Many children with special health care

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1 BRIEF REPORT Transporting Children in Wheelchairs in Passenger Vehicles: A Comparison of Best Practice to Observed and Reported Practice in a Pilot Sample Janell Yonkman, Joseph O Neil, Judith Talty, Marilyn J. Bull KEY WORDS benchmarking disabled children motor vehicles transportation wheelchairs OBJECTIVE. We compared observed and reported practice among children with special health care needs transported in wheelchairs with the recommendations from the American National Standards Institute/ Rehabilitation Engineering and Assistive Technology Society of North America Committee on Wheelchairs and Transportation voluntary standards for best practice for using wheelchairs in vehicles. METHOD. A convenience sample of vehicles exiting the garage of a children s hospital was observed. Certified child passenger safety technicians gathered driver demographics and the child s reported medical condition, weight, age, clinic visited, and relation to the driver. Technicians observed how the wheelchair and occupant were secured. RESULTS. A sample of 20 vehicles showed that 90% used four-point tie-down systems to secure the wheelchairs. A total of 88% of drivers tied the wheelchairs down correctly; only 20% used a separate lap shoulder belts to secure the occupants. Twenty-five percent used lap trays, which are not recommended. Fifteen participants traveled with medical equipment secured inappropriately. CONCLUSION. Many deviations from best practice were observed and highlight areas for increased awareness, education, and resources for caregivers. Yonkman, J., O Neil, J., Talty, J., & Bull, M. J. (2010). Brief Report Transporting children in wheelchairs in passenger vehicles: A comparison of best practice to observed and reported practice in a pilot sample. American Journal of Occupational Therapy, 64, doi: /ajot Janell Yonkman, MS, OTR, is Occupational Therapist, National Center for the Safe Transportation of Children With Special Health Care Needs, Riley Hospital for Children, Indiana University School of Medicine, 575 West Drive, Room XE 004, Indianapolis, IN 46202; jyonkman@clarian.org Joseph O Neil, MD, MPH, FAAP, is Neurodevelopmental Pediatrician and Co-Medical Director, Automotive Safety Program and National Center for the Safe Transportation of Children With Special Health Care Needs, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis. Judith Talty, BA, is Director, Automotive Safety Program and National Center for the Safe Transportation of Children With Special Health Care Needs, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis. Marilyn J. Bull, MD, FAAP, is Co-Medical Director, Automotive Safety Program and National Center for the Safe Transportation of Children With Special Health Care Needs, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis. Many children with special health care needs (CSHCN) are transported to school, to medical appointments, and within the community using their wheelchairs on buses, on public transportation, or in passenger vehicles. Parents and caregivers are responsible for safely transporting their child with special needs. A study by Korn, Katz-Leurer, Meyer, and Gofin (2007) showed that drivers may experience difficulty in selecting and installing the proper child restraint. On the basis of information showing that parents have difficulty selecting and installing conventional child restraints, we concluded that parents may experience even more difficulty properly securing both the wheelchair and the occupant when using a wheelchair as a transportation device. Helping to ensure the transportation safety of these children often falls on the occupational therapists who evaluate CSHCN for transport needs at school or in a clinical setting. Although occupational therapists are in a position to provide education to families about safely transporting CSHCN, a study by Blake, Sherman, Morris, and Lapidus (2006) showed that many rehabilitation therapists report having a low level of knowledge on this topic and may be unaware of resources to obtain current information on guidelines for safe transportation of CSHCN. In April 2000, the American National Standards Institute/Rehabilitation Engineering and Assistive Technology Society of North America (ANSI/RESNA) Committee on Wheelchairs and Transportation published voluntary standards for best practice for using a wheelchair as a seat in a motor vehicle (known as WC19). Other terminology that is commonly used that 804 September/October 2010, Volume 64, Number 5

2 refers to a WC19 wheelchair is wheelchairs with a transit option or transit-ready wheelchairs. According to the Rehabilitation Engineering Research Center (RERC; 2008b) on Wheelchair Transportation Safety, WC 19 is a voluntary industry standard for designing and manufacturing a wheelchair that will be used as a seat in a motor vehicle. RERC further states that a WC19 wheelchair has the following features: four permanently labeled securement points that can withstand the forces of a 30-mph crash, securement points that will accept a securement strap end fitting hook and allow proper placement of vehicle-mounted occupant safety restraints next to the body, anchor points for an optional wheelchair-anchored pelvic safety belt designed to withstand a 30-mph crash, and a standard interface on the pelvic belt to connect to a vehicleanchored shoulder belt. Objective The objective of this pilot study was to compare reported and observed practices among CSHCN transported in wheelchairs with the recommendations from the ANSI/ RESNA Committee on Wheelchairs and Transportation. This study also gathered pertinent information on the challenges that families face when transporting a child in a wheelchair. The ANSI/RESNA (RERC, 2008a) guidelines for using a wheelchair as a seat in a motor vehicle to transport CSHCN were used to develop some of the survey observations and questions for this study. The best practice recommendations and related study questions when transporting a CSHCN in a wheelchair are listed in Table 1. Some of the early recommendations were evaluated by DiGaudio and Msall (1991), who found that most children transported in their wheelchairs in both public and family vehicles were improperly secured. Also, the National Highway and Traffic Administration s (1999) Guidelines for the Safe Transportation of Pre-School Age Children in School Buses recommended that children <50 lb be transferred from their wheelchair to a child restraint that meets federal vehicle safety standards (U.S. Department of Transportation, n.d.). Method This was an observational study based on a convenience sample of vehicles exiting the parking garage of a tertiary children s hospital outpatient center. The study was conducted weekdays 10:00 a.m. to 4:00 p. m. between October 2005 and August As each nonprofessional transport vehicle exited the garage, the driver was asked whether he or she was transporting a CSHCN. If the answer was yes, the purpose of the study was explained, and the driver was invited to participate. As an incentive to this study, participants received a gift certificate and paid parking for the day. Once drivers exited the parking garage, they were escorted to a safe parking area next to the garage where the surveys were then conducted. Only drivers and CSHCN secured in wheelchairs in passenger vehicles participated in this study. If misuse was noted, information on best practice recommendations was provided. The caregivers also were provided with the business card of the occupational therapist trained in special needs transportation and encouraged to follow up for an evaluation to determine specific recommendations for safely transporting their child. Certified child passenger safety technicians with a health care background and specialized training in the transportation of CSHCN in wheelchairs asked the driver to complete a survey requesting demographic information, the child s reported medical condition, information about challenges they encounter, weight, age, clinic visited, and relation to the driver. The diagnoses were categorized intobehavioral/developmental, neurologic/neuromuscular, genetic disorder/ chromosomal abnormality, and other. The driver completed the survey on demographics and knowledge about transportation issues while child passenger safety technicians with expertise working with children with special needs observed the Table 1. Comparison of Best Practice Recommendations and Study Questions Best Practice Recommendations for Using a Wheelchair as a Seat in a Motor Vehicle Whenever possible, use only wheelchairs that are advertised as transport safe or transit wheelchairs as seats in motor vehicles. Always secure a wheelchair to the floor of the car, bus, or van in which you are riding. When securing a wheelchair to the floor using a four-point strap system, be sure that the straps attach to the wheelchair in four locations, two in the front of the wheelchair and two in the rear (using all four straps provided). Study Questions Does the wheelchair have a transit option? Is the child with special health care needs being transported in a power or manual wheelchair? Is a tie-down system present in the vehicle? Was the tie-down system installed by a mobility specialist? Is the tie-down system used on the transit locations? Attach securement straps only to the main frame of the wheelchair. Is the tie-down system tied around the frame? Ensure that you are facing toward the front of the vehicle. What is the direction of the wheelchair during transport? Insist that you wear the occupant-restraint belt (lap and shoulder belt) provided in the vehicle. Even though adjusting occupant restraint belts is difficult, try to find the best belt fit for you. Was a separate three-point restraint system used? Detachable wheelchair-mounted equipment should be removed for transit. Was a lap tray being used? Was the lap tray secured if not on wheelchair? Was medical equipment secured appropriately? The American Journal of Occupational Therapy 805

3 type of wheelchair positioning challenges and recorded occupant restraint use and anchoring of the wheelchair to the vehicle. Descriptive statistics were used to present the data and results. This study was approved by a university review board. Results The 20 children using their wheelchair as a transportation device is a subgroup of a larger study about transporting CSHCN. In the larger study, 400 eligible vehicles were approached, 301 drivers participated, and 319 CSHCN were observed. Twenty of the 319 CSHCN observed were transported in a wheelchair; results of the observations are highlighted in Table 2. The participants who did not participate generally declined because of time constraints. Child Characteristics The mean age of the children was 10.6 yr (SD yr); 12 (60%) of the children were male, and the mean weight was 65.5 lb (SD lb). Eighteen of the 20 (90%) were categorized into the neurologic/neuromuscular diagnoses category. The others had reported diagnoses by the driver related to pulmonary issues and developmental delay. Wheelchair Type Fifteen manual wheelchairs and 5 power wheelchairs were observed being used as transportation devices. Five manual wheelchairs (25%) met WC19 standards and were equipped with transit locations. Of the 5 wheelchairs with transit locations, 3 were secured using the proper locations to secure the wheelchair. No power wheelchairs were equipped to meet the WC19 standard. Vehicle Securement Table 2. Observations of Children Transported in Wheelchairs Characteristic of Wheelchair Transport System Wheelchair type (n 5 20) The orientation of the wheelchair in the vehicle was recorded to be facing forward for 18 of 20 children (90%); 2 wheelchairs were oriented perpendicular to the direction of travel. Eighteen vehicles had the tie-down system hardware installed by a mobility specialist. Four-point tie-down systems were observed to be in use for 18 of the 20 (90%) wheelchairs, and the tiedown systems were appropriately used on 16 wheelchairs (89%). Ten wheelchairs (50%) were nontransit wheelchairs, and 2 used the four-point tie-down system with the two rear straps secured to the rear wheels, which are not considered the mainframe of the wheelchair. The remaining 2 wheelchairs were secured using the EZ Lock system (EZ Lock, Baton Rouge, LA), which was also installed by a mobility specialist. Use of Occupant Restraints Six of 20 wheelchairs (30%) were using the positioning harness and the pelvic positioning belt for occupant protection instead of a crash-tested lap/shoulder belt. Four of 20 wheelchairs (20%) were using a separate lap/shoulder belt. Ten of 20 wheelchairs (50%) were using either a lap or a shoulder belt incorrectly. Lap trays, which are recommended to be removed during travel, were observed being used in 5 of the 20 wheelchairs; for 2 others for which the No. of Observations lap trays were not in use, they were transported unsecured in the vehicle. Six CSHCN required special medical equipment for transport; of these, none of the equipment was appropriately secured. Six children weighed <50 lb and were transported in their wheelchair; five caregivers reported knowing that large medical car seats exist. Postural Challenges Percentage Manual transit 5 25 Manual nontransit Power transit 0 0 Power nontransit 5 25 Direction of wheelchair (n 5 20) Forward Side 2 10 Wheelchair securement (n 5 20) Four-point tie-down system appropriately used Four-point tie-down system 2 10 inappropriately used EZ-Lock system 2 10 Vehicle securement (n 5 20) Vehicle tie-down system installed by mobility specialist Use of occupant restraints (n 5 20) Positioning harness/pelvic positioning 6 30 belt only used Lap/shoulder belt correctly used 4 20 Lap/shoulder belt incorrectly used Lap trays (n 5 7) Lap trays used while transporting 5 71 Lap trays not in use and unsecured 2 29 Medical equipment (n 5 6) Appropriately secured 0 0 Inappropriately secured All of the children using their wheelchair as a transportation device were using customized wheelchairs. However, 25% of the children could have benefited from additional trunk and head support during transport. Clinical assessment was completed by an occupational therapist with 8 yr pediatric experience in wheelchair fitting to determine whether children could have benefited from additional trunk or head support. Some children s wheelchairs were in need of adjustments because of growth, which affected fit of the wheelchair, 806 September/October 2010, Volume 64, Number 5

4 including trunk support. Although most wheelchairs had a headrest, some children s heads would fall forward; those children may have benefited from additional neck support such as a soft cervical collar. Driver Challenges Six of 20 (30%) drivers reported having to stop their car four or more times in a 1-mo period to attend to their CSHCN. Two drivers reported that they have traveled with another child unrestrained because of having to transport a CSHCN. Fifty percent reported they have to have an adult other than the driver sit next to and observe their child. One person reported having two car crashes within a 5-yr period because of attending to their child. Fourteen caregivers (70%) reported limiting their day-today travel because of challenges associated with transporting their child. Drivers often choose to use a wheelchair for transporting their child because the child is too heavy to transfer, has poor muscle control, has a severe orthopedic deformity, is too large to fit in any type of car seat available, experiences pain when transferred multiple times, or appears more comfortable in the wheelchair; the caregiver is unable to position the child in a car seat; the wheelchair is too difficult to lift and store in the vehicle; or the caregiver has reported injuries when transferring children. Discussion This pilot study is one of the first to observe passenger vehicles and how children are transported in wheelchairs and to compare these findings with best practice recommendations for wheelchair transport. We also noted many of the challenges that families face when transporting a child in a wheelchair. Many deviations from best practice were observed and serve to highlight areas in which increased awareness, education, and resources for caregivers who transport CSHCN in wheelchairs will benefit the safety of the occupants. Our study showed that most of the wheelchairs observed were nontransit models. However, most drivers transporting children in wheelchairs had a vehicle tie-down system installed by a mobility specialist, used the system correctly, and faced the child in the correct direction. Unfortunately, many children were not correctly using the vehicle seatbelt system or were using a non crash-tested positioning harness. CSHCN will continue to be transported using their wheelchair as a transportation device. Although wheelchair companies have tried to make their wheelchairs meet the WC19 voluntary standard, this study reveals misuse, even with clearly marked points on the wheelchair to tie it down. Both children and caregivers could benefit from wheelchair manufacturers having more options available on wheelchairs to increase safety when using the wheelchair for transportation. This pilot study also showed that families face many challenges when transporting their children in a wheelchair. Occupational therapists must be educated on the best practice recommendations when using a wheelchair as a transportation device to provide families and caregivers with correct information on safe transportation of CSHCN. The Ride Safe brochure, which highlights best practice when transporting a child in a wheelchair, can be downloaded free of charge at or therapists can contact the National Center for the Safe Transportation of CSHCN ( for guidance on transporting children with varying abilities. Limitations This was a small subgroup of 20 participants taken from a study that was based on a convenience sample of drivers at a tertiary children s medical center. The results may not generalize to all drivers who transport their children in their wheelchairs. We hope to expand the sample and include more details in future studies. Conclusion The results of this study demonstrate critical misuse among people using a wheelchair as a seat in a motor vehicle. Many children likely obtain their wheelchairs, which a physician must prescribe, through a therapist or a durable medical equipment provider. These health care providers should be educated on the benefits of proper use of a WC19 wheelchair. Because of their unique access to these patients, rehabilitation therapists such as occupational therapists have an obligation to be educated about the safe transportation of CSHCN. Occupational therapy schools should include detailed information about the safe transportation of CSHCN into their curricula to better prepare occupational therapists to disseminate proper information to families. Further research in this area is a necessity. s Acknowledgments We thank Kohl s Center for Safe Transportation of Children, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, which is funded by Kohl s Department Store and allocated money for this research project. Janell Yonkman presented a poster session at the Society for Advancement of Violence and Injury Research conference titled Transporting Children in Wheelchairs in Passenger Vehicles: A Comparison of Best Practice to Observed and Reported Practice. References Blake, E., Sherman, K., Morris, L., & Lapidus, G. (2006). Self-reported experience with safe transport of children with special healthcare needs: A rehabilitation therapist perspective. American Journal of Physical Medicine and Rehabilitation, 85, doi: /01.phm cf DiGaudio, K. M., & Msall, M. (1991). Guidelines for safe transportation of children in wheelchairs. American Journal of Diseases of Children, 145, Korn, T., Katz-Leurer, M., Meyer, S., & Gofin, R. (2007). How children with special needs travel with their parents: Observed versus reported use of vehicle restraints. Pediatrics, 119, e637 e642. doi: / peds National Highway Traffic Safety Administration (1999). Guidelines for the safe transportation of pre-school age children in school buses. Retrieved March 27, 2010, from dot.gov/people/injury/buses/guide1999/ prekfinal.htm The American Journal of Occupational Therapy 807

5 Rehabilitation Engineering Research Center (2008a). Best practices for using a wheelchair as a seat in a motor vehicle. Retrieved October 15, 2009, from org/rerc_wts2_kt/rerc_wts2_ KT_Stand/WC19_Docs/BestPractices. pdf Rehabilitation Engineering Research Center (2008b). The WC19 Information Resource: Crash-tested wheelchairs and seating systems. Retrieved October 15, 2009, from www. rercwts.org/wc19.html U.S. Department of Transportation. (n.d.). Federal motor vehicle safety standards. Standard No. 213; Child restraint systems. 49 C.F.R. x Retrieved October 30, 2009, from gpoaccess.gov/cgi/t/text/text-idx?c5ecfr& sid d5f601d4b245c38fac6df07f1& rgn5div8&view5text&node549: &idno September/October 2010, Volume 64, Number 5