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Abstract
Introduction: Establishment of strong emergency medical services (EMS) systems plays a pivotal role in reducing morbidity and mortality, especially in low and middle-income countries. We aimed to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Methods: Data regarding prehospital transport practices such as mode of arrival, utilization of EMS, resources available in the ambulance, presenting complaints, triage category, and demographic details were collected and analyzed. Subgroup analysis for time-sensitive complaints was done. Variables were subjected to univariate and multivariate analysis to find the predictors of ambulance usage. Results: The study included 3935 patients. The most common time-sensitive complaints were trauma (17%) and chest pain (11.5%). The most preferred mode of transport was the personal vehicle (45.6%). 29.8% of patients arrived in the ambulance. 97.7% of ambulances were not Advanced Cardiac Life Support equipped and 87.1% did not have an accompanying health care provider. 64.5% inter-hospital patient transfers were through ambulance, 83.8% transfers were unaccompanied. Among patients with time-sensitive complaints, EMS utilization was inadequate (46.8% in acute coronary syndrome, 34% in trauma, and 56.5% in early acute ischemic stroke). Conclusion: There was underutilization of the EMS services. Majority of the ambulances were not adequately equipped/staffed to deliver prehospital interventions. Policies at national level are required to encourage EMS utilization by the public and urgent measures are needed to improve services provided by them.
Keywords: Ambulance, emergency medical services, India, paramedic, prehospital
How to cite this article: Introduction 
The panorama of healthcare in India paints contrasting pictures. At one end, we have state-of-the-art medical care facilities attracting medical tourism from around the world. On the other end, we have prehospital emergency services, which are in the state of infancy.
It is known that a strong prehospital Emergency Medical Services (EMS) system reduces mortality. The availability of prehospital trauma systems in low- and middle-income countries (LMIC) has shown a 25% reduction in trauma-related mortality.[1] Evidence suggests substantially higher survival rates for cardiac arrests in places with advanced paramedical care, even among developed nations.[2] Similarly, conditions such as acute coronary syndrome (ACS), stroke are time-sensitive complaints, require urgent interventions, which need to be addressed by rapid prehospital interventions and transport.
EMS in India is largely provided by the land ambulances. There are ambulances which are government funded, as well as a multitude of private run operators. Sources estimate more than 30,000 ambulances are on the Indian roads,[3] but accurate official data are lacking. Although this number may meet the minimum recommended number of emergency transport vehicles for the Indian population, as outlined by the WHO experts, there is inadequate regulation of quality of care, equipment adequacy, or personnel competency training. There is no standard certification for prehospital ambulance personnel.[3] In recent times, measures are being undertaken to improve the quality of EMS in India.
At present, however, EMS still remains under-utilized and underequipped. Alarmingly, even in urban areas, a median of only 4% of trauma patients was transported to a hospital by ambulance and a median of only 15% received prehospital care.[4] A study among pediatric emergency patients found auto-rickshaw, and not ambulance was the most common mode of transport.[5]
Another challenge faced is that the ambulances are merely used as transport vehicles to shift patient from one place to another, and not an opportunity to provide care. This is due to the lack of trained EMS providers accompanying the patients. Properly trained prehospital emergency care provider (emergency medical technician and/or paramedic), well-equipped ambulance, universal notification system form a vital chain in optimizing outcomes.[3]
There is a lack of data regarding prehospital transport practices, and resources available in ambulances transporting these patients to a tertiary care hospital in our country. Our objective was to study the EMS utilization and resources available in the ambulances to deliver prehospital care among patients presenting to the Emergency Medicine Department in a tertiary care hospital in south India. Studying these practices to understand the lacunae in the prehospital system will help in planning resource allocation and promoting awareness to make better EMS systems.
Methodology The study was a prospective observational study conducted at the Emergency Department (ED) of a tertiary care teaching hospital in South India and approved by the Institutional Ethics Committee (IEC 383/2019). Our Hospital is located in a tier two city with a population density of about 329 per square km and caters to referral of patients from multiple districts in 100 square km radius. The EMS are mainly provided by ambulances. The government ambulance is available using the number “108.” There are various private ambulance operators as well in the region, catering to intra-district as well as inter-district transport of patients. There is lack of regulation of EMS provider availability and certification. In the recent past, a handful of colleges in India have started graduate courses in Emergency Medical Technology. But at present, there is lack of certified EMS providers in our region, as well as rest of the country.
The hospital has two-point entry to the ED and a separate Mother and Child health block. The study included all consecutive adult patients seeking emergency care (trauma and nontrauma) at the ED for 3 months, from February 2020 to April 2020. Pediatric and obstetric emergencies presenting to the separate block were not included in the study due to logistic constraints. Triaging is done in the ED by a triage nurse designated with this responsibility. Patients who have life/limb threatening emergencies and patients with time-sensitive complaints triaged as red.
Prehospital data were collected manually at the triage desk using a register after obtaining informed consent. The trained triage nurse would collect the data with patient details, which were then corroborated by the emergency physicians in the ED. The triage nurse went to the ambulance bay situated outside the triage area and noted the ambulance equipment and ambulance personnel details if the patient came in the ambulance. For cardiac arrest patients, prehospital interventions of cardiopulmonary resuscitation (CPR) and prehospital shocks were collected. Ambulances were tagged as Advanced Cardiac Life Support (ACLS) equipped ambulances if they satisfied the recommendations set by National Accreditation Board for Hospitals and Health care providers (NABH). Data regarding prehospital transport practices such as mode of arrival, referral center details, utilization of ambulance, resources available in the ambulance, presenting complaint, triage category, and other demographic details were noted.
Since it is a prospective study, there was no missing data. Data were entered into a Microsoft Excel spreadsheet 2016 (16.0.5134.1000) (Microsoft Corporation, Redmond, Washington, USA) and descriptive analysis was done using IBM SPSS statistics version 23 (International Business Machines Corporation, Armonk, New York, United States). For time-critical presenting complaints such as chest pain, suspected stroke and trauma, stroke subgroup analysis was done. Variables were subjected to univariate analysis to find the predictors of ambulance usage. The variables with a significance <0.05 were subjected to multivariate analysis. P < 0.05 was considered statistically significant.
Results During the study, 3935 patients presented to the ED of our tertiary care hospital. The baseline characteristics of the study population are enlisted in [Table 1]. A significant proportion of the patients presented with time-sensitive complaints such as polytrauma (17%) and chest pain (11.5%). 62.7% (n = 2467) presented to the department between 8 am and 8 pm. Majority of the patients were from places within a radius of 20 km to our center (48.5%), but a significant proportion also presented from a distance of more than 100 km (27.2%).
The details of the prehospital transport practices are summarized in [Table 2]. The most preferred mode of transport among the patients was found to be a personal vehicle (45.6%). A dismal 29.8% arrived in the ambulance. Most commonly, they were accompanied by a family member (73.7%). Majority of these patients came directly to our center and were not referred from another hospital (72.5%). Among the patients who were referred from another healthcare facility (n = 1082), interhospital transfer was through ambulance in 64.5%. In the ambulance transfers of these referred patients, 16.2% had healthcare providers accompanying and 2.6% were ACLS-equipped ambulances.
Table 2: Pre hospital transport practices of patients presenting to emergency departmentAmong the patients who came in an ambulance, 97.7% were not ACLS-equipped ambulances and 87.1% did not have any health care provider accompanying them. The details are listed in [Table 3].
Table 3: Emergency medical services utilization in time sensitive emergenciesAfter the initial assessment in the ED, patients were triaged as per institutional triage protocol into Red, Yellow, and Green categories based on acuity and severity of the illness. 33.7% (n = 1327) of the patients were triaged red, implying requirement of the immediate attention and highest acuity of care. The analysis of prehospital details revealed that 49% of these patients arrived in modes other than the ambulance. Among the patients arriving in the ambulance, only 3.4% were ACLS equipped ambulances, and 83.3% of ambulances were not manned by any healthcare provider.
The subgroup analysis of the prehospital transport practice among Red triaged patients and patients presenting with time-sensitive emergencies are available in [Table 3].
Our study included 8% (n = 314) patients who received a final diagnosis of ACS, 115 patients of stroke presenting within 24 h of symptom onset and 21 patients of out-of-hospital cardiac arrest (OHCA). Analysis of these patients showed that the majority (53.2% of ACS, 43.5% of stroke) had not arrived at ED by ambulance. Among the ambulances for ACS patients, only 4% were ACLS equipped with capabilities to deliver immediate care such as defibrillation. Majority of these ambulances were not accompanied by healthcare providers who could deliver any prehospital interventions [Table 3]. Only one of them received prehospital CPR and no prehospital shocks were delivered.
An analysis of trauma victims found that only 34% of patients arrived in an ambulance. Among the trauma patients who were critically ill, 69.3% arrived in the ambulance. Similar to all the time-sensitive emergencies studied above, the majority of patients who arrived in ambulances, were not accompanied by any health care provider.
To study the predictors of ambulance usage, a univariate analysis was done. Age, gender, triage category, time of arrival, the distance of residence, and referring hospital were the variables included in the univariate analysis. Since all the variables were found to be significant in Univariate analysis, all of the above were included in the multivariate analysis too. Older patient age, male gender, red and yellow triage category, distance from the hospital (<20 km or more than 100 km), and referral from other healthcare facilities were significantly associated with increased odds of ambulance usage [Table 4]. Multivariate analysis revealed that critically ill patients (Red triage category) were 5.2 times more likely to use an ambulance for hospital arrival compared to stable patients (95% confidence interval: 3.887–7.019, P < 0.001) and transfer from other healthcare facilities increased the odds of ambulance being used for patient transport.
Discussion EMS in India is still in a state of infancy. There is a great variation between cities and rural areas. Efforts are underway from both private sector, charitable trusts, and government to improve EMS provision, but there is still a long road ahead. There is lack of coordinated, centralized body to organize and dispatch EMS. Availability of EMS in India varies according to state, village, and hospital, due to topography, financial constraints, and availability of infrastructure to support an EMS system. A multicentric study done in private hospitals of 4 different geographic zones in India showed wide variation in EMS utilization among patients coming to the ED-1.4%, 9.9%, 12.2%, and 19.4%.[6] This study highlights both variation in EMS as well as under-utilization. Although there are guidelines for ambulances and recommendations given by the NABH and Healthcare Providers (NABH), the enforcement is not strictly done. Variation also exists in Indian EMS educational standards, service delivery, and outcomes.[7]
We studied 3935 patients presenting to the ED of our tertiary care hospital. The preferred mode of transportation to the ED was with their private vehicle (45.6%). Ambulance utilization was restricted to 29.8% of the emergency patients. This dismal figure highlights the underutilization of ambulance services in our country. At present, there is no prehospital/ED registry in India that measures EMS/ambulance utilization. A study done in a pediatric ED in India showed that auto-rickshaw was the preferred mode of transport (n = 138/319, 43.5%).[5] Although the availability of ambulances has increased in the past decade, the reluctance to use it for emergencies raises questions. Adding to this, we found that of the patients who presented in the ambulances, 97.7% were not ACLS equipped and 87.1% did not have any health care provider accompanying them. This underlines the lack of resources in the ambulance, which might contribute to the reason for nonutilization by the patients. The scenario is grim in our neighboring countries as well. A pilot surveillance study done in Pakistan regarding ambulance use found that only 4.1% of the patients presented to ED in the ambulance.[8] Considering the high impact EMS can have in reducing the mortality in LMIC,[1],[2] these statistics warrant introspection.
In our study, inter-hospital transfers from the referring facility were through ambulance in 64.5% of patients. But out of these, only 16.2% of the ambulances had healthcare providers accompanying the transfers. A study in the pediatric ED in India, also showed that 25 out of 26 inter-hospital ED transfers were unaccompanied by healthcare providers.[5] The importance of safe inter-hospital transfers through manned ambulances needs to be emphasized and practiced.
Among the patients categorized as Red (critically ill patients requiring high acuity immediate care) at the initial triage assessment in the ED, only half (51.1%) of the patients arrived in the ambulance, and majority (83.3%) were unmanned by any healthcare provider. Immediate prehospital interventions could be potentially life-saving in these patients and hence they must be accompanied by EMS providers. Currently, India does not have a centralized body that provides guidelines for the training and operation the EMS.[7] Although recently there is an increase in the establishment of paramedic courses such as Emergency Medical Technician, variability exists in EMS education standards.[7] Strict regulation of ambulances with regard to manpower and resources is necessary.
According to the World Health Organization, ischemic heart disease is the leading cause of death, responsible for 16% of the world's mortality,[9] out of which 75% occur in low-middle income countries.[10] Early recognition, early transport and early management would increase the chance of survival of the patient with ACS. In our study, we found that only 46.8% of ACS patients arrived in the ambulance, out of which only 4% were ACLS equipped ambulances. Most of the ambulances (84%) were unaccompanied by healthcare providers. In the United States, a study found that 53.4% of patients with myocardial infarction used EMS services to reach ED.[11] Advantages of greater utilization of EMS include management of arrhythmias by defibrillation, prehospital Electrocardiogram, ST-Elevation Myocardial Infarction alert, transportation to Primary coronary intervention capable centers. Alerting hospitals about ACS will reduce the door to balloon time. A study done in South India found that despite these benefits, some of the reasons for infrequent use of ambulances by the patients included lack of knowledge from the patients perspective that chest pain or other symptoms suggestive of ACS are appropriate reasons to request EMS, and lack of availability of EMS in some of the areas throughout the states, longer waiting times compared to private transportation, lack of a coordinated system to transfer to definitive therapy, expensive private ambulance services.[12] This merits further discussion to form coordinated regional EMS networks with a focus on ACS care and public awareness campaigns.
Among the patients with OHCA in our study, 71.4% arrived in an ambulance, but 80% were unaccompanied by healthcare providers, only 1 patient received prehospital CPR and no prehospital shocks were delivered. Another Indian study on prehospital care of cardiac arrest victims found that 30.7% had suffered cardiac arrest in transit to the hospital, 41.5% reached the hospital by means other than ambulance, 12.5% of the ambulances had basic life support trained personnel, only 9.8% had received CPR, and no prehospital shocks were delivered.[13] A study among the pediatric patients presenting in cardiac arrest also found that although 77% of the patients arrived in the ambulance, healthcare provider accompanied the sick child in 64% of cases, only 8% of children received CPR during transport.[14] The higher percentage of ambulance use in their study could be attributed to most of these being inter-hospital transfers (89%). The lack of CPR during transfer in all these studies is concerning.
Prehospital identification and swift transfer to the stroke center by EMS have played a pivotal role in improving outcomes in stroke. Patients who present early in acute ischemic stroke (AIS) may be considered eligible for fibrinolytic treatment and interventions, which can limit disability due to stroke. In our study period, 115 patients presented to ED within the 24 h onset of AIS. Among them, only 56.5% arrived in an ambulance and only 20% were accompanied by healthcare providers. A recent study done using Singapore Stroke Registry assessed patients presenting with AIS within 24 h and found that 68% arrived via EMS.[15] They also found that patients transported by EMS were more likely to receive rapid evaluation (door-to-imaging time ≤25 min), were more likely to receive fibrinolytic therapy and had better compliance to door-to-needle time ≤60 min. Hence, they concluded that the use of EMS leads to timely evaluation and treatment and advocated public campaigns to increase EMS use.[14] A study done in the United States also revealed 69% arrived at the hospital by EMS. Significant factors that positively influenced EMS use decisions were: Prior familiarity with stroke (self or family/friend with stroke), perceiving symptoms as relevant for self and indicating possible stroke, knowing the importance of EMS. Bystander discouragement to call 911 negatively influenced use of EMS.[16] Therefore, it is the need of the hour to draw up plans for public education to identify stroke and encourage the use of the EMS system to mitigate poststroke disability.
In terms of ambulance usage predictors, red triage category (critically ill) and transfer from other healthcare facilities were significantly associated with increased odds of use of an ambulance for patient transport. Though the overall usage of EMS was found to be low in our study, it is a promising trend to note that the predictors of ambulance usage are judicious and for the right indications as analyzed in previous studies.[17],[18],[19]
Prehospital interventions in trauma are revolutionizing trauma care. The building of strong prehospital trauma systems is even more vital in LMIC, where it has shown a 25% reduction in trauma-related mortality.[1] In developed systems, constant innovations are occurring in this area, with a special focus on preventing death due to hemorrhage which is the cause of 2nd peak in mortality due to trauma. Devices for better hemorrhage control in the field, prehospital administration of tranexamic acid, blood transfusion are being researched. In contrast, our study found that only 34% of patients arrived in an ambulance, and only 11.3% were accompanied by a healthcare provider who could deliver prehospital care. Even among the critically ill trauma patients (triaged Red in ED), 80% were not accompanied by healthcare providers who could administer prehospital care. This bleak statistic should ignite the discussion for the urgent pressing need to strengthen the prehospital system in India.
Limitation
Our study did not include obstetric and pediatric emergencies, due to separate entry of these patients to the ED posing logistic constraints. Data regarding prehospital notification and details of the prehospital care given by the accompanying providers except in the case of cardiac arrest were not collected. As noted in discussion, EMS utilization varies between different states and urban/rural areas. Hence, a nationwide registry will enable us to understand this variation better.
Conclusion The EMS system in India is still in its infancy. There is underutilization of the ambulance services, even for time-sensitive emergencies. Majority of the ambulances were not ACLS equipped, nor accompanied by a healthcare provider, and hence a crucial opportunity to deliver potentially life-saving prehospital interventions is missed.
Research quality and ethics statement
This study was approved by the Institutional Review Board/Ethics Committee (Kasturba Medical College IEC committee-383/2019). The authors followed applicable EQUATOR Network (http://www. equator-network. org/) guidelines during the conduct of this research project.
Acknowledgments
We would also like to acknowledge the support and contribution of the Department of Emergency Medicine & the Institute for data collection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jets.jets_83_21
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