vehicles Act (MVA) as amended from time to time. Rule 126 of CMVR mandates that every manufacturer of motor vehicles shall submit a prototype of the vehicle to be manufactured by him for test from government notified agencies and as per Section 32 of MVA, no owner of a motor vehicle shall so alter the vehicle that the particulars contained in the certificate of registration are at variance with those originally specified by the manufacturer. These regulations posed a unique challenge for ambulance purchasers as the majority of the base vehicles of ambulances were usually sold as passenger/goods vehicles and subsequently fabricated and retro-fitted to convert them into ambulances. This, in turn, meant that after fabrication, either every purchaser needed to get a prototype of the finished product tested as per CMVR or take the risk of violating the regulatory framework by registering the base vehicle and playing an altered one on the roads – which often the case was.

Further, CMVR classifies passenger vehicles as category M1, M2, and M3; with category M1 for vehicles with up to eight passenger seats and categories M2 and M3 for nine or more passenger seater vehicles. With the norms for M1 category being the most stringent, manufacturers and fabricators often inclined toward classifying the ambulances under M2 category and in-turn cramped the passenger compartment with additional seats just to meet the regulatory requirement. This was primarily because of the fact that though the patient stretcher occupied the space equivalent to four passengers, nowhere in the regulatory framework was there a provision for the stretcher to account for more than one passenger. Also, though various automotive standards regarding fire safety, and electrical safety. were mandatory for passenger vehicles plying on Indian roads, none were being adhered to in the majority of the ambulances plying on Indian roads as most of them were retrofitted vehicles and CMVR did not have ambulance as a specific category under its preview.

Then there are also other challenges for healthcare providers while writing the specifications of ambulances as automobile components are usually not the same as the ones used by them on a daily basis. A simple corollary is the way we charge our mobile phones in vehicles wherein a car charger is not the same as the routine wall charger. Similarly, in vehicles, air conditioning capacity is not defined in tons, which is often the case in daily life. Electrical devices load calculation and balancing is also an important aspect in automobile design as vehicle engines often have limited capacities and not all devices suitable for use on 220V AC circuits can be used on 12/18V DC vehicle electrical circuits. Storage spaces in automobiles pose another challenge as unless appropriately latched, the contents would scatter around when the vehicle is in motion while too secure a latching would make storage spaces inaccessible for medical care providers in times of need.

From the medical care perspective too; ambulances have certain peculiarities, which are different from hospital environment which majority of healthcare providers are accustomed to, the foremost difference being that while hospitals are stationary, ambulances are mobile. Hence, the medical devices used in ambulances must be motion tolerant, 12/18V DC powered (if electrically powered) and securely wall/roof/floor mounted to ensure they do not become a projectile when the vehicle is in motion or brakes hard. Automobile Industry Standards (AIS) define the anchorage strength for all standard fitments like seats and fixtures and it is mandatory for automobile manufacturers to comply with them. But the same was never mandatory for ambulances as majority of medical equipment like stretcher were retro-fitted and equipment specifications never detailed for motion specific mounting requirements due to ignorance amongst healthcare providers which was primarily because of the fact that they were not exposed to such challenges during their training and practice. Similarly, small medical equipment like bubble type oxygen flowmeter is totally dysfunctional in an ambulance when it is mobile as the bubble keeps bobbling and does not give an accurate reading. To mitigate such challenges in mobile environment, solutions like dial type flowmetercare easily available in the market are recommended, but were not prescribed in as they are not in wide use in the hospital environment.

The Ministry of Road Transport and Highways of India had in 2011 set up five working groups on 4Es of road safety i.e. education, engineering (vehicles), enforcement, and emergency care on the recommendation of the National Road Safety Council (NRSC). The working group on emergency care in its report observed that the real concept of an ambulance is missing in India and recommended that there is a need to formulate the national ambulance code with necessary amendments in Central Motor Vehicle Rules (CMVR) that defines the constructional and functional requirements for road ambulances. Subsequently, the Ministry of Road Transport and Highways on May 30, 2013, approved the national ambulance code drafted by a multi-disciplinary committee as Automotive Industry Standard – 125 (AIS-125) and on September 8, 2016, notified the necessary amendments in CMVR, thereby making compliance with AIS-125 (Part 1) mandatory for all road ambulances manufactured on and after April 1, 2018 – thereby ushering in a new era of quality road ambulances in the country.

National Ambulance Code (AIS-125) specifies the constructional and functional requirements of Category M (four wheelers) and L (two and three wheelers) vehicles used for transport and/or emergent care of patients (road ambulance). AIS-125 for the first time in the history of India legally enshrines the definition of a road ambulance as road ambulance or a specially equipped and ergonomically designed vehicle for transportation/emergent treatment of sick or injured people and capable of providing out of hospital medical care during transit/when stationary, commensurate with its designated level of care when appropriately staffed. It further classifies the road ambulances as:

• Type A: Medical first responder. Primarily focused on two-wheeler ambulances designed to provide care to patients at the site of medical emergency;
• Type B: Patient transport vehicle. For transporting patients who are not expected to become emergency patients, e.g., patients going for elective diagnostics, etc;
• Type C: Basic life support ambulance. For transport and care of patients requiring non-invasive airway management/basic monitoring; and
• Type D: Advanced life support ambulance. For transport and care of patients requiring invasive airway management/intensive monitoring.

The ambulance code also addresses other vehicle specific parameters like seating, electricals, fire safety, stretcher loading angle, etc., with a view to simplifying the matters for healthcare providers who are often not well versed in automobile engineering aspects. With the NAC in place, all the healthcare provider needs to specify for the base ambulance vehicle is that the vehicle should be as per AIS-125 (Part 1). The code also negates the requirement of cramping patient compartment with additional seats to meet CMVR M2 category requirements of nine passenger seats as it enables stretcher to be accounted for four passenger seats and also prescribes minimum seating requirements for each category of ambulances.

The ambulance code also standardizes the recognition and visibility requirements of ambulances. Special stress has been laid on increasing the conspicuity of ambulances on the road such that these vehicles shall be uniformly identifiable across the country. The requirements of warning lights, siren, etc., have also been standardized for all categories of ambulances which should go a long way in improving the road presence and right of way for these vehicles when in an emergency.

Technology trends
As technology advances, so do emergency medical services, adapting to new developments and utilizing them to improve their quality of patient care. Breakthroughs in communications and fleet tracking technologies are helping save lives while other innovations, such as power saving devices, are helping healthcare providers reduce the amount of time their vehicles spend idling.

The list of bare minimum essentials needed to stock an ambulance these days consists of over seventy items. And while this list continues to grow, emergency responders find themselves capable of providing more lifesaving tactics while transporting patients to the hospital. Where years ago, supplies were limited, there are not many limits to the procedures that can be performed in the back of an ambulance to save a person’s life. EMTs and paramedics can actually place IVs, administer medication, even place a patient on advanced life support and perform more advanced airway procedures-all from the back of an ambulance. And in many cases, this could be the difference between life and death as a patient is transported to the right facility.

Tele-ambulances. Communications technology has come a long way. Teleconferencing helps paramedics treat and diagnose patients on their way to the hospital. The vehicles are equipped with audio-visual communication platform, empowering ambulance staff to have direct consultation with hospital physicians. This allows paramedics to transmit key information to doctors, including vital signs and, more importantly, photos of the patient’s wounds. Thereby, doctors provide critical care instructions and can make the necessary preparations for the patient’s arrival.

GPS technology. GPS tracking and remote monitoring technologies are now available which gives healthcare managers incredible power in managing their mobile workforce. GPS tracking not only lets one know where their vehicles are at any given moment, it can also help to optimize route management, which, in the end, can save precious minutes in response time. Dispatchers can make note of obstacles (such as construction sites) that can slow ambulances down and relay faster, alternate routes to their drivers.

Digital ambulances. Implementing real-time instrumentation, such as a multiplex system, in ambulances improves the overall efficiency of the emergency transportation system. For example, fleet managers can receive real-time data regarding the speed of the vehicle, when lights and sirens are being used and even maintenance readings from the chassis, resulting in lower operating costs throughout the vehicle’s life cycle.

Energy conservation. Traditional ambulances need to stay running in order to provide power for onboard systems (like ECG units, defibrillators, medical cooling units, etc.). This means that these vehicles spend a lot of time idling. When this happens, fuel is wasted, costing money and polluting the environment. However, there are emerging technologies that can help prevent this wasteful practice. New advanced tools provide electricity for vehicle heating, lighting, emergency equipment, and computers. They can be charged from the ambulance while driving, or plugged in at headquarters.

Air ambulances. Air ambulances are increasingly becoming popular in India, especially in parts of the country that lack connectivity to hospitals in big cities. Today, many of the large hospital chains in India, such as Apollo, Fortis, and Max, have their own air ambulance services. Demand for air ambulances is also seen from the residents of Tier-II and Tier-III cities. The demand is so high that it has attracted many international companies into the country as well, such as Air Medical Group Holdings (AMGH), one of the biggest privately-held providers of air ambulances in the world who has tied up with an Indian company, Aviators Air Rescue. While there is  complete unanimity among those involved in the healthcare industry that India needs more air ambulance services, the fact is these services are still very much in their infancy in India.

Outlook
Things will get better in the ambulance world, as they are driven by better science. Changes in the interior configurations and the specialty vehicle, such as mobile stroke units, critical care transports, neonate transports, will see a growing trend in the future. Most ambulances today are already hotspots, so they have Internet connectivity and can transmit a variety of information. Therefore, telemedicine could be used more over the next few years.

The next generation of ambulance technology will be driverless. With autopilot technologies, autonomous ambulances could be just around the corner. Driverless ambulances are just one way to help cities meet increased demand for care. Driverless ambulances and other technology could take some of the strain off the emergency services, freeing paramedics to deal with high-risk patients where each minute waiting for treatment significantly reduces a patient’s chance of surviving.

One can only imagine how advances in technology will continue to positively affect the world of emergency medical service. As healthcare services continue to improve, boards and committees are formed and looked to for advice of what ambulance services can improve on in the future. Among the top suggestions are side entry doors, better visibility, and specialized units to respond to chronically ill patients. The sky is the limit as technology advances and lucky for those of us living in the modern age, patients benefit medically from the improvements to emergency responding units as technology allows them to advance.

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