What is known about the quality of out-of-hospital emergency medical services in the Arabian Gulf States? A systematic review

Autoři: H. N. Moafa aff001;  S. M. J. van Kuijk aff003;  G. H. L. M. Franssen aff004;  M. E. Moukhyer aff005;  H. R. Haak aff002
Působiště autorů: Faculty of Public Health and Tropical Medicine, Jazan University, Jazan, Saudi Arabia aff001;  CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands aff002;  Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands aff003;  Maastricht University Library, Maastricht, The Netherlands aff004;  Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia aff005;  Department of Internal Medicine, Maxima Medisch Centre, Eindhoven, The Netherlands aff006;  Division of General Internal Medicine, Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands aff007
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0226230



The Emergency Medical Services (EMS) have been developed in the Arabian Gulf States (AGS) in the last three decades. The EMS needs continuous quality assessment of their performance to improve and provide the best out-of-hospital care. This study aims to assess the quality of EMS in the AGS according to the six quality domains of the Institute of Medicine.


We searched four databases (i.e., PubMed, EMBASE, Web of Science, and CINAHL) for studies that reported on the quality of EMS in any of the AGS using clinical or non-clinical performance indicators. To quantify study quality and risk of bias, the adapted Newcastle Ottawa Scale was used. We focused on structural and functional indicators, clinical and non-clinical.


Twenty-five studies were eligible for inclusion. One study contained result of safety, fifteen time-centeredness, twenty effectiveness, five patient-centeredness, and thirteen studies reported on equity of EMS. None of the studies reported on efficiency of EMS. A significant proportion of studies showed high scores on the Newcastle-Ottawa scale. Limited studies on EMS quality were available, not covering all relevant quality domains and not covering the whole AGS region. The equity domain showed the best outcome performance finding, whereas finding of the patient-centeredness domain showed room for improvement in the foreseeable future.


This review highlights the need for more and better studies of sufficient quality about all domains of quality in EMS in all the AGS. EMS research in Kuwait and Bahrain is warranted, as currently studies of EMS quality are unavailable for these States. Moreover, efficiency researches exploring this discipline should be conducted specially no studies were found has been searching this domain.

Trial registration

PROSPERO registration number: CRD42019123896.

Klíčová slova:

Ambulances – Critical care and emergency medicine – Death rates – Hospitals – Intubation – Kuwait – Medical services – Transportation


1. Saudi Red Crescent Authority. About the Authority. 2018 [Available from: https://www.srca.org.sa/en/About/About.

2. Baker R. Crossing the quality chasm: A new health system for the 21st century. The Journal of Clinical Governance. 2002;10(1):43–4.

3. The Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century: National Academies Press; 2001.

4. World Health Organization. Quality of care: a process for making strategic choices in health systems. 2006:Page 3.

5. Jrcalc A. UK Ambulance Services Clinical Practice Guidelines 2016. illustrated ed: Class Publishing; 2016. 546 p.

6. American Ambulance Association. Mission of the American Ambulance Association 2018 [Available from: https://ambulance.org/our-mission/.

7. The National Association of State EMS Officials. Mission and Goals of The National Association of State EMS Officials 2019 [Vision, Mission, Strategy,and Goals. Available from: https://nasemso.org/about/overview/.

8. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS medicine. 2009;6(7):e1000100. doi: 10.1371/journal.pmed.1000100 19621070

9. Herzog R, Álvarez-Pasquin MJ, Díaz C, Del Barrio JL, Estrada JM, Gil Á. Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC public health. 2013;13(1):154.

10. Abdelrahman H, El-Menyar A, Al-Thani H, Consunji R, Zarour A, Peralta R, et al. Time-based trauma-related mortality patterns in a newly created trauma system. World journal of surgery. 2014;38(11):2804–12. doi: 10.1007/s00268-014-2705-x 25099683

11. Al-Ghamdi AS. Emergency medical service rescue times in Riyadh. Accident; analysis and prevention. 2002;34(4):499–505. doi: 10.1016/s0001-4575(01)00047-1 12067112

12. Al-Shaqsi S, Al-Kashmiri A, Al-Hajri H, Al-Harthy A. Emergency medical services versus private transport of trauma patients in the Sultanate of Oman: A retrospective audit at the Sultan Qaboos University Hospital. Emergency Medicine Journal. 2014;31(9):754–7. doi: 10.1136/emermed-2013-202779 23825061

13. Al-Thani H, El-Menyar A, Latifi R. Prehospital versus emergency room intubation of trauma patients in Qatar: A-2-year observational study. North American Journal of Medical Sciences. 2014;6(1):12–8. doi: 10.4103/1947-2714.125855 24678471

14. Alanazi AF. Emergency medical services in Saudi Arabia: A study on the significance of paramedics and their experiences on barriers as inhibitors of their efficiency. International journal of applied & basic medical research. 2012;2(1):34–7.

15. AlHabib KF, Alfaleh H, Hersi A, Kashour T, Alsheikh-Ali AA, Al Suwaidi J, et al. Use of Emergency Medical Services in the Second Gulf Registry of Acute Coronary Events. Angiology. 2014;65(8):703–9. doi: 10.1177/0003319713502846 24019088

16. AlHabib KF, Sulaiman K, Al Suwaidi J, Almahmeed W, Alsheikh-Ali AA, Amin H, et al. Patient and System-Related Delays of Emergency Medical Services Use in Acute ST-Elevation Myocardial Infarction: Results from the Third Gulf Registry of Acute Coronary Events (Gulf RACE-3Ps). PloS one. 2016;11(1):e0147385. doi: 10.1371/journal.pone.0147385 26807577

17. Alhabib KF, Kinsara AJ, Alghamdi S, Al-Murayeh M, Hussein GA, AlSaif S, et al. The first survey of the Saudi Acute Myocardial Infarction Registry Program: Main results and long-term outcomes (STARS-1 Program). Plos One. 2019;14(5).

18. Alrazeeni DM, Sheikh SA, Mobrad A, Al Ghamdi M, Abdulqader N, Al Gadgab M, et al. Epidemiology of non-transported emergency medical services calls in Saudi Arabia. Saudi medical journal. 2016;37(5):575–8. doi: 10.15537/smj.2016.5.13872 27146623

19. Althubaity E, Yunus F, Al Khathaami AM. Assessment of the experience of Saudi emergency medical services personnel with acute stroke: On-scene stroke identification, triaging, and dispatch of acute stroke patients. Neurosciences. 2013;18(1):40–5. 23291796

20. Batt AM, Al-Hajeri AS, Cummins FH. A profile of out-of-hospital cardiac arrests in Northern Emirates, United Arab Emirates. Saudi medical journal. 2016;37(11):1206–13. doi: 10.15537/smj.2016.11.16126 27761558

21. Bin Salleeh HM, Gabralla KA, Leggio WJ, Al Aseri ZA. Out-of-hospital adult cardiac arrests in a university hospital in central Saudi Arabia. Saudi medical journal. 2015;36(9):1071–5. doi: 10.15537/smj.2015.9.12081 26318464

22. Callachan EL, Alsheikh-Ali AA, Bruijns S, Wallis LA. Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi. Journal of the Saudi Heart Association. 2016;28(1):7–14. doi: 10.1016/j.jsha.2015.05.005 26778900

23. Callachan EL, Alsheikh-Ali AA, Nair SC, Bruijns S, Wallis LA. Utilizations and Perceptions of Emergency Medical Services by Patients with ST-Segments Elevation Acute Myocardial Infarction in Abu Dhabi: A Multicenter Study. Heart views: the official journal of the Gulf Heart Association. 2016;17(2):49–54.

24. Callachan EL, Alsheikh-Ali AA, Nair SC, Bruijns S, Wallis LA. Outcomes by mode of transport of st elevation mi patients in the United Arab Emirates. Western Journal of Emergency Medicine. 2017;18(3):349–55. doi: 10.5811/westjem.2017.1.32593 28435484

25. Dhaffar KO, Sindy AF, Gazzaz ZJ, Shabaz J. Evaluation of an emergency service attempted by the Saudi Red Crescent Society. Saudi Medical Journal. 2005;26(2):357–9. 15770333

26. El-Menyar A, Consunji R, Abdelrahman H, Latifi R, Wahlen BM, Al-Thani H. Predictors and Time-Based Hospital Mortality in Patients with Isolated and Polytrauma Brain Injuries. World journal of surgery. 2018;42(5):1346–57. doi: 10.1007/s00268-017-4310-2 29063224

27. Fares S, Zubaid M, Al-Mahmeed W, Ciottone G, Sayah A, Al Suwaidi J, et al. Utilization of emergency medical services by patients with acute coronary syndromes in the Arab Gulf States. Journal of Emergency Medicine. 2011;41(3):310–6. doi: 10.1016/j.jemermed.2010.05.002 20580517

28. Hamam AF, Bagis MH, AlJohani K, Tashkandi AH. Public awareness of the EMS system in Western Saudi Arabia: identifying the weakest link. International Journal of Emergency Medicine. 2015;8 (1) (no pagination)(35).

29. Irfan FB, Bhutta ZA, Castren M, Straney L, Djarv T, Tariq T, et al. Epidemiology and outcomes of out-of-hospital cardiac arrest in Qatar: A nationwide observational study. International Journal of Cardiology. 2016;223:1007–13. doi: 10.1016/j.ijcard.2016.08.299 27611569

30. Irfan FB, Consunji R, El-Menyar A, George P, Peralta R, Al-Thani H, et al. Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar: A nationwide population-based study. International Journal of Cardiology. 2017;240:438–43. doi: 10.1016/j.ijcard.2017.03.134 28395982

31. Nadar SK, Mujtaba M, Al-Hadi H, Sadiq M, Al-Riyami A, Ali M, et al. Epidemiology, Outcomes and Coronary Angiography Findings of Patients Following Out-of-Hospital Cardiac Arrest: A single-centre experience from Oman. Sultan Qaboos University medical journal. 2018;18(2):e155–e60. doi: 10.18295/squmj.2018.18.02.006 30210844

32. Ong MEH, Shin SD, De Souza NNA, Tanaka H, Nishiuchi T, Song KJ, et al. Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: The Pan Asian Resuscitation Outcomes Study (PAROS). Resuscitation. 2015;96:100–8. doi: 10.1016/j.resuscitation.2015.07.026 26234891

33. Shehab A, Al-Habib K, Hersi A, Al-Faleh H, Alsheikh-Ali A, Almahmeed W, et al. Quality of care in primary percutaneous coronary intervention for acute ST-segment—elevation myocardial infarction: Gulf RACE 2 experience. Annals of Saudi Medicine. 2014;34(6):482–7. doi: 10.5144/0256-4947.2014.482 25971820

34. Tham LP, Wah W, Phillips R, Shahidah N, Ng YY, Shin SD, et al. Epidemiology and outcome of paediatric out-of-hospital cardiac arrests: A paediatric sub-study of the Pan-Asian resuscitation outcomes study (PAROS). Resuscitation. 2018;125:111–7. doi: 10.1016/j.resuscitation.2018.01.040 29421664

35. Al Sabah S, Alsharqawi N, Al Haddad EJIJoS. The aftermath of the Kuwait mosque bombing: A retrospective cohort analysis and lessons learned. 2018;56:15–20. doi: 10.1016/j.ijsu.2018.06.003 29886282

36. Fisher JD, Freeman K, Clarke A, Spurgeon P, Smyth M, Perkins GD, et al. Patient safety in ambulance services: a scoping review. Health Serv Deliv Res. 2015;3(21).

37. Mell HK, Mumma SN, Hiestand B, Carr BG, Holland T, Stopyra J. Emergency medical services response times in rural, suburban, and urban areas. JAMA surgery. 2017;152(10):983–4. doi: 10.1001/jamasurg.2017.2230 28724118

38. Hamad Medical Corporation. Qatar Ambulance Service Qatar: Hamad Medical Corporation; 2018 [Available from: https://www.hamad.qa/EN/Hospitals-and-services/Ambulance-Service/Pages/default.aspx.

39. Munk M-D, White SD, Perry ML, Platt TE, Hardan MS, Stoy WAJPEC. Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System. 2009;13(2):185–92. doi: 10.1080/10903120802706120 19291555

40. AlShammari T, Jennings P, Williams B. Evolution of emergency medical services in Saudi Arabia. Journal of Emergency Medicine, Trauma and Acute Care. 2017;2017(1):4.

41. Eisenberg MS. Resuscitate!: How Your Community Can Improve Survival from Sudden Cardiac Arrest: University of Washington Press; 2013.

42. Yarris LM, Moreno R, Schmidt TA, Adams AL, Brooks HS. Reasons why patients choose an ambulance and willingness to consider alternatives. Academic emergency medicine. 2006;13(4):401–5. doi: 10.1197/j.aem.2005.11.079 16531606

43. Seo M, Begley C, Langabeer JR, DelliFraine JL. Barriers and disparities in emergency medical services 911 calls for stroke symptoms in the United States adult population: 2009 BRFSS Survey. Western Journal of Emergency Medicine. 2014;15(2):251. doi: 10.5811/westjem.2013.9.18584 24926394

44. Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scandinavian journal of trauma, resuscitation and emergency medicine. 2013;21(1):9.

45. Vloet LC, de Kreek A, van der Linden EM, van Spijk JJ, Theunissen VA, van Wanrooij M, et al. A retrospective comparison between non-conveyed and conveyed patients in ambulance care. Scandinavian journal of trauma, resuscitation and emergency medicine. 2018;26(1):91. doi: 10.1186/s13049-018-0557-3 30373652

46. National Institutes of Statistics. Total population and percentage of nationals and non-nationals in GCC countries (latest national statistics, (2010–2015). Gulf Research Center; 2015 31 March 2015.

47. Shire F, Kasim Z, Alrukn S, Khan M. Stroke awareness among Dubai emergency medical service staff and impact of an educational intervention. BMC research notes. 2017;10(1):255. doi: 10.1186/s13104-017-2585-x 28683821

48. Alshahrani H, McConkey R, Wilson J, Youssef M, Fitzsimons D. Female gender doubles pre-hospital delay times for patients experiencing ST segment elevation myocardial infarction in Saudi Arabia. European Journal of Cardiovascular Nursing. 2014;13(5):399–407. doi: 10.1177/1474515113507159 24104612

49. Howard I, Cameron P, Wallis L, Castren M, Lindstrom V. Quality indicators for evaluating prehospital emergency care: a scoping review. Prehospital and disaster medicine. 2018;33(1):43–52. doi: 10.1017/S1049023X17007014 29223193

50. Delbridge TR, Bailey B, Chew JL, Conn AK, Krakeel JJ, Manz D, et al. EMS agenda for the future: where we are… where we want to be. Prehospital Emergency Care. 1998;2(1):1–12. doi: 10.1080/10903129808958832 9737400

51. Alam N, Oskam E, Stassen PM, van Exter P, van de Ven PM, Haak HR, et al. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet Respiratory Medicine. 2018;6(1):40–50. doi: 10.1016/S2213-2600(17)30469-1 29196046

52. Wei Lam SS, Zhang ZC, Oh HC, Ng YY, Wah W, Hock Ong ME, et al. Reducing ambulance response times using discrete event simulation. Prehospital Emergency Care. 2014;18(2):207–16. doi: 10.3109/10903127.2013.836266 24134647

Článek vyšel v časopise


2019 Číslo 12
Nejčtenější tento týden