In low- and middle-income countries (LMICs), time-sensitive illnesses including cardiac arrest, stroke, sepsis, obstetric emergencies, and traumatic injuries greatly contribute to premature mortality and disability. Emergency medical service (EMS) infrastructures are essential for improving health outcomes for high-acuity patients and minimizing long-term disability by increasing access to emergency care and decreasing time to critical interventions. Implementation of EMS systems in LMICs has been shown to reduce trauma-related mortality by over 25%. Unlike many LMICs, Sri Lanka has developed a national EMS system that can be accessed by calling a centralized dispatch center using a toll-free, four-digit telephone number. The response system unites 322 ambulances and over 1,300 employees under one technology-aided dispatch system. While Sri Lanka has made impressive progress in providing free-of-charge (to the patient) prehospital care, the effectiveness of an EMS system greatly depends on its ability to be responsive in a timely manner to the population it serves.
Based on recent data, the emergency service appears to be underutilized; a trend that is linked to longer hospital stays in Sri Lanka. Approximately 600,000 trauma patients are hospitalized each year at Sri Lankan government hospitals, with a majority of moderate to severe cases resulting from motor vehicle collisions. Trauma kills more than 12,000 people in Sri Lanka every year, with most deaths occurring prior to hospital arrival. Despite high levels of hospital admissions due to acute injury, fewer than 20% of patients who experience traumatic injuries in Sri Lanka utilize the emergency ambulance service to receive prehospital care and transportation, with the remainder arriving via private vehicle, predominantly three-wheelers. While decreasing trauma morbidity and mortality is an essential function of EMS systems, they also provide care to those experiencing acute illnesses and medical complaints. In Sri Lanka, similar patterns of EMS underutilization exist for patients experiencing cardiovascular emergencies and poisonings. International standards recommend one emergency ambulance per 50,000 people in LMICs. Sri Lanka falls short of this benchmark, with only one ambulance per 66,000 people. Critically injured patients are more prone to death if they do not arrive at definitive surgical care within one hour of the initial injury, and a sufficiently resourced EMS system is an important step toward ensuring timely access to such care.
While EMS systems have a proven ability to decrease trauma mortality in LMICs, minimal research has been conducted to assess the operations, accessibility, protocols, training, areas of activity, and patient outcomes to identify challenges and uncover potential areas for evidence-based, interdisciplinary improvements of the Sri Lankan system. With this gap in understanding, data-driven quality improvement interventions have been challenging to craft. Simultaneously, government-owned hospitals in Sri Lanka control a fleet of approximately 2,000 facility-based ambulances that are used for interfacility transports, transporting patients between hospital facilities for tests, procedures, or to be evaluated by specialty services. While this is an essential service, observations by local physicians indicate that these ambulances experience significant idle-time. Other LMICs, including Kenya and Cambodia, have worked to integrate facility-based ambulances into the emergency response system to improve response times. Our project will complete a retrospective data review of EMS activities, mapping functions, and identifying current gaps and redundancies in both emergency and facility-based ambulances to determine if a more efficient ambulance system is feasible.