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In this piece, Dr Barend ter Haar, Director of BES Healthcare, discusses some of the key, need-to-know points relating to the updated BPG1 guidelines for healthcare professionals.

Dr ter Haar has been involved in seating and mobility for over 30 years, including lecturing internationally and developing international standards. 

The Best Practice Guidelines for Transportation of People Seated in Wheelchairs (BPG1), first published in 2013, has been updated this year by an international team of experts, and again made available for public access on the Posture & Mobility Group’s (PMG) website.

This guidance provides healthcare professionals who prescribe wheelchairs and seating systems for individuals with mobility impairments with guidance on the prescription and selection of equipment likely to be used in transport. The document is divided into sections for ease of navigation, and includes a new section on Risk Management. Each section begins with a summary so that readers may refresh quickly their knowledge as required.

Generally, it is safest for a wheelchair occupant to make an internal or external transfer out of their wheelchair to a fixed vehicle seat and use the vehicle seatbelt system, or a restraint system for children which complies with vehicle legislation. It is therefore strongly recommended that wheelchair occupants transfer into a vehicle seat where possible and practical. This is especially true in the case of mobility scooters, which are generally not intended to be transported.

Where an occupant transfers out of their wheeled mobility device, the device should be safely secured in the vehicle as an item of luggage, although it is acknowledged that this in itself can present a challenge.

Updates in approach to transportation of children

Historically, transport best practice has recommended that occupants of a mass less than 22kg should be transferred to a Child Restraint System (CRS) approved for use in motor vehicles. However, it has been observed that there are significant occasions where it is necessary to provide wheelchair seated transport for an individual of mass less than 22kg who, because of extreme discomfort or difficulty, could not transfer to a CRS device. This may be due to a complex form of disability and the mobility device plays an important or fundamental role in maintaining position and/or providing postural support.

On occasions, a child may have dependency on medical devices attached to their buggy or wheelchair, or their physical proportions do not align with nondisabled peers. At times, risks associated with the manual handling of a child from a mass or a safeguarding respect can also discourage the transfer of a child to a CRS device.

It is in recognition of these considerations that amendments to the scope of the crash standard ISO 7176-19 are being made. The expected 2019/20 issue of the standard will include devices intended for use in transport for occupants of a mass range of 12kg -22kg, with a design requirement for the device to be supplied with a five-point occupant harness type restraint system integrated into its structure, supplied and fitted by the original equipment manufacturer (OEM), in a similar manner to a compliant CRS.

While it is the objective of each stakeholder to seek levels of safety for wheelchair seated passengers comparable with those for vehicle seated passengers, there are bound to be variances in the risk of injury posed to the two groups. Wheelchair occupants will frequently have reduced musculoskeletal strength due to injury or disability, and contractures or physical deformities may lead to reduced injury tolerance. Such characteristics may also create difficulties with the accommodation and application of occupant restraint systems. Careful selection by prescribers of the wheelchair and seating systems that are capable of allowing best possible routing of an occupant restraint system will play an important role in reducing risks to acceptable levels during transport.

New areas covered in the guidelines

The success of the original document has been observed and noted. The extent of its success culminated with the UK Medicines and Healthcare Products Regulatory Agency’s (MHRA) withdrawal of their guidelines document DB2001(2003) and subsequent referral of readers to the IPMG BPG1 content. This in itself indicates that the readership of the BPG1 document has gone well beyond PMG membership and has reached the eyes of a broad range of stakeholders.

Comments gathered by the review process indicated a need for greater clarification on a number of subjects, a greater depth of understanding on other subjects, and the addition of transport related topics not addressed in the first edition. A simple means of navigation around the document, where inter-relating topics within the various sections can be easily found, has been addressed by the division and sub-division of headings within each section and the addition of internal links to relevant subject headings within sections.

In some instances, revisions that have been made to industry standards have addressed technical issues raised, such as the addition of ISO 7176-19:2008+A1:2015  Informative Annex G for rear impact assessment of wheelchairs and the inclusion of children of mass 12kg-22kg within the next expected revision of ISO 7176-19. Additional subjects such as use of tilt and recline in transport, the value and function of postural support devices including head supports, and the function of effective occupant restraint have also been addressed.

Risk management

A notable development has been the addition of Section 7 on Risk Management. The new section identifies two distinct arenas for the subject: the prescription of medical devices, and risk management in a transport environment. The new section on transport risk management also suggests a probable list of an individual’s transport requirements to be summarised by equipment prescribers and clinicians for presentation and risk assessment discussion with transport professionals. Based on the content of the summary, clinicians and transport professionals can identify together low risk transport solutions for further implementation. An example of transport risk management in action, as conducted by the Royal Perth Hospital, Western Australia, provides a working demonstration of the process.

Generally, the choice of a wheelchair for a person is based on their clinical need and their requirements for comfort, postural support, tissue integrity, function, and general mobility. Use of a wheelchair as a seat in a motor vehicle is an important additional consideration to be addressed by wheelchair manufacturers and equipment prescribers when taking into account a wheelchair occupant’s many differing social and medical needs. Safe transport is a key element in a wheelchair occupant’s ability to improve quality of life through participation in education, work, and leisure as well as to access medical facilities.

Equipment prescribers should consider transport needs at an early stage in the wheelchair and/or seating assessment process, and should make use of the transport safety information regarding crashworthiness available from respective wheelchair and seating manufacturers, as this may influence the choice of wheelchair and/or seating to be prescribed.

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