An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs.

This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle–Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies.

The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.

Patients’ health outcomes can suffer as a result of poor knowledge and unfavorable attitude towards prehospital emergency care. The purpose of this study was to assess emergency health care providers’ (EHCPs’) knowledge, attitude, and associated factors towards prehospital care in selected prehospital Emergency Medical Service institutions in Addis Abeba, Ethiopia.

An institutional-based cross-sectional study design was conducted among EHCPs working in the three selected prehospital emergency medical care centers in Addis Ababa. Data were collected using a standard self-administered questionnaire, cleaned, coded, and entered into EPI Data Version 6, and then exported to SPSS Version 26 for further analysis. The generated data were compiled using frequency tables, charts, and percentages. Logistic regression analysis was used to see the association between independent and dependent variables.

One hundred thirty-five (135) study participants were included in this study, with a response rate of 95.7%. The mean age of the respondents was 29.2 years (SD = 4.86). Almost three-quarters of the respondents (71.1%) were aged between 26 and 35 years. Of the total participants, 58.5% and 62.2% of EHCPs had good knowledge and a favorable attitude towards prehospital care, respectively. The study revealed that profession (AOR = 3.2; 95% CI, 1.03 - 7.65), educational status (AOR = 1.17; 95% CI, 1.08 - 4.93), and having training (AOR = 2.25; 95% CI, 1.33 - 4.52) were significantly associated with the knowledge of EHCPs. This finding also revealed that the respondent’s knowledge (AOR = 1.36; 95% CI, 1.05 - 2.32) and having training (AOR = 3.2; 95% CI, 1.24 - 7.83) were significantly associated with EHCPs’ attitudes towards prehospital care.

The knowledge and attitude of EHCPs regarding prehospital care were found to be good and favorable as compared to previous studies. In-service training regarding emergency health conditions and the time needed to care for the patient is important for quality prehospital emergency medical care.

Emergency Medical Services (EMS) are designed to respond to and manage patients experiencing life-threatening emergencies; however, not all emergency calls are necessarily emergent and of high acuity. Emergency responses to low-acuity patients affect not only EMS, but other areas of the health care system. However, definitions of low-acuity calls are vague and subjective; therefore, it was necessary to provide a clear description of the low-acuity patient in EMS.

The goal of this study was to develop descriptors for “low-acuity EMS patients” through expert consensus within the EMS environment.

A Modified Delphi survey was used to develop call-out categories and descriptors of low acuity through expert opinion of practitioners within EMS. Purposive, snowball sampling was used to recruit 60 participants, of which 29 completed all three rounds. An online survey tool was used and offered both binary and free-text options to participants. Consensus of 75% was accepted on the binary options while free text offered further proposals for consideration during the survey.

On completion of round two, consensus was obtained on 45% (70/155) of the descriptors, and a further 30% (46/155) consensus was obtained in round three. Experts felt that respiratory distress, unconsciousness, chest pain, and severe hemorrhage cannot be considered low acuity. For other emergency response categories, specific descriptors were offered to denote a case as low acuity.

Descriptors of low acuity in EMS are provided in both medical and trauma cases. These descriptors may not only assist in the reduction of unnecessary response and transport of patients, but also assist in identifying the most appropriate response of EMS resources to call-outs. Further development and validation are required of these descriptors in order to improve accuracy and effectiveness within the EMS dispatch environment.

In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques.

The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum.

Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs.

Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data.

: Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries.GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB.Needs Assessment for Simulation Training for Prehospital Providers in Botswana. Prehosp Disaster Med. 2018;33(6):621–626.

Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum.

A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review.

A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease.

Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills.

WijesekeraO, ReedA, ChastainPS, BiggsS, ClarkEG, KoleT, ChakrapaniAT, AshishN, RajhansP, BreaudAH, JacquetGA. Epidemiology of Emergency Medical Services (EMS) Utilization in Four Indian Emergency Departments. Prehosp Disaster Med. 2016;31(6):675–679.

More than 90% of traumatic morbidity and mortality occurs in low- and middle-income countries (LMIC). Haiti is the poorest country in the Western Hemisphere and lacks contemporary statistics on the epidemiology of traumatic injuries. This study aimed to characterize the burden of traumatic injuries among emergency department patients in the Northeast region of Haiti.

Data were collected from the emergency departments of all public hospitals in the Northeast region of Haiti, which included the Fort Liberté, Ouanaminthe, and Trou du Nord sites. All patients presenting for emergent care of traumatic injuries were included. Data were obtained via review of emergency department registries and patient records from October 1, 2013 through November 30, 2013. Data on demographics, mechanisms of trauma, and anatomical regions of injury were gathered using a standardized tool and analyzed using descriptive statistics. Temporal analysis of injury frequency was explored using regression modeling.

Data from 383 patient encounters were accrued. Ouanaminthe Hospital treated the majority of emergent injuries (59.3%), followed by Fort Liberté (30.3%) and Trou du Nord (10.4%). The median age in years was 23 with 23.1% of patients being less than 15 years of age. Road traffic accidents (RTAs) and interpersonal violence accounted for 65.8% and 30.1% of all traumatic mechanisms, respectively. Extremity trauma was the most frequently observed anatomical region of injury (38.9%), followed by head and neck (30.3%) and facial (19.1%) injuries. Trauma due to RTA resulted in a single injury (83.8%) to either an extremity or the head and neck regions most frequently. A minority of patients had medical record documentation (37.9%). Blood pressure, respiratory rate, and mental status were documented in 19.3%, 4.1%, and 0.0% of records, respectively. There were 6.3 injuries/day during the data collection period with no correlation between the frequency of emergent trauma cases and day of the week (R^2=0.01).

Traumatic injuries are a common emergent presentation in the Northeast region of Haiti with characteristics similar to other LMIC. Documentation and associated data to adequately characterize the burden of disease in this region are lacking. Road traffic accidents are the predominate mechanism of injury, suggesting that interventions addressing prevention and treatment of this common occurrence may provide public health benefits in this setting.

AluisioAR , De WulfA , LouisA , BloemC . Epidemiology of Traumatic Injuries in the Northeast Region of Haiti: A Cross-sectional Study. Prehosp Disaster Med. 2015;30(6):599–605.

Although prehospital care is recognized as key in health systems development, it has been largely neglected in Haiti. The North East Department is one of the poorest areas of Haiti, and is a region where no data on out-of-hospital health care exists. This research assessed prehospital characteristics in the North East Department with the aim of providing baseline data to inform prehospital systems development.

In this observational study, data were collected from patients presenting at the Fort Liberté Hospital, the public regional referral health center in the North East Department. Data were accrued from April 2, 2012 through June 5, 2012. All patients accessing acute care at the hospital were eligible for enrollment. After obtaining consent, data on demographics, health needs, and prehospital information were gathered via a standardized questionnaire administered by hospital staff trained in study protocols.

Data were collected from 441 patient visits. The median age was 24 years, with 62% of the population being female. Medical complaints comprised 75% of visits, with fever and gastrointestinal complaints being the most common reasons for presentation. Traumatic injuries accounted for 25% of encounters, with an equal distribution of blunt and penetrating events. Extremity injuries were the most common traumatic subclassification. The majority of patients (67.2%) were transported by motorcycle taxi and paid transport fees. Trauma patients were more likely to be transported without charge (OR = 9.10; 95% CI, 2.19-37.76; P < .001). Medical patients were most commonly brought from home (78.5%) and trauma patients from a road/street setting (42.9%). Median time to presentation was 240 minutes (IQR = 120-500) and 65 minutes (IQR = 30-150) for medical and trauma complaints, respectively (P < .001). Eleven percent of patients reported receiving care prior to arrival. As compared with medical patients, trauma victims were less likely to have received prehospital care.

Assessing prehospital care in this low-income setting that lacks surveillance systems was feasible and required minimal resources. Motorcycle taxi drivers function as the primary emergency transport mechanism and may represent an access point for prehospital interventions in the North East Department of Haiti. Out-of-hospital care is nearly nonexistent in the region and its development has the potential to yield public health benefits.

AluisioAR, GoreR, DecomeI, De WulfA, BloemC. Prehospital Characteristics in the North East Department of Haiti: A Cross-sectional Study from a Low-income Setting Without Prehospital Systems. Prehosp Disaster Med. 2014;29(3):1-7.

Road traffic accident (RTA) is a common cause of pediatric trauma death and disability, constituting a worldwide loss of financial resources and potential manpower. This study was designed to determine the causes, prehospital care, presentation, and injuries that resulted in deaths among pediatric victims of RTA in Nigeria, and to make suggestions, based on the study data, to reduce RTA deaths.

This is a retrospective analysis of pediatric RTA presenting to a Nigerian referral center. The records of all pediatric RTA between January 2006 and December 2010 at the University of Benin Teaching Hospital were analyzed for age, gender, causes of death, injury, rescue team prehospital treatment, injury to hospital arrival time, clinical condition on arrival, treatment, duration of hospitalization before death, challenges, and postmortem findings.

Twenty-six (18%) of 143 pediatric RTA, comprising 18 males and 8 females, between less than one and 18 (mean 9.3 ± 5.2) years of age died. There was no significant statistical demographic difference observed when 15 (58%) deaths recorded among 67 (46.9%) children involved in motor vehicle accidents were compared with 11 (42%) involved in 76 (53.1%) motorcycle accidents (P = .31). More severe injuries resulting in the majority of deaths were associated with alcohol intoxication (P < .0001). Fourteen (54%) of the deaths were pedestrians, eight of whom were selling wares on the roadside; six were crossing roads that had no traffic signs or traffic control. Of the eight vehicle passengers who died, only two wore seat belts or used pediatric car seats, with no statistical significance compared to those who did not use seat belts or car seats (P = .37). Four of 14 front seat passengers and four of 32 rear seat passengers died (P = .222). Of motorcycle passengers, none of those who wore protective crash helmets died, while four died who were not wearing helmets. Passers-by and sympathizers served as rescuers provided emergency treatment, and presented the victims between one hour and four days after the accidents. Head injury in 14 (54%) cases was the most common cause of death.

Pediatric RTA deaths in this study were due mainly to preventable causes. There is a need to stress road safety education to children, drivers, the general public and government policy formulators, and to adopt RTA preventive measures in this region of Nigeria.

Osifo OD, Osagie TO, Iribhogbe PE. Pediatric road traffic accident deaths presenting to a Nigerian referral center. Prehosp Disaster Med. 2012;27(2):1-6.