of acquiring and transmitting a 12-lead electrocardiogram), and external pacing.

A major function of state EMS offices is ambulance credentialing and inspection. In 2003, 41 state offices were involved in credentialing ambulances, while 42 state offices were engaged in ambulance inspections. Typically, states require EMS vehicles to be recredentialed every 1 to 2 years (Mears et al., 2003). The federal government also requires that all federal agencies—as well as other public and private services that use federal funding to purchase ambulances—comply with what are known as the KKK standards. Some states have adopted these standards as well and require their service to purchase KKK-compliant ambulances. However, these state and federal requirements typically address only basic ambulance capacity, not health and safety issues, which have become an increasingly significant problem.

From the standpoint of the EMS worker, the basic ambulance design is highly problematic. An assessment of EMS working conditions inside ambulances revealed that more than 40 percent of the working postures associated with high-frequency EMS tasks—including oxygen administration, heart monitoring, and blood pressure checks—create excessive musculoskeletal strain that requires corrective measures from an ergonomic perspective (Ferreira and Hignett, 2005). Ambulances are also unsafe for workers because they create an environment in which airborne and bloodborne pathogens can easily be transmitted.

In addition to these dangers, crashes involving ground ambulances are a major concern because of the frequency of high-speed, lights-and-siren driving; the transport of vulnerable patients and family members; and the poor restraint positions of EMS personnel. According to the Centers for Disease Control and Prevention (CDC), 300 fatal crashes involving ambulances occurred in the United States between 1991 and 2000. These crashes resulted in 357 fatalities, 275 of which were occupants of other vehicles or pedestrians (CDC, 2003). These data highlight the major threat posed by ambulances to their crews, their patients, and others on the road.

A number of solutions have been proposed to address these hazards. For example, some ambulances are now equipped with harnesses that allow EMS personnel to work in the back of the ambulance while still providing them with a restraint in the event of a crash or a sudden stop. Newer ambulance designs also include features that prevent patients from being projected through to the main compartment in the event of a crash.

There are also a number of efforts under way to reduce accident rates for ambulances. NHTSA has developed an Emergency Vehicle Operators Course (EVOC) National Standard Curriculum that some states require their providers to complete before being able to drive an ambulance. Other states, local EMS agencies, and even some insurance carriers require their

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