Study Selection

The search strategy yielded 4,909 citations from four databases. After duplicate removal, a total of 3,876 studies were retrieved for the title and abstract screening, of which 213 studies were selected for full-text screening. After the full-text screening, 126 studies were excluded for the following reasons: wrong outcome, wrong study design, wrong study period, not conducted in LMICs, full-text not found, and wrong study setting. Therefore, a total of 87 studies met the inclusion criteria and were included in this review, as depicted in Figure 1 using the PRISMA diagram.

Figure 1. Flow Diagram of the Study Selection.

Abbreviation: LMIC, low- and middle-income countries.

Characteristics of the Included Studies

Of the 87 included studies, the majority were cross-sectional (n = 52) in design, followed by qualitative studies (n = 15), prospective studies (n = 11), and cohort studies (n = 9). Most of the studies were from Iran (n = 23), followed by India (n = 7), South-Africa (n = 7), and Brazil (n = 5). Also, Asian countries represented the maximum number of studies (n = 54), followed by African (n = 23), South American (n = 6), European (n = 3), and North American (n = 1).

The studies included different cases of prehospital emergencies. Overall, among the 87 studies included in the review, trauma and injuries (n = 40) were the major emergency conditions requiring prehospital care. Other studies included emergencies of chronic diseases (n = 21), disasters (n = 7), pediatrics (n = 4), obstetrics (n = 4), and other conditions (n = 11).

The outcomes were categorized into six major categories: prehospital emergency care structure (n = 26 studies), transport care (n = 26 studies), prehospital times (n = 22 studies), health outcomes (n = 18 studies), quality of information exchange (n = 4 studies), and patient satisfaction (n = 3 studies). Some of the studies reported multiple outcomes, therefore, the total number exceeded 87.

Methodological Quality

The individual scores ranged from three-to-eight for cross-sectional studies on the NOS. Twenty of the studies were classified as being of high methodological quality, 41 were appraised as being of moderate quality, and two were classified as low quality. For the cohort studies, the individual scores ranged from four-to-eight points. Four of the studies were classified as being of high quality, and the remaining five were classified as having moderate methodological quality.

Qualitative studies were subject to quality assessment using the CASP checklist. Out of a total score of ten, eight studies received a score of ten, five studies received a score of nine, and two studies received a score of eight.

Status of Prehospital Emergency Care Services

Prehospital Emergency Care Structure—Twenty-seven studies assessed the prehospital emergency care structure in various countries and regions and identified a range of challenges and deficiencies. Prehospital emergency services provided in most areas were suboptimal. Several studies in South Africa, ^{Reference Anest, Stewart de Ramirez, Balhara, Hodkinson, Wallis and Hansoti31} Pakistan, ^{Reference Bhatti, Waseem, Razzak, Shiekh, Khoso and Salmi32} Malawi, ^{Reference Chokotho, Mulwafu, Singini, Njalale, Maliwichi-Senganimalunje and Jacobsen33} Iran, ^{Reference Khashayar, Amoli, Tavakoli and Panahi34} Yemen, ^{Reference Naser, Alsabri, Salem, Yu and Ba Saleem35} and Peru ^{Reference Vasa, Falkenstein and Centrone36} found uncoordinated, fragmented, and insufficient prehospital care systems. Another study in Iran by Bidgoli, et al showed an unequal distribution of prehospital trauma care facilities between provinces. ^{Reference Haghparast Bidgoli, Bogg and Hasselberg37}

On the aspect of human resources, most of the patients were attended by members of the public as first responders. ^{Reference G/Ananya, Sultan, Zemede and Zewdie38–Reference Reilly, Khan and Iqbal40} Many studies highlighted a lack of trained medical personnel and first responders, which could lead to delays in providing care and poor outcomes for patients. ^{Reference Khashayar, Amoli, Tavakoli and Panahi34,Reference Haghparast Bidgoli, Bogg and Hasselberg37,Reference Alinia, Khankeh, Maddah and Negarandeh41,Reference Khorasani-Zavareh, Mohammadi and Bohm42} Insufficient multidisciplinary teams and poor infrastructure, including road access, lack of basic materials, and uncoordinated and fragmented system, were frequently cited as a challenge to the effective functioning of the prehospital care system. ^{Reference Vasa, Falkenstein and Centrone36,Reference Khorasani-Zavareh, Mohammadi and Bohm42–Reference Nayeri, Sari, Neghad, Hajibabaee and Senmar45}

Five studies assessed prehospital care and preparedness plans during disasters. ^{Reference Mousavi, Khankeh, Atighechian, Yarmohammadian and Memarzadeh44,Reference Djalali, Khankeh, Öhlén, Castrén and Kurland46–Reference Sorani, Tourani, Khankeh and Panahi49} Issues like lack of a structured disaster management plan, absence of standardized medical teams, shortages of resources, lack of basic knowledge among rescue teams, and ineffective coordination were observed in the studies (Table 1 ^{Reference Mould-Millman, Oteng and Zakariah11,Reference Anest, Stewart de Ramirez, Balhara, Hodkinson, Wallis and Hansoti31–Reference Zalihić, Šljivo, Ribić, Gavranović and Brigić55} ).

Table 1. Summary of Findings from Studies Assessing Prehospital Emergency Care Structure

Abbreviations: AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; EMS, Emergency Medical Services; FGD, focus group discussion; OHCA, out-of-hospital cardiac arrest; RTM, road traffic mortality; RTI, road traffic injuries; TBI, traumatic brain injury.

Transport Care—Twenty-five studies reported a number of issues related to transport care regarding prehospital emergency care. Many studies found that patients were often transported by family members or private vehicles rather than ambulances. ^{Reference Ibrahim, Ajani and Mustafa8,Reference Kawu, Olayinka, Ayokunle, Mustapha, Sulaiman and Gbolahan10,Reference Bhat, Ravindra, Sahu, Mathew and Wilson56–Reference Mowafi, Oranmore-Brown, Hopkins, White, Mulla and Seidenberg58} Patients in difficult terrains experienced delays in reaching health facilities. Also, there was a significant association of longer transport time to worse outcomes. ^{Reference Paravar, Hosseinpour, Mohammadzadeh and Mirzadeh59,Reference Sabde, De Costa and Diwan60}

Studies have found that the use of automated external defibrillators (AEDs) and Advanced Life Support (ALS) interventions during ambulance transportation can improve patient outcomes. ^{Reference Paravar, Hosseinpour, Mohammadzadeh and Mirzadeh59,Reference Apiratwarakul, Tiamkao, Cheung, Celebi, Suzuki and Ienghong61,Reference Najafi, Bahramali, Bijani, Dehghan, Amirkhani and Balaghi Inaloo62} However, the percentage of ambulances equipped with AEDs, ventilator, disposable splint, and wheelchair were very far from standards. ^{Reference Hoang, Do and Vu57,Reference Mowafi, Oranmore-Brown, Hopkins, White, Mulla and Seidenberg58,Reference Haddadi, Sarvar, Soori and Ainy63}

Only a minority of ambulances across LMICs were physician-staffed or had Basic Life Support (BLS)-trained personnel. ^{Reference Mabry, Apodaca, Penrod, Orman, Gerhardt and Dorlac64–Reference Turan, Saz and Anil68} A study conducted among cardiac emergency cases in Iran found a lower death rate when transported by EMS. ^{Reference Najafi, Bahramali, Bijani, Dehghan, Amirkhani and Balaghi Inaloo62} Similarly, a study in Turkey reported a higher short-term mortality rate among pediatric emergencies if the ambulance was staffed by only paramedics. ^{Reference Saz, Turan and Anıl65}

Overall, factors such as absence of dedicated vehicles, lack of equipment on ambulances, and lack of skilled personnel during transportation were major challenges for effective transport care during an emergency (Table 2 ^{Reference Ibrahim, Ajani and Mustafa8,Reference Kawu, Olayinka, Ayokunle, Mustapha, Sulaiman and Gbolahan10,Reference Anest, Stewart de Ramirez, Balhara, Hodkinson, Wallis and Hansoti31,Reference Bhat, Ravindra, Sahu, Mathew and Wilson56–Reference Norouzpour, Khoshdel, Modaghegh and Kazemzadeh78} ).

Table 2. Summary of Findings from Studies Assessing Transport Care

Abbreviations: AED, automated external defibrillator; CPR, cardiopulmonary resuscitation; JSY, Janani Suraksha Yojana; SAMU, Urgent Medical Aid Service; SCI, spinal cord injury; STEMI, ST elevation myocardial infarction; RTC, road traffic collision; RTA, road traffic accident; ALS, Advanced Life Support; EMS, Emergency Medical Services.

Prehospital Time Intervals—Twenty-two studies assessed prehospital time intervals including activation time, response time, scene time, and transport time. Activation time (Range: 0.4-4.5 minutes), response time (Range: 6.6-24.2 minutes), scene time (Range: 10.3-18.0 minutes), and transport time (Range: 7.2-83.5 minutes) varied widely across the studies and countries.

Studies conducted among trauma patients in India ^{Reference Meena, Gupta and Sinha39} and Ethiopia ^{Reference G/Ananya, Sultan, Zemede and Zewdie38} showed that only 34.5% and 56.1%, respectively, were able to reach health facilities within the golden hour. A slightly higher proportion of patients were transported to the emergency centers (ECs) in Rwanda within the golden hour. ^{Reference Mbanjumucyo, George and Kearney79}

Studies have found that the use of specialized vehicles such as motorlances (motorcycles modified to be used as ambulances) and helicopter Emergency Medical Services (HEMS) can lead to shorter response times than traditional ambulances, ^{Reference Apiratwarakul, Tiamkao, Cheung, Celebi, Suzuki and Ienghong61,Reference Apiratwarakul, Suzuki and Celebi69,Reference Ghaffarzad, Ghalandarzadeh, Rahmani, Rajaei Ghafouri, Dorosti and Morteza-Bagi80} which was in turn associated with improved health outcomes and lower mortality. ^{Reference Paravar, Hosseinpour, Mohammadzadeh and Mirzadeh59,Reference Caviglia, Putoto and Conti81,Reference Sladjana, Gordana and Ana82} Factors that affected response times included the distance from the hospital, location, type of emergency, and ambulance mechanism. Additionally, several studies found that response times in rural areas were generally longer than those in urban areas ^{Reference Di, Yazid, Hamzah, Kamauzaman, Yaacob and Rahman83–Reference Paravar, Hosseinpour and Salehi85} (Table 3 ^{Reference G/Ananya, Sultan, Zemede and Zewdie38,Reference Meena, Gupta and Sinha39,Reference Paravar, Hosseinpour, Mohammadzadeh and Mirzadeh59,Reference Apiratwarakul, Tiamkao, Cheung, Celebi, Suzuki and Ienghong61,Reference Haddadi, Sarvar, Soori and Ainy63,Reference Apiratwarakul, Suzuki and Celebi69,Reference Bhoyar, Borle, Khajanchi and Nagral74,Reference Mbanjumucyo, George and Kearney79–Reference Zimmerman, Fox and Griffin93} ).

Table 3. Summary of Findings from Studies Assessing Prehospital Time Intervals

Abbreviations: AIS, acute ischemic stroke; EC, emergency center; OHCA, out-of-hospital cardiac arrest; TBI, traumatic brain injury; RTA, road traffic accident; EMS, Emergency Medical Services; HEMS, helicopter Emergency Medical Services.

Health Outcomes—Eighteen studies assessed health outcomes following prehospital emergency care. The studies reported that prehospital care interventions performed were associated with EMS personnel’s skills and educational level. Prehospital systems of trained paramedics and layperson first responders reduced trauma mortality in severe RTA injuries. ^{Reference Adib-Hajbaghery, Maghaminejad and Rajabi94,Reference Murad, Issa, Mustafa, Hassan and Husum95} Increasing prehospital time was associated with adverse outcomes and mortality among emergency cases. ^{Reference Caviglia, Putoto and Conti81} Especially following cardiac emergencies like out-of-hospital cardiac arrest (OHCA), the survival rate was low. Factors like bystander cardiopulmonary resuscitation (CPR), public availability of AED, and public awareness of early cardiac arrest were more likely to increase the survival rate among cardiac emergencies and RTAs. ^{Reference Aziz and Muhamad86,Reference Chen, Yue and Wu96–Reference Raffee, Samrah, Al Yousef, Abeeleh and Alawneh98} Advanced transport systems like HEMS and Urgent Medical Aid Service (SAMU) have reduced transportation time and played a crucial role in reducing mortality. ^{Reference Ghaffarzad, Ghalandarzadeh, Rahmani, Rajaei Ghafouri, Dorosti and Morteza-Bagi80,Reference Junger and Cavalini99,Reference van Niekerk, Welzel and Stassen100} A study conducted by Sobuwa, et al ^{Reference Sobuwa, Hartzenberg, Geduld and Uys101} showed that prehospital intubations performed among traumatic brain injury patients did not demonstrate improved outcomes, however, another study conducted in South Africa reported a 98% success rate of prehospital endotracheal intubation ^{Reference Stassen, Lithgow, Wylie and Stein102} (Table 4 ^{Reference Ghaffarzad, Ghalandarzadeh, Rahmani, Rajaei Ghafouri, Dorosti and Morteza-Bagi80,Reference Caviglia, Putoto and Conti81,Reference Aziz and Muhamad86,Reference Adib-Hajbaghery, Maghaminejad and Rajabi94–Reference Wylie, Araie and Hendrikse108} ).

Table 4. Summary of Findings from Studies Assessing Health Outcomes

Abbreviations: AED, automated external defibrillator; AMI, acute myocardial infarction; CPR, cardiopulmonary resuscitation; EMS, Emergency Medical Services; ETI, endotracheal intubation; HEMS, helicopter Emergency Medical Services; IHCA, in-hospital cardiac arrest; LMIC, low- and middle-income countries; OHCA, out-of-hospital cardiac arrest; ROSC, return of spontaneous circulation; SH, symptomatic hypoglycemia.

Patient Satisfaction—Three studies reported on the satisfaction of patients regarding prehospital care and all were conducted in Iran. ^{Reference Aboosalehi, Kolivand and Jalali109–Reference Maghaminejad and Adib-Hajbaghery111} Aboosalehi, et al ^{Reference Aboosalehi, Kolivand and Jalali109} found that almost 80% of emergency patients were highly satisfied with the services provided by Tehran EMS. Also, high educational and economic status, proper sent vehicle, and accurate diagnosis were amongst the factors leading to higher satisfaction among patients. ^{Reference Aboosalehi, Kolivand and Jalali109} Another study found that patient satisfaction with the dispatcher was good, but satisfaction level with EMTs’ performance, physical situation, and facilities inside the ambulance was moderate ^{Reference Heydari, Kamran, Zali, Novinmehr and Safari110,Reference Maghaminejad and Adib-Hajbaghery111} (Table 5 ^{Reference Aboosalehi, Kolivand and Jalali109–Reference Maghaminejad and Adib-Hajbaghery111} ).

Table 5. Summary of Findings from Studies Assessing Patient Satisfaction

Abbreviation: EMS, Emergency Medical Services.

Quality of Information Exchange—Four studies assessed the quality of information exchange in the prehospital setting. It appeared that the quality of information exchange in the prehospital setting was an issue that needed to be addressed. Communication barriers between dispatch personnel and medical facilities/EMS personnel were deemed to be a high priority. ^{Reference Anest, Stewart de Ramirez, Balhara, Hodkinson, Wallis and Hansoti31} The dispatching unit personnel in prehospital emergency care were confronted with various interactional, organizational, and professional issues. ^{Reference Mohammadi, Jeihooni, Sabetsarvestani, Abadi and Bijani112} Also, inter-facility communication was found as poor in a study conducted in Ethiopia ^{Reference Abebe, Dida, Yisma and Silvestri113} (Table 6 ^{Reference Anest, Stewart de Ramirez, Balhara, Hodkinson, Wallis and Hansoti31,Reference Mohammadi, Jeihooni, Sabetsarvestani, Abadi and Bijani112–Reference Mucunguzi, Wamani, Lochoro and Tylleskar114} ).

Table 6. Summary of Findings from Studies Assessing the Quality of Information Exchange

Abbreviations: EMS, Emergency Medical Services; RTC, road traffic collision.