Dr Angel Rajan Singh
Assistant Professor of Hospital Administration and Project Officer
National Cancer Institute, AIIMS

National Ambulance code Dawn of A New Era in Quality of Ambulance Design

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).

Sick and injured are not cargo to which ordinary rules of logistics can be applied. They are perishable and hence they must be evacuated in comfort and provided with all requisite lifesaving support, en route to the medical establishment. The aforementioned lines from the US Field Ambulance Manual very beautifully encapsulate the basic principles of transferring patients in ambulances and are true globally. The 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/UT’s 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 vehicle tested and as per Section 32 of MVA, there can be no change in particulars mentioned in registration certificate of a vehicle (e.g. seating capacity).

These regulations posed a unique challenge for ambulance purchasers as 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 ply an altered one on the roads – which often the case was. This also meant that though various automotive standards regarding fire safety, electrical safety, etc., were mandatory for passenger vehicles plying on Indian roads, none were mandatory for retrofitted ambulances.

Then there were other challenges 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 our routine wall charger. Similarly, in vehicles, air conditioning capacity is not defined in tons, which is often the case in our daily life. 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 may make storage spaces in-accessible for medical care providers in times of need.

From the medical care perspective too, ambulances have certain peculiarities which are different from hospital environments 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, 12/24V DC powered (if electrically powered) and should be securely wall/roof/floor mounted to ensure they do not become a projectile when the vehicle is in motion or brakes hard. After all, we never have passenger car seats flying in air when the car breaks or standard car accessories falling off in a mobile environment.

This is so because Automobile Industry Standards (AIS) define the anchorage strength for all standard fitments like seats, fixtures etc. 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 stretchers, etc. were retro-fitted and equipment specifications never detailed motion specific mounting requirements due to ignorance amongst healthcare providers which was primarily because of the fact that they have not been exposed to such challenges during their training and practice. Similarly, small medical equipment like a bubble type oxygen flowmeter is totally dysfunctional in an ambulance when it is mobile as the bubble keeps bobbling and will never give an accurate reading. To mitigate such challenges in mobile environments, solutions like dial type flowmeter, etc. are easily available in the market but were not prescribed as they are not in wide use in the hospital environment.

The working group on emergency care setup by Ministry of Road Transport and Highways in 2011 had 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 CMVR. In line with this recommendation, the ministry 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.

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 ambulance is 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, for example, 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.

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 simplify 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 the patient compartment with additional seats to meet CMVR M2 category requirements of nine passenger seats as it enables stretchers 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.

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