2.4.1 - Tertiary Safety Implementation

Version 4


    In a landmark study, the American traumatologist Donald Trunkey defined the Trimodal Distribution of Trauma Deaths following road accidents:


    • for 50 % of victims, death occurs within seconds or minutes of the accident,
    • for 30 % of victims, death occurs within minutes or hours of the accident from the injuries sustained,
    • for the remaining 20 %, death occurs days or weeks after the accident mainly due to multiple organ failure.


    This study endorses the concept of a "Golden Hour" - the countdown following an accident during which an injured person has the greatest chance of survival and during which the efficiency of the emergency services and quality of care has the greatest impact on saving lives.


    Although some recent studies have thrown the concept into question, it is nevertheless true to say that the speed of arrival and the pertinence of pre-hospital treatment are largely responsible for the survival and recovery of accident victims.


    Regular progress is being made in this race against the clock with new procedures being tried out and new technologies developed at every stage of the emergency care chain. Some of these innovations include:


    1) In-vehicle emergency call systems


    The principle behind the automatic emergency call devices which a number of manufacturers now fit on their cars is to enable a vehicle to be located rapidly even if the occupants are unable to respond. Detectors are triggered by various accident indicators such as impact sensors, airbag deployment or seatbelt pretensioners. The on-board computer is alerted either manually or automatically by these devices, immediately establishing contact with the emergency services (112 in Europe or 911 in the US) or the manufacturer’s call center providing them with useful information of varying detail depending on the model of vehicle: GPS coordinates, impact points, speed at the time of the accident, route taken etc. The emergency services or the motoring breakdown service can then contact the occupants of the vehicle and launch the emergency operations.


    Do they work?


    According to studies commissioned by the EU, widespread use of in-vehicle emergency call systems would halve the time it takes emergency services to reach the scene, cut the number of fatalities by 8 % (representing about 2,500 lives saved a year) and slash the number of serious casualties by between 10 and 15 % in Europe.


    The findings of another study, conducted in Australia this time, on the OnStar system designed by US automaker General Motors concluded that this emergency call system would reduce fatal accidents by 10.5 % in urban and 12 % in rural areas.


    Other studies however point to a more limited impact of in-vehicle emergency call devices. The British Transport Research Laboratory estimated that deploying such a system in Britain would result in a mere 1 % drop in fatal accidents and only 0.5 % fewer serious casualties.


    Will these systems become mandatory?


    Europe is in the forefront for regulatory measures. In July 2012, the European Parliament adopted a draft resolution to make it compulsory to fit the e-Call system on all vehicles in Europe by 2015. When activated, e-Call would establish a direct connection with 112, the European emergency services number. The Commission is currently drafting relevant legislation. However, not all countries agree on the benefits of such a system. Some remain unconvinced of the cost-benefit ratio and others fear it will represent a threat to personal freedom as e-Call authorizes GPS tracking of the vehicle.



    What functions do they offer?


    Few vehicles are fitted with in-vehicle emergency call systems: less than 1 % of private cars in the European Union today. However, some manufacturers are moving ahead integrating emergency call systems on some or all of their models and focusing on safety in their advertising campaigns. This is the case of the Swedish manufacturer Volvo with its On Call system.

    Strategies vary from manufacturer to manufacturer: some systems are standard, others optional, some are fitted to all vehicles, others just to premium models, some are free of charge, others available on subscription, some are connected to an interactive service platform, breakdown or emergency call center. Here are some of the more sophisticated examples on the market:



    e-Call system developed by Gemalto and Deutsche Telekom.

    Fitted to more than 200,000 BMW vehicles in Europe.

    Peugeot Connect SOS system: free emergency call system with GPS tracking available in 11 European countries.

    More than 1,200,000 Peugeot and Citroën vehicles in Europe offer the system.

    Up to June 30, 2012, PSA had handled 6,000 emergency calls.

    Citroën localized emergency call system: in the event of the driver being involved in an accident, fainting or being attacked, a panic button can be used to contact the Citroën Urgence call center.  Sensors on the vehicle can also alert the emergency services automatically. Free system, operating in 11 European countries.

    This emergency call system is fitted on more than 1,200,000 Peugeot and Citroën vehicles in Europe. Up to June 30, 2012, 6,000 emergency calls had been handled.

    Volvo On Call includes an automatic warning system in the event of a collision, a SOS button for emergencies and a button to obtain road or breakdown assistance.

    Ford Sync 911 is an embedded system for alerting the emergency services automatically or manually. Over 2 million Fords are fitted with the system in the US.

    In Europe, Ford launched its first models fitted with an emergency call device in July 2012.

    OnStar, the manufacturer’s embedded interactive service platform includes an automatic crash response system which notifies the emergency services in the event of an accident sending them information such as exact location, points of impact and speed at the time of the crash. OnStar has 6 million subscribers in the US.

    In the United States, Toyota offers a Safety Connect device on subscription consisting of an SOS button and a warning system for the emergency services in the event of a collision.




    2) Seamless emergency service chain



    The success of treatment does not only depend on the speed with which the accident is reported.  It depends on a combination of interrelated factors: the time it takes the emergency services to reach the scene, accuracy of the medical information to hand, availability of appropriate skill sets and equipment, the effectiveness of first aid, speed of transfer to hospital, quality of the treatment received in A&E or the relevant hospital department. Efforts and innovation particularly need to focus on the following areas:



    Various people play a role at the scene of an accident in the following hours: bystanders, police officers, emergency doctors, firefighters, ambulance drivers, surgeons etc. Efficient coordination and sharing of information is essential in order to reduce intervention time and optimize pre-hospital treatment. 

    In response to this need, local authorities, government bodies, A&E, health and emergency service staff in some areas all belong to a network with a clear division of roles, joint training and practice sessions and pooling of feedback and experience.


    Example: In July 2010, the Fire and Emergency Services Department (SDIS) of the French departments of Essonne and Val-de-Marne under the impetus of the French National Commission for Evaluating Road Construction Safety (CNESOR) conducted a life-size road accident simulation exercise in Orly in order to fine tune the reflexes and the coordination between the various parties from different areas (fire brigade, doctors, hospitals, paramedics, local authorities, etc.).


    Stationing of emergency services 


    However quickly the accident is reported, the risk of mortality shoots up if the emergency services are based a long way away and take a long time to arrive. Tertiary safety is also a matter of logistics: vehicles and teams need to be on hand ready to rush to the scene. This is problematic in areas with poor healthcare coverage where the emergency services often have a long distance to travel.  Some local authorities have turned to new technologies to fill the gap. The State of Western Australia, for example, has invested 450 million euros in an extensive Telehealth system (videoconferencing, remote diagnosis, electronic exchange of medical records, etc.). In the event of an accident in a remote area, the casualties are taken to the nearest health facility where the teams are connected by video to a doctor or surgeon in Perth who advises on the immediate treatment from a distance while the air transfer to the State Capital or nearby city is arranged.


    Example: In Boston, during the rush hour, the Emergency Medical Services station 24 ambulances manned by emergency workers and doctors at strategic points in the city. The locations were chosen based on a detailed statistical analysis of the emergency calls received in recent months and years. The emergency teams are on hand in those places where there is the greatest likelihood of an accident occurring.


    Information sharing and availability


    This is essential to the success of post-accident intervention: performing a rapid overview of the patient’s medical history starting with the information required to dispense first aid: blood group, previous illnesses, cardiac problems, asthma, allergies etc. Methods for obtaining this information and sharing it with the professionals on the scene vary from country to country depending on legislation. The following are examples of some of the solutions which have been tried out or implemented:


    Ensuring automatic transmission of medical data from the car involved in the accident.  The e-Call system backed by the European Commission provides for the car’s on-board computer to relay medical information about the driver or the occupants of the vehicle at the same time as the alert is given. The car owner is responsible for defining the scope of the data to be transmitted. 


    Pooling information via an interactive platform. The Lozère General Council in France, for example, has set up a computerized communication system between the emergency service operators, emergency medical practitioners and paramedics. They use multimedia terminals to consult each other on the diagnosis and exchange medical information in real time from the moment the emergency services are notified right up until the accident victims are admitted to hospital.


    Transferring the medical files onto a web server, accessible to emergency and health professionals should the need arise. The counties of Kent and Medway in South-East England have launched a program to digitalize and store the medical data of over 1 million inhabitants, i.e. some 60 % of the local population, in the form of summary care records on an electronic database. In the event of an emergency - particularly a road accident - a doctor, fireman or hospital worker can immediately consult key clinical information via smartphone. More than 16 million summary care records have already been created across Britain.


    Storing medical records on a magnetic or electronic smartcard that everyone can carry on them and which can be consulted by emergency staff or doctors in the event of an accident. This system has been widely adopted in the US advocated by federal programs, inter-professional bodies and think tanks such as the Smart Card Alliance Healthcare Council which draws its members from the health industry, insurance companies and technologists. A variety of models of health smartcard are now in circulation in the US (see specimen here). Information as to whether someone is in possession of a smartcard and its exact location can be marked on the car windscreen.


    Simplifying vehicle extrication. Emergency rescue services can save precious minutes if they have instant access to information about the vehicle’s body structure and the extrication protocol indicating which parts should be avoided (fuel tank, battery, gas generator, etc.) and instructions on how to cut the vehicle open. Solutions are also being developed to ensure immediate access to information without having to consult thick auto handbooks. RescueCode is a system created by public and private operators: it takes the form of a QR code on the front of the vehicle which can be scanned with a tablet and gives access to extrication instructions. Some manufacturers, such as Opel, have created their own web portal which can be accessed from any smartphone and provides the extrication data for a large number of models.


    3) Prevention of accident escalation



    One accident can easily lead to another (the pile up is a classic example) or cause traffic jams. This is why the authorities in many countries are attempting to prevent accident escalation in three ways:


    • Training course draft law to provide for the 5 lifesaving actions to be included in driving lessons and the driving test; this type of training is already compulsory in several European countries (Germany, Austria, Denmark, and Switzerland).


    • Smart highway infrastructure VICS


    • Local and national road accident management programs to make the accident scene safe and prevent chain accidents and traffic jams. In the US, for example,  the Emergency Transportation Operations and Traffic Incident Management divisions belonging to the US Ministry of Transport coordinate the work of public and private bodies across the US in order to develop technology and processes and provide the human and material resources required for road incidents to be detected and traffic to return to normal as quickly as possible.