Understanding the Roles of Payors, Clinicians, Providers & Consumers

To understand the current challenges faced by the assistive technology professionals advocating for better understanding and use of WC19 and improved transportation safety for wheelchair-seated travelers, think of another piece of automotive equipment: the child safety seat.

Child safety seats are designed to protect infants and young children in motor vehicle crashes. The designs of safety seats and an appreciation for their benefits continue to improve — for instance, although child safety seats were originally mandated only for infants and toddlers, many states have extended their laws to include safety seats for children even after they start elementary school, including belt-positioning booster seats for children up to nine years old.

Yet it seems that every year or two another government study reveals that large numbers of parents and caregivers are not installing and using child safety seats correctly, or they aren’t using them at all. Why? Parents’ failure to comply is most commonly thought to stem from a lack of education: They don’t know how safety seats should be installed and how the restraint harness should be adjusted; they’re in a rush to get somewhere and don’t want to take the time to get a fussy toddler into the seat properly; they don’t know that the government recommends that older children should be sitting in belt-positioning booster seats until they reach 4’9″; and/or they don’t fully appreciate how critical those safety seats are if a crash should occur.

There are many similarities between the issues surrounding proper use of child safety seats and the situation of occupants seated in wheelchairs — especially wheelchairs that have been crash-tested to the so-called “WC 19” standard.
According to the WC 19 page on the Web site of the Rehabilitation Engineering Research Center on Wheelchair Transportation Safety (RERC WTS), www.rercwts.org, WC 19 is a “voluntary industry standard for designing and manufacturing a wheelchair that will be used as a seat in a motor vehicle.” A WC 19 wheelchair has:
•    At least four permanently labeled securement points that can withstand the forces of a 30-mph, 20-g impact;
•    Specific securement-point geometry that will accept a securement strap end fitting hook;
•    Anchor points for an optional wheelchair-anchored pelvic safety belt that is designed to withstand a 30-mph, 20-g impact;
•    And a standard interface on the pelvic belt to connect to a vehicle-anchored shoulder belt.
In addition, manufacturers of some wheelchair tiedown and occupant restraint systems (also known as WTORS) such as Q’Straint, Sure-Lok and Ortho Safe Systems make equipment that secure wheelchairs to the automotive vehicle by using four tiedown straps that easily attach to the WC 19 securement points and that include lap/shoulder belt occupant restraint systems. These companies and their products therefore play a vital role in making travel safer for wheelchair-seated passengers.

The Role of Wheelchair Manufacturers — & Funding Sources

Dr. Lawrence Schneider is head of the Biosciences Division at the University of Michigan Transportation Research Institute (UMTRI) and is one of the recognized experts on the WC 19 standard and related issues of transportation safety for people seated in wheelchairs.

He says using a WC 19 wheelchair is a key factor to providing safer transportation for wheelchair-seated passengers, but that the current status of products that comply with WC 19 varies across manufacturers. However, more wheelchair manufacturers are designing and testing products to meet WC 19 requirements: “We conducted almost a hundred wheelchair crash tests last year, and there has been an increase in the number of tests being conducted for adult and powered wheelchairs.”

Still, he says, “There’s a lot of caution from some wheelchair manufacturers to making and marketing products that comply with WC 19 due to concerns about liability should a person seated in a wheelchair be injured in a crash. I think the responses of some manufacturers to those concerns are backwards. There’s no question that people are using most wheelchair models as seats in motor vehicles, so the concerns about liability should motivate wheelchair manufacturers to design and test their products to WC 19 requirements.”

A key factor for increasing the number of wheelchair models that comply with WC 19 is for the Healthcare Common Procedure Coding System (HCPCS) used by Medicare to reference compliance with WC 19. Schneider says, “This reference to WC 19 has been scheduled for inclusion in the wheelchair Medicare codes for most categories of adult powered wheelchairs with a phase-in period of three to five years, depending on the wheelchair category.” But, Schneider adds, “It’s really hard to know what the current status of plans to reference WC 19 in these codes is at this time. However, to the extent that

Medicare does reference WC 19 testing for wheelchairs, that encourages manufacturers to get on board with more models that comply with WC 19.”
Schneider would also encourage manufacturers to more actively publicize that they have products that comply with WC 19; he’d like to see, he says, “wheelchair manufacturers be more proactive with marketing WC 19 products. They know that many wheelchair users of particular models are likely to be traveling in motor vehicles while seated in their wheelchairs, so they shouldn’t be hiding from public knowledge the fact that they’ve successfully crash-tested wheelchairs to WC 19.”

And he’d like to see those efforts by wheelchair manufacturers recognized and rewarded on the payor end: “Third-party payors, including Medicare, state Medicaid programs, and other insurance companies, need to step up to the plate and recognize that paying the extra $50 to $200 for a WC 19-compliant wheelchair is well worth it because using a WC 19 wheelchair will significantly reduce the risk of serious injuries in a crash.”

The Importance of Proper Seatbelt Use & Positioning

When we hear “WC 19,” it’s common to think of crash-test dummies and wheelchair tiedown points. But just as important to wheelchair user safety is proper use and positioning of the belt restraints while riding in motor vehicles. And that’s a topic that also needs to be emphasized, Schneider says.

“We’ve talked a lot about finding the best securement points on wheelchairs, crash-testing wheelchairs with WC 19 securement points, and looking at the strength of the chair during a frontal crash,” he explains. “But WC 19 also includes a rating test for how easy it is to properly position a vehicle-anchored lap/shoulder belt on the person in the wheelchair and, in particular, how easy is it for a driver or caregiver to properly position the lapbelt low on the pelvis.
“It’s not a pass/fail requirement at this point, but ratings of excellent, good, acceptable or poor are supposed to be disclosed by manufacturers in pre-sale literature. The test at least draws attention to the fact that wheelchairs need to be designed not just for securability and crashworthiness, but it is very important that they are designed to make it easy to achieve proper positioning of lap/shoulder belts.” While many wheelchair manufacturers have conducted the seatbelt accommodation test, Schneider says that some manufacturers may only have conducted the frontal crash test.
“One thing we’re seeing in our investigation of real-world motor-vehicle accidents is that, in many cases, the wheelchair is being effectively secured, even if it wasn’t a WC 19 chair,” he says. “But people are coming out of the wheelchairs in sudden stops or in low-speed crashes, and they are getting seriously and fatally injured because they weren’t using any seatbelt or because the seatbelt wasn’t properly positioned. So securing the chair and the crashworthiness of the chair is only part of the solution. It’s an important part, but you still have to have an effective, properly positioned lap/shoulder belt for safe travel.”

Concern over proper positioning of seatbelts on wheelchair-seated occupants is playing an important role in making revisions to WC 19. “The revised version of WC 19, which will be balloted in the first half of 2009, will not only require that a manufacturer perform the accommodation rating test for vehicle-anchored lap/shoulder belts, but they will be required to get a certain rating,” Schneider says. “In the future, a wheelchair won’t comply with WC 19 unless it receives at least an ‘acceptable’ rating for ease of positioning the seatbelt properly, as well as for how well the seatbelt fits the wheelchair occupant once it has been optimally positioned.

“I’ve often said that we seem to be losing the wheelchair transportation safety ballgame right now in the real world largely because people seated in wheelchairs are not using properly positioned belt restraints. People often have their chairs effectively secured, but they’re sliding out of the seat because the lapbelt is positioned too high over the armrests, or because the lapbelt wasn’t used at all. A big part of the problem is with wheelchairs that make it difficult to achieve proper seatbelt use and positioning — wheelchairs need to be designed not just to be crashworthy and easily secured, but they need to allow easy positioning of lap/shoulder belts anchored to the vehicle.
“But,” he adds, “this is also a training problem.”

The Need for Education

“For this reason, we put a lot of effort in the RERC on Wheelchair Transportation Safety on information dissemination,” Schneider says. “There’s a lot of information available on www.rercwts.org. RERC WTS staff also gives numerous workshops, seminars and courses every year. One of the key groups that we need to do a better job reaching is the clinicians who work directly with people in wheelchairs.”

Schneider adds, “Caregivers and drivers of vehicles transporting people in wheelchairs need to have detailed training on how to use the WTORS equipment, including how to position the lapbelt on people in different types of wheelchairs. Even if every wheelchair manufacturer agreed to start designing their products so that it was easy to properly position the lapbelt, it would be a long time before all those new wheelchairs were out there being used. We’ve got to deal with the world of wheelchairs as we know it now, and that requires that we have better driver training programs, whether it’s on city buses or in paratransit and family vans and minivans. They all need to understand why it’s important to use WTORS equipment properly and how to do this.”

Speaking of a learning curve, quite soon the entire seating & mobility industry may have new information to study regarding WC 19 — because the standard itself is being expanded and revised.
“We’re in the process of revising WC 19,” Schneider says. “It’s been under revision for awhile now, and it’s been out for what we call pre-ballot voting and commenting by members of the RESNA Committee on Wheelchairs and Transportation. There’s a new volume of ANSI/RESNA wheelchair standards coming out called Wheelchairs & Transportation, and WC 19 is going to be in Volume 4.

“That volume will contain the revised version of WC 19, as well as a revised version of the WTORS standard, which is currently an SAE (Society of Automotive Engineers)-Recommended Practice, SAE J2249 — that will become WC 18 of Volume 4.”

There will also be a new standard, WC 20, for wheelchair seating systems, Schneider says: “If you manufacture wheelchair seating systems — many of which are specialty products by wheelchair seating companies — you will be able to independently test and evaluate that seating system both for its crashworthiness as well as for its accommodation of proper positioning of lap/shoulder belts.”
WC 19 is also up for other changes.

“There are significant revisions,” Schneider notes. “In addition to the change in requirements for accommodation of vehicle-anchored seatbelts, we’re going to be enhancing the scope so there will be new requirements for wheelchairs designed for children who are under 50 lbs. Standard lap/shoulder belts are really not adequate for small children, so (manufacturers) of wheelchairs for small children will be required to provide a five-point, crash-tested restraint harness that’s anchored to the wheelchair, similar to the five-point harness provided with child safety seats.”

Getting the Word Out to All

Perhaps the biggest challenge for WC 19 and wheelchair-transportation-safety advocates is to get the information out to all the key stakeholders. Schneider says that high-quality educational materials and training videos are available from WTORS manufacturers, but “the problem is a lot of the information in these materials doesn’t reach the consumer or the driver of the vehicle. We need to get simple training materials into the hands of transit managers and transit providers, who need to have a very hands-on, active training program.”

He’d also like to see “clinicians on a wider-spread basis getting to where they automatically think of WC 19 when they’re prescribing a wheelchair for someone.”

To return to that child safety seat metaphor: “Even today, as effective as child safety seats are, there are still reports that 80 percent of them are not properly installed and used,” Schneider says. “There’s a good analogy there. Getting the word out is so much of what we’re about, but it’s very challenging to reach the stakeholders and not only educate them, but get them to change their policies in ways that will improve transportation safety for people seated in wheelchairs.”

Ideas to Pass On

What can seating & mobility suppliers do to spread the word about the value of WC 19?
Convaid’s Sue Johnson suggests the following:

•    Ask questions about and observe how the client will ride in the family vehicle and how the client will ride to/from school or work.

•    Provide “Ride Safe” brochures (available for purchase or download at www.travelsafer.org) to referral sources and consumers both pre-sale and after sale.

•     Recommend that the transit option be ordered with wheelchairs whenever possible.

•   In the course of service delivery and user instruction of the use of the wheelchair and transit safety technologies, provide instruction for the wheelchair tiedown and occupant restraint systems (WTORS) or provide resources for the consumer to obtain instruction.

•     Express support for crash-testing to wheelchair manufacturers through ordering and by calling manufacturers for tiedown instructions for all wheelchairs provided, WC 19 or not. This will let manufacturers know that the safety standard is important to you and consumers.

•     Invite and/or facilitate in-services to clinicians, consumers and funding sources about the safety standard and “best practices” for wheelchair transportation.