Safe Restraint & Transport of Children in Emergency Vehicles

Section 2 - EMERGENCY OPERATIONS

PURPOSE:

This policy establishes procedures for the safe restraint and transportation of ill or injured children in the patient compartment of transport units following the best practices outlined according to the National Highway and Traffic Safety Administration (NHTSA).

EMS providers have always faced significant challenges when it comes to safely restraining children for transport in emergency vehicles. NHTSA established a working group to identify the best practices and to publish a white paper on national recommendation on the safe restraint methods to transport children; their recommendations are the basis for this policy.

PROCEDURE:

General Safety Rules:

• The most essential principle to follow on ALL transports regardless of whether it involves a child or not, is to make everything as safe as possible.
• The ultimate goal of this policy is to prevent forward motion/ejection, secure the torso and protect the head, neck and spine of all children transported.
• General safety requirements:

1. Seat belts and restraints must be used for ALL ambulance occupants whenever the vehicle is in motion.
2. Crews shall make every effort to secure all portable or loose equipment.
3. Follow all current pediatric standards of care for injured children
4. Monitor personnel driving practices through use of technology and other means
5. Follow policies and medical parameters to reduce the unnecessary use of emergency lights and sirens (when transporting patients) when appropriate.
6. At NO TIME shall a child, even when secured in an appropriate child restraint system, ride secured in the squad bench or any seat which places the child riding sideways (facing the side of the vehicle).

State of Florida Requirements:

• Florida Statute 316.613 (1) (a) requires that all children riding in a motor vehicle shall:

“If the child is 5 years of age or younger, provide for protection of the child by properly using a crash-tested, federally approved child restraint device. For children aged through 3 years, such restraint device must be a separate carrier or a vehicle manufacturer’s integrated child seat. For children aged 4 through 5 years, a separate carrier, an integrated child seat, or a seat belt may be used.”

Transportation of an Uninjured, Non-patient Child:

NHTSA’s recommendation is to transport the unharmed child “in a vehicle other than an emergency ambulance using a size appropriate child restraint system that complies with FMVSS No. 213.”

• As a result of the recommendation MFRD personnel are NOT authorized to transport an uninjured minor/child in the transport unit as a rider.

1. Exception may be granted (with Battalion Chief approval) in the event that an older child (who does not require riding in a CRS device) is actively engaged in assisting with care, for example: breaching communication barriers by translating information between the crew and patient. The child must still be appropriately secured in the rear-facing captain’s chair only. At NO time shall the child ride on the side bench or a side mounted seat on the transport unit.
   • In such an event the supervisor must weigh the risk vs. benefit of utilizing the child to assist, resorting to this as the last viable option.

• Whenever responding to an incident where the adult caregiver is ill, injured or otherwise incapacitated and there is no other competent adult family member to care for a minor/child who is unharmed, the crew will take the following actions:

1. Notify the Communications Center requesting the Battalion Chief for immediate response.
2. The crew will brief the Battalion Chief upon their arrival of the situation and leave the unharmed minor/child in their custody.
   • In the event the adult patient is critical, the transport unit will proceed with transport immediately and the other on-scene crew will remain with the child until the Battalion Chief arrives to take custody of the minor/child.
   • The Battalion Chief will attempt to contact family members and/or caregivers for the child. If this option is unavailable, the Battalion Chief will consider contacting law enforcement or taking the child to the hospital where the adult patient is being transported to.

Transporting the Ill/Injured Child

• A child who is ill or injured but does not require spinal immobilization shall be transported using one of the following options:

1. Transport the child in the rear-facing captain’s chair in an appropriate size convertible CRS (if available) that complies with FMVSS No. 213, utilizing the forward-facing belt path.
   • An integrated CRS in the captain’s chair may be used in place of the regular seat if the unit is equipped with such device and is of appropriate size for the child.
2. In the absence of a CRS, the child must be transported secured to the stretcher cot, head first, using three horizontal stretcher restraints across the child’s torso (chest, waist and knee) and one set of vertical restrains across the child’s shoulders (fivepoint cot restraint).
   • The back rest of the cot may be raised/positioned in a way to provide comfort/cradling based upon the child’s condition and to allow for proper medical care.
   • For very small children, padding on either side of the child safely secured under the straps may provide additional support.
3. Variations of the stretcher restraint configuration may be required if the child’s condition is critical or requiring active, aggressive medical management. In these situations, common sense and practicality shall prevail, keeping in mind that the goal is to have the child secured to the cot in the best possible way to prevent forward motion/ejection, secure the torso and protect the head, neck and spine of all children transported in emergency ambulances.
4. Child restraint devices (i.e. KangooFix, Neonatal Restraint System, and the Ambulance Child Restraint-ACR4) that are approved by the Maitland Fire Rescue Department, can be used to restrain children while being transported. These devices must be used and operated per the manufacturer’s instructions

• A child requiring spinal immobilization shall be secured in an appropriately sized immobilization device (Pedi-immobilizer or LBB) and the device then securely strapped to the cot using three horizontal cot restraints across the child’s torso (chest, waist and knees) and one set of vertical restraints across the child’s shoulders.
• An injured or ill child SHALL NOT ride unsecured at any time in the transport unit.

1. If an adult caregiver is allowed to accompany the ill/injured child in the patient compartment during transport, this caregiver must be seated securely using the appropriate restraint system in the captain’s chair.
   • Ideally, the adult caregiver should ride properly secured in the forward facing right front seat of the transport unit.

Definitions:

• Bench Seat: Also known as the squad bench, this is the multi-person side facing seat alongside the cot mounting area in the rear of an ambulance.
• Captain’s Chair: Also known as the EMS provider’s seat, this is the passenger location that (usually an EMS professional) faces the rear exit of the emergency ambulance that is typically located immediately behind the driver’s seat. From this location, the person is physically able to see the patients being transported.
• Child (Children): For purposes of this policy and in accordance with NHTSA recommendations, a child is defined as any individual who the provider believes is a pediatric/child size seat by height, weight or combination of both.
• Child Restraint System (CRS): A CRS is any device (except a passenger system lap seat belt or lap/should seat belt), designed for use in a motor vehicle to restrain, seat, or position a child.
• Convertible Child Restraint System: Any CRS device designed for use in a motor vehicle that can be secured either in a forward or rear facing configuration. Convertible CRS have separate belt paths for both configurations.
• Cot: A temporary bed used in ambulances for the purposes of transporting patients to a medical facility for treatment. Also commonly referred to as a stretcher or gurney.
• Cot Restraints: A restraining device that is designed for use on a cot in an ambulance to restrain or position a child in a sitting position. Cot restraints may be devices that are permanently mounted (integrated), or can be secured to a cot in an ambulance.
• Five-Point Cot Restraints System: A system for restraining a patient to the cot of an ambulance, consisting of three horizontal restraints across the patient’s torso (chest, waist and knees) and two vertical shoulder restraints across each of the patient’s shoulders.
• FMVSS No.213: Federal Motor Vehicle Safety Standard No. 213 is the standard for child restraint. FMVSS no. 213 specifies requirements for child restraint systems used in motor vehicles and aircraft. The purpose of FMVSS No. 213 is to reduce the number of children killed or injured in motor vehicle crashes and in aircraft.