An 18-month-long project has led to a full-scale mock-up of an ambulance fit for the 21st century.
Given the astonishing pace of medical technology innovation, you would be forgiven for thinking that the modern ambulance must surely be a slick box of tricks on wheels.
But from a design point of view, the ambulance has changed very little in the past 30 years or so. In fact, the basic concept of ’swoop and scoop’ to hospital that is still largely in place dates back even further – despite changing healthcare paradigms.
The figures are telling. In 2009-10, ambulance crews dealt with 7.87 million emergency calls – yet around 40 per cent did not require treatment in an A&E hospital.
The skills of ambulance staff and paramedics have evolved markedly, as has the technology potentially available to them, but their ambulances have failed to keep up. The problems are numerous but include hygiene and infection control, patient experience and digital communications.
The NHS has recognised the need for change since the 2000s, yet progress has been slow, with some conceptual projects funded but nothing concrete achieved.
However, the latest project to address the issue is altogether more ambitious – aiming to build a full-scale mock-up of the back of an ambulance fit for the 21st century.
The 18-month-long project was led by the Helen Hamlyn Centre for Design at the Royal College of Art in London, alongside the London Ambulance Service, Imperial College Healthcare NHS Trust and the University of the West of England.
’There’s a number of problems with existing ambulances, because they’ve sort of evolved from horses and carts – it’s an old cliché, but they were used in the Crimean War just to cart soldiers back from the front line and get them to some kind of hospital treatment,’ project collaborator Dr Ed Matthews, senior research fellow at the Hamlyn Centre, told The Engineer.
’Nobody, until now, has stood back and looked at the design of an ambulance with what it has to do now, where you’ve got paramedics that are trained to diagnose. They don’t just have to take people straight to A&E; they carry quite sophisticated drugs with them, they prescribe and administer and they can actually discharge people on scene.’
The first rather radical step in terms of research was for members of the Hamlyn design team to ride with an ambulance crew on full 12-hour shifts around London.
The most immediate issue seemed to be a lack of space. The internal structure of an ambulance is very modular and vehicles are often overstocked due to the ’just-in-case scenario’, and sometimes end up running over legal weight. Alternatively, equipment might be missing or batteries discharged. Moreover, there has been virtually no standardisation of ambulance specifications across the UK, which has created logistical and managerial problems for ambulance trusts.
’We started inspecting everything; we dismantled an ambulance and just took everything out in terms of equipment and consumables to understand volumes and where everything needs to be laid out,’ said Gianpaolo Fusari, research associate at the Hamlyn Centre. ’At the same time, we were sketching ideas and doing 1:1 mock-ups and asking paramedics to come back and test these things with us.’
Part of the solution was a ’working wall’ that had all the equipment readily available, including five universal treatment packs containing consumables for commonly occurring call-outs – namely wound dressings, airways and oxygen, maternity, burns and cannulation. ’So that it almost jumps to you rather than going to a cupboard and finding your way,’ Fusari said.
By creating a leaner internal environment, the team was able to free up space and move the patient trolley bed into the middle for 360° access. In current ambulances, the trolley is clamped to the right-hand side of the wall, making it difficult for paramedics to work on the left-hand side of the patient.
Another modification was to include a moulded composite interior with just two components, creating a single seam in the middle, complete with curved, flushed surfaces for shelves and cupboards. This was intended to help with infection control.
’If you look at a standard ambulance, it is full of panels and screws with lots of nooks and crannies – all put together with bits of melamine and Perspex – which gather dirt and bacteria,’ Matthews said.
From a technological point of view, the aim was to choose the right off-the-shelf solutions and ’bolt them together’ as robustly as possible.
There are also three so-called digital communication portals.
The overhead monitor above the patient trolley folds down and carries all the functionality of a Lifepak 15 device, including a defibrillator and a monitor for oxygen saturation and blood pressure. The monitor also has a video link to the receiving hospital doctor or expert consultants for complex cases. Meanwhile, the driver’s console includes satellite navigation as well as the option to see what’s going on in the back.
Finally, there is a handheld digital tablet for administration and entering patient reports. Data from the central monitor is automatically uploaded to it.
’At the moment, [paramedics] write notes on their glove and then transpose those onto a patient’s sheet, and then that gets transposed finally onto the NHS system and becomes digitised – with ours it’s all wireless,’ said Matthews.
The team has now built a full-scale ambulance in the back of a trailer box. It has been tested in clinical trails, where it showed significant improvements over conventional ambulances in dealing with scenarios such as cardiac arrests. Notably, a contamination scenario was performed with a simulated bleeding leg ulcer infected with MRSA. UV staining revealed a nearly 70 per cent drop in simulated infection spread.
“Nobody has stood back and looked at the design of an ambulance and what it needs to do”
Dr Ed Matthews, Hamlyn Centre
The ambulance box is now touring the UK at medical conferences in the hope of raising awareness and drumming up further funding. Although there are promising leads, there is no main commercial partner as yet. Part of the problem lies with the conservative nature of the ambulance manufacturers, according to the team.
’They’re very comfortable and happy to sit on their hands. They’re paid £170,000 for an ambulance and we look at it and say: “Well there’s a £15,000 chassis – how much does it cost to build a caravan on the back of that and then fit all the electronics?” They’re spoon-fed by the NHS in a way and they’re not used to thinking “how do we raise our game to get a bit more of the market share”.’
Fusari added: ’We’re in a position where the paramedics want it, and the NHS thinks it’s fantastic, but they say “if you build it we’ll buy it” – and the builders say “yes it’s great” and “if the NHS buys it then we’ll build it”.
Keyfeatures lifesaver
The ambulance is designed to meet the needs of modern paramedics
- Single ’working wall’ with modular treatment packs for common call-outs
- Central patient trolley for easy access and improved patient experience
- Central console with Lifepak 15 functionality, plus video link for consultation
- Moulded composite interior with curved surface to enable improved infection control
We have introduced an advanced ambulance system developed for some years with the U.S. Military integrating some of these features, and more. Take a look at http://www.lifebot.us.com
The DREAMS Project was a $35 million dollar military project much of what
The design looks amazing. As a paramedic I can see all the advantages of the new design. It’s an absolute shame that you have to jump through hoops and red tape to even achieve the possibility of it being considered. I wish you the best of luck with this advanced design. I would love to work in this ambulance.
Nice idea in theory but if the defib is fitted to the roof what do we take into a patient’s house..??
Could probably think of many other things but it’ll never happen in this country as no-one has any money to fund the full-scale development of an operational vehicle let alone equip the countries ambulance services with a huge fleet of new vehicles or, at best, a demountable body to fit existing coachbuilt vehicles let alone the thousands of van-conversion vehicles out on the road..
Great in theory, highly unlikely to ever see production.. sadly..
Nice concept, central stretcher is a good idea. Would the lifepak be removable? Grab bag idea also good taking in smaller specific kit to addresses rather than large generic kit. How easy would it be to customise? Managers won’t buy it if they can’t put existing, expensive monitoring kit and defibs on? What about different manufacturers of say splints and vac mats? They take up different space. Great concept though and long overdue!
Is there another monitor screen apart from the one on the ceiling for the attendant to see, or does he/she have to hurt his/her neck to look up constantly? And does the attendant have to reach across the patient every time some items are required from the working wall?
What about a review of the ambulances’ delivery-van-like suspension systems?
On poor road surfaces these can be torture racks for injured patients.
Could anyone out there give me an indication as to the costs of this build, and that should include import costs, etc.. as we are in South Africa.
Ive been a paramedic for well over 20 years. They keep changing the back on motors and every time it’s worse than the last..a centre trolley doesn’t work, as you would know if your trying to do CPR on someone at 60 mph, you get flung all over the place..
What would you use in the house or at the scene? another set of equipment? How would this interface with the onboard system? In 1978 I worked for an EMS agency in Buffalo that locked the defibrillator in the ambulance. Saves were far and few between. Treatment must start where you find them. I hope we are not moving backward in time.
I’m really intrigued by this report – because over 20 years ago I was working for an ambulance manufacturer, and we were building ambulance bodies which substantially embodied the key features listed at the end of the article, although without the modern electronics. I left that area of manufacturing 18 years ago, and I would like to know how things appear to have gone backwards since then, as they must have done if there has been an 18 month consutation exercise to end up with what we was recommended 20 years ago. Can anybody out there provide a history of ambulance manufacture since 1995?
If the NHS is being charged £170K for the current ambulances, then it’s about time they took a good long look at their procurement practices; it seems to me they are being ripped off.
A standard UK ambulance design, manufactured by several different manufacturers, with competitive tendering sounds long overdue.
The design proposed in your article may not be the answer, but it should not be impossible to come up with something that meets the requirements of the paramedics who have to use it, and the needs of the majority of patients requiring treatment. Once a requirement is established, I would suggest you contact Ron Dennis. If ever a vehicle needed a radical redesign, the ambulance is a classic case in point, and Ron Dennis is ‘the man’ for a radical approach.
I see you are still sticking them in head first, great way to be in the event of a crash, head first.
To add to the comment by Roger Heath. Why is there no mention of research to find out what other countries and organisations are doing? There does seem to be tendency in certain organisations to reinvent the wheel from scratch instead of learning from other’s experience.
Great concept, but really needs to be matched to a 21st-century chassis that has, as a minmum , air suspension on the rear axle. Should be a doddle with an almost constant axle load, and could incorporate active ride control which could enable actual treatment while on the way to hospital. The reduced vibration would also extend the life of the electronics on board.
Good morning
I´m mailling from Portugal.
Look´s very good.
3 year´s ago my company have developed a mok-up ambulance .
The question i´m puting is if this system have the modularity to construct the interior ambulance as the ask of the user corporation?
Consider that the “caravan” can be made gas tight to facilitate decontamination fumigation at intervals e.g. with formaldehyde or hydrogen peroxide.
Should the driver cab be segregated from the “caravan” in case of accidental gas leakage that might impair his driving ability or a violent patient disturbing his driving.
In response to Graham Field’s observation, I suspect the NHS is not being charged £170k per ambulance, but that it costs the NHS £170k to procure an ambulance. The ambulance, in true UK public sector fashion, will not doubt cost less than half of this, probably one third to one quarter. Each procured ambulance will require a Project manager, two accountants, feasiblity study manager, program director, finacial controller, auditor and no doubt a few hangers-on, too. How else do you account for the oft-quoted- by UK Governments-statistic that the NHS employs more people than the French and German Health Services combined, when they are each able to provide services for a population of 60 million or so, while ours cannot.
Concept looks great, few design ideas i would remove. I.e windows. are these necessary or would you rather have more space for equipment or storage? why not have the medic strapped into a chair which is secured to the floor but not fixed so that he can mover around freely on the chair on a track like system while being secured if the vehicle is moving. Everything they need to reach will be within moving distance and at arms reach height.
There is research being done in the United States on ergonomics and safety. This work is being carried out by the Ambulance Manufacturers Division, cot manufacturers, seating manufacturers, equipment manufacturers NIST (National Institute for Standards Technology) and NIOSH (National Institute for Occupational Safety and Health part of CDC) and funded by Homeland Security. The goal is to create a working environment that is safe for the health care professionals and the patient that is being transported.
The last time I went in an ambulance in Brighton 2011, I was intigued to find that one of the compartments was fitted with a catflap set to open one way only!. I thibk it was so that you could put ‘sharps’ through the door and they couldn’t fall out !!
Seriously? This looks awesome. @BagMonkey: mate, if you want to carry your LP15 in with you, rock on, but if it’s a cardiac arrest, surely you want to be in open space with decent 360 access, rather than what we always seem to end up doing, on the floor, in the bathroom. An FR2 will do, surely?
@Anonymous (paramedic for 20 years):I suspect that one of the things that is going to happen with respect to CPR is that you’ll get something like Autopulse. In fact, I reckon we should all be moving towards that anyway. Manual CPR (unless done extremely well) isn’t as good as Autopulse CPR (done well). Also, I’m not sure, but there shouldn’t be any difference bracing off against a centre trolley versus a trolley on the right wall, surely?
@DannyZ – we have always been reaching over the patient to get at stuff in the lockers, haven’t we? Ergonomically speaking, looking up is safer/better/more comfortable than leaning forward and looking left, except for certain body shapes. And it looks like that monitor swivels.
Why don’t the manufacturers just build them, car manufacturers dont wait for orders to then start building, have faith in your product take on board the suggestions from the people who are going to use it and build it.
Barry, the whole ambulance market is a few hundred vehicles a year in the UK. It’s tiny. No major manufacturer makes ambulances because the numbers aren’t worth getting out of bed for! It’s left to specialist converters, who are much smaller companies. Added to that, ambulances are very high value products, with huge investment costs. If a major manufacturer wouldn’t be prepared to commit the necessary investment for so few sales, the converter is REALLY up against it!
If we’re to see any significant improvement in “front line” ambulance design, my belief is that it MUST start with the NHS agreeing ONE, NATIONAL, universal ambulance specification. I think that’s the only way we’re likely to tempt the converters to make the (huge) investment necessary.
Totally agree with this!
A controversial thought is that we revert to a ‘national ambulance service’ but then this would be seen as a backwards step by man!
Following on from my earlier posting – I’m the guy who was involved in ambulance body building 20 years ago: each authority went out to tender for either coachbuilt bodies or van conversions to their individual specifications. I doubt if that has changed. But again, 20 years ago, we were building vehicles with a solid bulkhead between driver’s compartment and the saloon, layout substantially as described in the article. Importantly though – LDV offered a base vehicle with air suspension, two alternators and three batteries. I seem to recall that there atre medical reasons why it is better for the patient to carried head first.
Get the people at Lola together with these guys, they have all the necessary expertise for design from the ground up and manufacture as well!
i love the tech, idea’s placement changes with each service, gear at hand so to speak, i do want to put in two things: first adverse weather / patient comfort ever had an asthma attack doing 65mph over washboard roadways? . second space imagine enough space for 3 people working in unison on a full code than picture it with one person.
nice idea but… not enough seating in rer for crew prent and child scenario, seats not of stndard construction to incorperate seat belt fixings that are effective only when travelng forwrd. No safe way to do cpr on route unles there is some device similar to lucas-2 currntly being trialed, high level monitors stain necks and stop you looking at patient when they are the one being treated not the machines.
There will be some great improvements no doubt but its always a good idea lead by special interests and its not a special interest thing, its a one size fits most area and the most is getting bigger, harder to move, needing hoists and heavy weight equipment let alone enough space to get around patient.
Working walls were in and out several times and as others hve commented on, its always reaching over patient or over head when health and safety state nothing should be stored above heads in case it falls on people nd so on, so get act togehter with h&s, common sence, vehicle construction and use reulations and also when going about it make a change to law so that ambulance crew are legaly allowed to be in back without belts like police and fire crews when at present they are supposed to sit straped in and watch people throw up as its not life threatening enough to justify getting out of seat so save life which is current get out.
more rant can be given but I suspect I will not be the only one and am more than happy to coment and hope good will come of the comments
Lets remember all Ambulance trsuts specify exactly what they fit in an Ambulance. The perception is still that the Coachbuilder designs and ‘sells’ a product. They do not, they build exactly what the NHS Ambulance Trusts and their working groups specify. Good to see no mention of the CEN standard defining the layout for a European Ambulance or the Type Approval, which is now required to register the vehicle to use on the road. Front line vehicles do not cost £150k, nor does a Mercedes chassis (specified and supplied by the NHS) cost £15k. Try £40K plus including the Telma retarder. £15K for a defib, £15K for a Barriatric capable stretcher and crash tested locks. All nice for a ‘design study’ but why not start with the legalities first?
As a member of the public who has had to travel in the back of one of these ambulances I totally agree with the comments regarding chassis/suspension needs looking at when you are designing something like this you design the chassis first!
superficially it may suit more of today needs in terms of access and monitoring patient needs, building an injury profile etc but there are many fundamental issues that are being completely overlooked. I have the embryo of a totally new approach to city ambulances that won’t cost the earth and will completely turn swoop and scoop on it’s head for the better: interested?
I am interested in your thoughts, from a perspective of an NGO in Thailand that is taking the lead in redefining pre-hospital care…one of the projects is to review and redesign the standard ambulance! Any input you may have would be appreciated!
SITTING in the hospital car park just now, a row of ambulances reminded me how often we hear that someone has too wait because an ambulance can’t leave because the last patient has to wait for a bed.
What is an ambulance, though? Basically it’s just a box of medical stuff, sitting on a set of wheels and an engine and manned by a highly skilled crew.
So why would it be too difficult to make the box removable, even if that does bring to mind kiddy-toy images of Thunderbird 2 with its single body and interchangeable payloads.
Then when there are no beds in the building, the ambulance reverses up to a platform, unlatches the body with all the equipment as well as the patient, picks up another body with a full set of equipment and races away.
My pod body would allow huge variations to what’s inside so no arguments between operators needed.
Even if it does cost several hundred thousand for each vehicle, isn’t a paltry few million quid in research grants just what the EU exists for?
With or without any of that, why has it never been obvious that the NHS should have joint-venture agreements with whomever it takes to facilitate not only permanent research and development but also manufacture and servicing of ambulances, as it should for everything else needed on a large scale and the more so when it’s adjustable bed-frames, oxygen bottles or anything else that’s needed almost exclusively by the NHS – such as… uh… ambulances – because that removes the specious argument that public-sector bodies shouldn’t be competing in the commercial arena.
Are there no universities with departments of engineering as well as medicine, that could work together with manufacturers and the NHS to build a choice of prototypes for testing in the real world?
Quite separately I wonder why your extremely interesting project aroused to little interest and even, there was a gap of four years…
Indeed a four year gap – I remember the hype about this project at the time and I commented to a few people that it would never move past the ‘prototype’ phase…and guess what, it hasn’t!
Why? I guess that the main holdup will be the cost of this, resistance to change and does the design actually reflect what we need? Having read the various articles on this design, it seems whilst it is quite ‘nice’ does it meet the real on the road needs of ambulance crews?
The ‘box’ Mercedes type vehicles are great to work in, the narrower Vauxhall type ones are great too…it’s down to taste and preference of the purchasing Trust I guess.
With the recent announcement that LAS is introducing 140 new Mercs into its fleet to supplement and replace old vehicles, I think we won’t see this new design in the near future.