Emergency Medical Rescue Services in Dhaka City, Bangladesh: A Situational Analysis and Needs Assessments

Background: Deaths and disabilities due to the lack of proper Emergency Medical the poor structure of EMRS. Major concerns were: Policy deficit, corruption, no coordination centre with unique phone number, poor ambulance services, and traffic-jams. Conclusion: To reduce the number of deaths and disabilities, Dhaka needs to upgrade and improve its EMRS through a step-by-step process of telephone assisted emergency first responders led pre-clinical care.


Introduction
Deaths, disabilities and human suffering due to the lack of proper Emergency Medical Rescue Services (EMRS) at emergency situations have become a global public health concern. In 2019, of the estimated 55.4 million global deaths, 73.6% were related to noncommunicable diseases (NCDs), 18.4% were caused by communicable diseases (CDs) along with maternal, neonatal and nutritional problems, and 8.0% were due to injuries [1]. Many of these global deaths were in the category of emergency medical situations, particularly cardiovascular diseases (CVDs; 17.9 million deaths) and injuries (4.4 million deaths) including road traffic incidents (RTIs; 1.3 million deaths), that required immediate and efficient pre-clinical intervention [1,2].
The mortality was much higher in low, middle, and upper-middle income countries (80.7% of all deaths; 86.4% of all injuries and 92.3% of all RTIs; 77.0% of all NCDs and 81.6% of all CVDs; 93.1% of all CDs) than in high income countries (HICs) [1,2]. Many studies in the HICs showed that immediate resuscitation with efficient professional basic first aid and advanced life support pre-clinical care and rapid transportation from the scene of an incident to an appropriate hospital could provide timely and effective clinical care and could prevent a large numbers of deaths and disabilities [3][4][5][6]. In low and middle income countries (LIMICs), there is paucity of focus on emergency care in pre-hospital and intrahospital health care settings, which are ill-equipped and unorganized to offer appropriate, immediate and efficient professional rescue care with first aid in emergency situations and resulting in a high burden of preventable deaths and disability [2,[7][8][9][10][11].
In Bangladesh, of the total estimated country-wide deaths in 2019 (630.0 deaths per 100,000 population), 75.2% were related to NCDs (38.1% were with CVDs), 18.8% to CDs and 6.1% to injuries including RTIs Figure 1: Six key stages of a modern EMRS care [22]. observational measurements were conducted for one week in each hospital using an observational checklist to scrutinize the hospital's ambulance and emergency medical services. Each day one shift was covered followed by the cycle of morning, evening and night shift during the week. The numbers and details (e.g., medical reasons, means of transports, delay times, demographic data) of emergency patients who arrived at the emergency room were recorded during the shift. Incoming patients were observed and the notes by doctors and nurses were checked. During the working shift, the management of incoming emergency calls and deployment of hospital ambulances were observed and documented. The delay times (from incoming call to return of the ambulance) of medical rescue trips of the hospital ambulances were measured. In addition, the management and delay times of 17 purposively selected medical rescue operations (from incoming call to return of the hospital) that were transported by the hospital ambulance were observed and analyzed.
In-depth interviews with emergency patients' relatives: 56 interviews with relatives of emergency patients were carried out in a separate room of the hospital to know about their experience and perceptions of EMRS in Dhaka. After receiving informed consent the interview was conducted applying the data collection guidelines. The duration was on average about 30 minutes.
In-depth interviews with EMRS service providers and managers: 23 in-depth interviews with representatives of local hospitals and other organizations dealing with emergency operations in Dhaka city were conducted using interview guidelines. The duration of the interview ranged from 30 to 60 minutes. Potential service providers and managers were purposefully selected according to their importance and relevance and were contacted for an appointment for the interview.
Translation of the data collection forms: Data collection instruments were not translated in to the local language (Bengali) as the principal and assistant researchers speak the language.

Data Analysis
A descriptive data analysis method was applied. Frequencies were computed with SPSS 18.0 and Microsoft Excel 2007. For the time analyses, the medians were computed because the data were not normally distributed.

Ethics Statement
This study was conducted in strict compliance with the ethical principles of the Nuremberg Code and the Declaration of Helsinki [25,26]. The study was approved by the Ethic Committee of Freiburg University, Germany (Approval No. 165/17) which was accepted by the participating hospitals in Bangladesh. Written informed and paramedics, and (3) Rescue team with helicopter [2,19,20]. The success and operational effectiveness of the system depends on the collective and collaborative action of the model Figure 1.
In view of the outstanding importance of EMRS particularly in densely populated cities, it was the aim of the study to contribute to improving the existing EMRS by identifying major shortcomings in the current system in Dhaka city and identifying possible solutions. The specific objectives of our study were: (1) To analyze the mortality and morbidity due to different medical emergency situations; (2) To review and explore the current EMRS with their operational effectiveness and difficulties in Dhaka city; and (3) To assess the acceptance and perceived effectiveness of existing EMRS by EMRS providers and users.

Methodology Study sites, participants and procedures
The research was conducted in Dhaka city during July and August 2017 including a one-week observational study in each of four selected local hospitals (two public and two private For the selection of hospitals and study participants, purposive sampling techniques were applied. The sample size of in-depth interviews with relatives of emergency patients was 56 and with EMRS service providers and managers it was 23.

Document analysis
Local hospitals' medical records: The two private hospitals were not able to provide the one year mortality and admission records. In the two public hospitals their published mortality and admission data in 2015 were used which could be retrieved from the Bangladesh Health Bulletin 2016 [23,24].

Published and unpublished reports and articles:
Relevant information, reports and articles were collected from different online sources (mainly Google Scholar and stakeholders' websites). Relevant key words on EMRS were employed: emergency, medical, rescue, ambulance, services, pre-clinical care, diseases, accidents and injuries, mortality, morbidity, Dhaka, Bangladesh.
Photo documentation: Photos were taken during the field work to visualize important EMRS issues.

Mixed methods (qualitative and quantitative) Participant observations about EMRS: Participant
The male to female patient ratio was 1.98:1.00. 22.2% (163) of emergency patients were below 18-years-old, 74.8% (549) in the age group of 18-65 and 3% were over 65 years. The median age of emergency patients was 27.0 years (range: 1 to 90 years).

Organization of EMRS in Dhaka hospitals:
Provider's aspects Emergency call services: Since 2017, the Government of Bangladesh (GoB; Bangladesh Police) has been launching the national emergency call centre with a universal phone number 999 to support people in urgent need with police, fire, ambulance and other services [27], but there was no central call centre with universal phone number on EMRS in Dhaka city. The individual hospitals were responsible for emergency call care including medical transport (ambulance) service. Only one hospital out of four had a call center but not with a universal phone number. GPS was used only for tracing the ambulance location. In the other three hospitals ambulance service were operated by the emergency department.

Hospital ambulance services:
In Dhaka city the availability of ambulances was estimated to be 2.8 per 100,000 inhabitants (in total 53 ambulances in 4 hospitals; Table 1). According to our interviews with EMRS providers and own observations, the ambulances are equipped with a driver, oxygen and rarely with a first aid box, but with no other facilities and no paramedics or supporting staff (Photo 1). Ambulance drivers are not trained in emergency care.
The fare is fixed at a price corresponding to approximately 3.4 Euros in the public hospitals, while in private hospitals it was 3.4 to 10.3 Euros (based on distance; Table 2). Ambulance services have to be paid from out-of-pocket money as private or public insurance does not exist in the hospitals (see users' information about ambulance costs below). consent was obtained from the participating hospital authorities and emergency patients' relatives. Whenever -in exceptional cases -a selected participant refused to continue the interview, it was ended immediately.
The two public hospitals recorded in 2014 a total of 13,707 deaths. CVDs (16.6%) were the most frequent cause followed by RTIs (12.6%), other accidents and injuries (11.3%), and suicidal attempts (5.4%; Figure 2). These most frequent causes of deaths accounted for 45.9% (6296) of the total deaths. The remaining deaths (7411, 54.1%) were due to other non communicable and communicable diseases. Three percent of deaths occurred in under-fives; the male to female mortality ratio was 1.3:1.0 [23,24].

Use of hospital ambulance services:
The observational study also focusing at ambulance services showed that only one hospital was transporting the emergency patients with an ambulance. The other three hospitals used ambulances exclusively for transferring or discharging patients. In total only 0.5% of the emergency patients were transported by hospital ambulances Ambulance management costs (e.g., maintenance cost of ambulances, changing of oil filters, changing of filters or of the oxygen supply, salaries for ambulance drivers and other related staff) were collected from the study hospitals. Based on the operational costs and number of transported patients (either bringing emergency patients to hospitals or discharged patients home), it was estimated that per EMRS rescue operation the expenditure was about 8 Euros ( Table 2). The transport cost was 19 Euros per emergency patient (for incoming patients and referrals).

EMRS issues in Dhaka: User's aspects
Incoming emergency call services: During the four-week (1 shift per day) observation period in 4 study hospitals, we assessed a total of 127 incoming emergency calls searching for an ambulance in hospitals' call centre or/and emergency departments  Of the 83 patients arrived at the hospitals by an ambulance, 32.5% (27) cases were transported by public institutions operated ambulances (e.g., public hospitals, fire service department) and 67.5% (56) by private institutions operated ambulances (e.g., private hospitals, private companies). 98.8% (82 out of 83) of the used ambulances were equipped with oxygen, but only in 8.4% (7) ambulance transports had the availability of additional medical equipment (e.g., basic wound dressing consumables, common drugs). The existed facilities were observed in use by patients only in 7.3% (6 out of 82) cases. None of the ambulances was equipped with specially trained medical staff. Ambulances were mainly used for patients with CVDs (e.g., heart attacks, strokes) or RTIs victims; Figure 4).
Major reasons for not using ambulances by 651 emergency patients were: Unavailability (534, 82.0%), unawareness of the services (152, 23.4%), high fare (94, 14.4%), hospital staff was not cooperative or demanded (Table 1). Ambulances were used only for about 10.7% of their available time for transporting patients (either for bringing discharged patients home -58.5%-or for bringing them to another hospital -41.5%); 89.3% of the available ambulance time was used for other purposes (e.g., to transport hospital staff or to bring medicine, food or supplies) or the ambulances were just in-active in a garage.

Transport media to get to the hospitals' emergency department:
The means of transport of 734 emergency patients were observed and recorded at the emergency room during 7 days, 1 shift per day, it was found that only 11.3% (83) of them came by ambulances and 88.7% (651) had used local transport (Figure 3). 62

25.80%
Ambulance Rickshaw/motor-rickshaw Car/bus   for its ambulance services: We observed and measured in the 4 hospitals during 4 weeks the delay times of 17 rescue operations of the hospital ambulances. On average the transport by ambulance (from incoming call to arriving back at hospital) took 85 minutes (median) with a range of 22 to 150 minutes ( Figure 5). During day time the median delay was 102 minutes, while at night the median delay was only 45 minutes. In terms of travel conditions, to cross 1 kilometer (k.m.) it took on average 5.3 minutes (during the day-time 6 minutes and during the night-time 3.6 minutes). On average it took 157 minutes (median) from starting the emergency call to hospitalization with a range of 75 to 990 minutes. The median delay was 171 minutes during day-time and 110 minutes during night-time. The observed reasons for substantially long ambulance transport times were mainly related to situational and structural limitations, such as congested traffic situations (Photo 2), weak traffic laws and management including public awareness regarding giving right to way to an ambulance (Photo 2), weak organizational structure, management and monitoring system.

Delay of emergency patients using private
extra money (17, 2.6%), use of own vehicle (78, 12.0%; multiple responses). When asking the relatives of 52 emergency patients in 4 hospitals why they did not use ambulances, 78.9% of them reported that they did not wait for ambulances and 67.3% that they were unavailable or 51.9% that they did not know where to call for ambulances ( Table 4; multiple responses).

Transportation costs to hospitals:
According to the interviews with relatives of 52 (out of 56) emergency patients who had used local transport, only 4 (7.7%) did not spend any money because one used a private car and three patients were brought by the people who had witnessed the emergency. For the others, the median cost for using local transport (rickshaws, motor-rickshaws, bus, taxi) was 2.1 Euro (range of 0.2 to 83.7 Euro, 1 Euro = 96.8 BDT). 19 patients out of 52 had used-according the relatives interviews-an ambulance but most of them (84.2%) for referral from one hospital to another. The median payment for ambulance services was reported to be approximately 31 Euro (range of 3.4 to 134.3 Euro).    hospitals with a delay of over 60 minutes.

Transportation delay times to hospitals Delay times as observed/measured in 4 hospitals
Major reasons for delayed arrivals at hospitals' emergency department were: 56.9% of the total emergency patients had to discuss first with relatives or friends what to do ( Table 5); 45.8% experienced traffic jams (see Photo 2); 36.6% had difficulties in arranging a transport and 33.4% went first to a nearby dispensary before coming to the hospital (multiple responses).

Dissatisfaction with EMRS and recommendations by patients' relatives
Relatives of emergency patients (N = 56) rated their satisfaction with the existing EMRS with only 1.8 on a scale from 0 (= poor) to 4 (= very good). Reasons for their lack of satisfaction were: 82.1% (46) of the relatives of emergency patients stated lack of ambulances with equipment for emergency care, 75.0% (42) mentioned traffic-jams and that the public or police did not guide ambulances through the crowd, 28.6% (16) mentioned corruption, 23.2% (13) mentioned lack of awareness of transport: According to the interviews of emergency patients' relatives, 44.4% (326) of the 734 emergency patients arrived at the four hospitals between 30 to 60 minutes after start of the medical emergencies and the others (408, 55.6%) needed more than 60 minutes or even more than 1440 minutes ( Figure 6). The total median delay to arrive at hospitals after the start of the emergency for ambulance users was 360 minutes (45 minutes to 2880 minutes) and for local transports users was 120 minutes (40 minutes to > 2880 minutes). For both ambulance and local transports users the total median delay was 120 minutes (40 minutes to 2880 minutes). The long delays were belonging mostly to situations when victims wait or relatives could not decide to go or not to go to hospital. The median transport duration (from finding transports to arrive at hospitals) for ambulance users was 60 minutes (20 to 480 minutes) and for local transport users was 40 minutes (10 to 800 minutes), and for both users was 40 minutes (10 to 800 minutes). Interestingly, out of the 325 critically ill patients, 67.1% (218) came to the operated effectively. The others 22 service providers and mangers held the view that none of the investigated aspects of local EMRS (quality, need, saving lives and disabilities, economic aspects, awareness) was working well although they argued that there was a high need of this service to save lives and avoid disabilities.
The service providers and managers recommendations to improve the local EMRS were: Organize capacity development (22, 95.7%); re-equip the ambulances (19, EMRS, and 57.1% (32) reported about other situational and structural issues (N = 56; multiple responses).

Opinion of EMRS service providers and managers
Most of the 23 EMRS service providers and managers lamented the non-existence of pre-clinical emergency care in Dhaka city. There was no early response system, no care at scene or during transport and that emergency patients come usually to the hospital by themselves.
Only one service provider (1 out of 23) reported that the EMRS in Dhaka city was partially managed and The concerns of relatives of emergency patients and of service providers and managers were related to three groups of limitations of the current EMRS in Dhaka city:

1) Deficit of policy and inter-sectoral collaboration:
• Deficit of policy and guidelines for the operation of ambulances [7,9,[34][35][36] • Weak traffic laws and management regarding giving right to way to an ambulance • Absence of a common fare policy including health insurance practice • Lack of inter-sectoral collaboration and initiatives

2) Poor Structure of the Current EMRS System:
• The absence of a universal coordination centre with standardized phone numbers in Bangladesh (which was also documented in other studies) [7,[36][37][38][39].
• The low availability of ambulances due to the limited number (2.8 ambulances per 100,000 population), the misuse of ambulances and the low proportion of functional ambulances out of the existing ones (which was also reported form other cities in Bangladesh) [13,36,37,[39][40][41] • Poor ambulance equipment and lack of skilled staff for emergency care (ambulances were used like taxis as there was only the un-trained driver and no skilled staff) [38,39] • Absence of emergency physicians and trained rescue teams for pre-clinical care (studies in other countries -Germany, Switzerland, Japan, South Korea, and Trinidad and Tobago -showed that an ambulance equipped with skilled paramedics, essential medical devices and drugs as well as the short response time of 15 minutes was found to be crucial for the patient`s survival and positive clinical outcome [4,19,20,42,43].

3) Lack of Awareness in the Population on EMRS
• Absence of basic EMRS education in academic curricula and in professional training particularly for police and public transport drivers • Lack of training of lay people including school children and students to detect medical emergencies and to offer first aid • Lack of awareness in the general public about ambulance services including where to call and transport costs (The median payment for ambulance use in our study was -according to the relatives of emergency patients-31 Euros, which was much higher than the actual fare (3.4-10.3 Euros) [41].

Many of these limiting factors explain the long delays of emergency transport operations
The median delay times of ambulances from the call 82.6%); assure quality (ambulances with paramedics and equipment for basic emergency care), affordability (reasonable fixed fare) and availability of ambulances (17,73.9%); formulate policies and guidelines for dealing with ambulances on the street and in traffic jams (police to give preference to ambulances; general public to make space for ambulances in traffic jams; 16, 69.6%); offer awareness raising programs for the police and the public (15, 65.2%); monitor progress (12, 52.2%); establish universal coordination centre with a standardized phone number (11,47.8%); push for governmental initiatives and investment in EMRS (10, 43.5%); strengthen multi-sectoral coordination and management system (9, 39.1%); and promote health insurance which covers the costs of pre-hospital emergency care (7, 30.4%).

Discussion
The study aimed at contributing to improve the existing EMRS in Dhaka city, Bangladesh through a situational analysis and needs assessment of EMRS.

Burden of diseases in Dhaka related to deficient EMRS
Our document analysis of 2 major hospitals in Dhaka city showed that 45.9% of the deaths in 2014 were due to CVDs, RTIs, other accidents or injuries, and suicidal attempts. This is similar to the findings in other parts of Bangladesh [15,18,28,29]. These analyses showed also that the number of deaths from medical emergencies increased over the last decades in the country. Particularly the increase of CVDs in urban Bangladesh has reached alarming levels [15,18,28,30]. Also deaths due to disasters such as building collapse, fire, gas explosion, occupational accidents are increasingly important [12,14,17,31]. Likewise CDs (particularly acute diarrhoea, pneumonia, dengue fever in children), the leading causes of morbidity in Dhaka city [13,14], would often be fatal if emergency services cannot be ensured.
The scarcity of ambulances was found to be highly associated with an increased number of deaths due to medical emergencies in other South-Asian countries such as India and Pakistan [7,8]. Therefore WHO identified emergency medical care at scene as one of the core initiatives for preventing mortality and disability but also for reducing the treatment costs [2,4,6,11,32,33].

Deficient pre-clinical care of emergency patients
We quantified in our study the deficient transport of emergency patients in Dhaka city. We found that particularly rickshaws or motor-rickshaws were used for patient transport which is slow and uncomfortable for the patients. Studies in India and Pakistan also showed that over 70% of patients arrived at hospital by local transport and that many of these emergency patients die before reaching clinical care [7,8].
The response times of ambulances could be improved through (a) The increase number of ambulances [55,56], (b) The decentralization and reallocation of ambulances throughout the city (for this purpose the use of police and fire service stations might be helpful [56][57][58][59][60][61][62], and (c) The developing of an emergency lane for emergency vehicles.

Limitations of the Study
The present study had limitations. Other hospitals and rescue service providers and managers could not be included. Due to shortage of sufficient medical records (studied hospitals did not want to open), the results related to sudden deaths and disabilities are not representative for the whole city.
to getting the patient to hospital was 85 minutes (during the day 102 minutes and at night 45 minutes). The transportation delays were longer for ambulance users (60 minutes) than for local transport users (40 minutes). The total delay (time from the count to arriving at hospital) was unacceptably long: Median delays 360 minutes for ambulance users and 120 minutes for public transport users. This is similar to findings in other studies in Bangladesh [44][45][46] and in India 80% of the emergency patients arrived at hospitals with a delay of over one hour [47]. This is well above the rule that emergency patients should be treated at scene within 15 minutes [4,19,20,42,48].

Recommendations for improving the current EMRS situation in Dhaka city
A step-by-step approach is recommended based on the above described identified three groups of limitations of the current EMRS in Dhaka (Figure 7). Possible steps could be: First step: Strengthen inter-sectoral collaboration and formulate policy: Inter-sectoral collaboration is needed to formulate a Specific, Measurable, Achievable, Result-orient, Time-bound (SMART) policy for EMRS operations and management. In the SMART policy, a sector wide long-term (e.g., 10 years or more) target should be set and emphasis should be given to transparency and accountability. A common fare policy for ambulances also should be included in the policy.
Second step: Upgrade and improve the system: A standardized telephone assisted call centre should be installed to provide information and advice to scene and to deploy an emergency medical first responders (EMFRs) and an ambulance [2,19,21,49]. EMFRs (ranging from community volunteers to paramedics) should be formed to offer first aid at scene before arriving of To provide information & advice to scene To deploy an EMFR and an ambulance To decide and inform hospital for early response