Examine the usage of prehospital EMS across rural and urban areas in Riyadh region in the Kingdom of Saudi Arabia.

O P E N A C C E S S Research article

Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison Ahmed Ramdan M Alanazy, Stuart Wark, John Fraser, Amanda Nagle

ABSTRACT

Background: There is limited research outside the USA, Europe, or Australia on the capacity, efficiency,

and development of prehospital emergency medicine services (EMS) between urban and rural areas.

This study aimed to examine the usage of prehospital EMS across rural and urban areas in Riyadh

region in the Kingdom of Saudi Arabia.

Methods: A random sample of 800 (400 urban and 400 rural) emergency patient records from the

Saudi Red Crescent Authority EMS was collected. The following variables were analyzed: patient

demographics, clinical characteristics, length of hospital stay, and length of intensive care unit (ICU)

stay.

Results: A skewed distribution was noted with respect to sex, i.e., 559 men versus 241 women. Rural

patients were younger (42.75 vs. 39.72 years) and had significantly longer hospital (15 days versus

9 days) and ICU (5 days versus 2 days) stays than urban patients following transportation. All injury

types were comparable, except for head injury, which was higher in the rural group than in the urban

group. Advanced treatment and trauma transport were more often used in rural areas than in urban

areas.

Conclusions: In this study, rural EMS users were more likely to experience trauma-related incidents that

necessitate EMS transportation, while medical reasons were more common among urban EMS users.

Moreover, men used EMS at much higher rates than women and were more likely to be transported to

the hospital following a call-out.

Keywords: Rural; Urban; Emergency Medical Services; Saudi Arabia; Riyadh

Cite this article as: Alanazy ARM, Wark S, Fraser J, Nagle A. Utilization of prehospital emergency medical services in Saudi Arabia: An urban versus rural comparison, Journal of Emergency Medicine, Trauma & Acute Care 2020:9 http://dx.doi.org/10.5339/jemtac.2020.9

http://dx.doi.org/ 10.5339/jemtac.2020.9

Submitted: 20 May 2020 Accepted: 21 September 2020 ª 2020 Alanazy, Wark, Fraser, Nagle, licensee HBKU Press. This is an open access article distributed under the terms of the Creative Commons Attribution license CC BY- 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.

School of Rural Medicine, Faculty of

Medicine and Health, University of New

England, Australia

*Email: aalanazy@myune.edu.au

INTRODUCTION

For a patient requiring urgent medical assistance, due to either traumatic injury or acute illness, one of

the most significant factors affecting their short- and long-term health prognosis is time. 1 In particular,

the time period before a patient starts receiving healthcare support, usually on site from an emergency

medicine services (EMS), is considered a critical aspect of improving mortality rates and reducing both

the magnitude and longevity of illness or incapacitation of an individual. 2 Similarly, the quality of EMS

support, both initially and then during transportation to a clinical setting, can influence patient

outcomes.

While there is existing research on the availability of EMS in different countries, there is less

consistent evidence on the capacity, efficiency, and development of prehospital EMS structures across

disparate geographic locations. However, some studies have reported a significant difference in EMS

services between urban and rural areas within countries. 3,4

A recent systematic review concluded that

EMS in rural areas were more likely to have longer response times, transport times, prehospital times,

and on-scene times than urban areas. In addition, almost all relevant research was undertaken in the

USA, Europe, or Australia. 5 As a simple example of how this difference manifests in patient outcomes,

Jennings et al. 6 noted that the survival rate of patients following an emergency cardiac event was

considerably higher in urban areas than in rural areas. Other studies have found a significant difference

between urban and rural models as regards response and time transfer and that urban EMS are

generally associated with enhanced performance measures, which in turn increased the survival rates

of patients, compared with rural EMS. 7,8

This study aimed to establish a general picture of patients’ usage of prehospital EMS within the

Riyadh region in the Kingdom of Saudi Arabia, with a specific focus on any variation in patient

presentation between urban and rural locations. A literature search did not reveal any research in

Riyadh that specifically examined this issue, and only a few studies were conducted outside the USA,

Europe, and Australia that compared urban versus rural EMS outcomes. This paper is part of a larger

research project examining issues associated with the performance of EMS in rural and urban locations

within Saudi Arabia.

METHODS

Study design and setting

A cross-sectional study was conducted using emergency patient records (EPRs) collected over a period

of one year from January 1, 2017, to December 31, 2017, by the Saudi Red Crescent Authority EMS in the

Kingdom of Saudi Arabia. The Saudi Red Crescent Authority started providing EMS in the Kingdom in

the early 1930s, and remains the primary provider of EMS in the Kingdom. 9 Ethical approval was

obtained from the University of New England’s Human Research Ethics Committee, Saudi Arabia

Ministry of Health Ethical Committee, King Abdelaziz Medical Cities Ethical Committee, and Saudi Red

Crescent Authority.

The geographic setting for this study was the Riyadh region in the Kingdom of Saudi Arabia. Riyadh is

one of the 13 administrative regions and is located approximately in the center of the country. Initially,

the project planned to focus on data from the Makkah administrative region, as it has the largest

population base and highest EMS transportation rates. However, following a review of the region’s

general demographic data, it was not considered representative of all of Saudi Arabia. It has significant

religious events (pilgrimage) that result in large numbers of international visitors; the General Authority

for Statistics noted an annual 1.8 million visitors to the region. 10 Riyadh, the region with the second

highest number of transported cases, was then reviewed and ultimately selected as the data source. 11

Riyadh region has an estimated population of eight million people, who live across a geographic area

of 400,000 km 2 , and includes the capital city of Saudi Arabia, also called Riyadh. In accordance with

the geographic classification provided by the Saudi Red Crescent and use of EPR forms, individuals

residing in Riyadh City were considered ’urban,’ while all other areas of Riyadh region were defined as

‘rural.’

Data collection and analysis

A random sampling method was employed to select EPRs included in this study. While it would have

been preferable to include all EPRs, there were no comprehensive electronic datasets of patient records

available; therefore, each hard copy was physically read and data manually transcribed. To ensure a

Page 2 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

suitable sample, a sample size was calculated prior to the commencement of the project 12 and was

determined to be 392 EPRs. Prior to data collection, 400 EPRs would be selected from urban areas and

400 EPRs would be selected from rural areas, resulting in a total sample of 800.

The 800-item dataset was sourced from the hardcopy EPRs created following an EMS response to

each emergency call-out. EPRs were stored at the Saudi Red Crescent central office in Riyadh City,

including all forms submitted from each of the 78 EMS stations (30 rural and 48 urban sites) in Riyadh

region. The files were selected using a computer-generated random number list, with a supervisor from

Saudi Red Crescent, and all records that were randomly selected were then de-identified. These files

were then provided to the lead author, and data were transcribed into IBM SPSS Statistics for Windows

version 25 (IBM Corp., Armonk, NY, USA). Simple descriptive statistics were used to describe the cohort

profile, while Chi-square tests were used for comparison purposes.

The following variables were collected from the EPRs:

1. Patient demographics

Demographic data included age, sex, and residential location (rural or urban).

2. Clinical characteristics

Clinical characteristic data included the on-scene outcome (treatment, nontreatment, transfer to

hospital), type of on-site care provided (airway, breathing, circulation, extrication or immobilization),

general classification of illness/injury (medical or trauma), and specific classification of illness/injury

(head injury, dizziness, etc.).

3. Length of hospital stay

The length of stay in hospital was noted in whole days.

4. Length of intensive care unit (ICU) stay

The length of stay in an ICU was noted in whole days.

RESULTS

Differences in patient demographic data by sex

On initial inspection, there was a clear skew in data with respect to sex. Overall, the sample was

composed of 559 men and 241 women. There was also a difference between sexes in terms of age,

where female EMS users (41.2 years) were slightly older on average than male EMS users (39.72 years).

Basic support on the scene was far more common than advanced treatment for both sexes, with 551

men and 237 women receiving basic support in contrast to just eight male EMS users and four female

EMS users receiving advanced treatments. There were 18 male deaths and three female deaths on

scene. For male EMS users who were transported to a hospital from the scene, the reasons for

transportation were evenly divided, with 282 for medical reasons and 277 for trauma reasons. This

pattern was quite different for female EMS users, with 189 transports for medical reasons and 52 for

trauma reasons, which represented a ratio of 3.6 medical cases to every one trauma case. Table 1

provides a summary of the key patient data for both male and female EMS users. The incident type ‘no

medical care provided’ refers to situations in which patients were transferred between locations for

Table 1. Key patient data for sex

Variables Male Female Sig. (p values)

Patient taken from scene to hospital Yes 70 32 0.046* Incident type No medical care provided 18 6 0.578

Fracture/laceration 94 17 ,0.001* Head-neck injury 85 15 ,0.001* Chest injury 22 3 0.045* Dizziness 61 41 0.018* Wound/burn 37 9 0.108 Cardiorespiratory 22 10 0.887 Gastrointestinal 25 14 0.420 Neurological 14 13 0.830 Respiratory 34 19 0.347 Others 147 94 ,0.001*

Page 3 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

treatments, such as for hemodialysis, and where the EMS was not required to provide any medical

interventions.

Significant differences were noted in EMS usage between male and female EMS users. Male EMS

users are more significantly likely than female EMS users to be taken to a hospital following an EMS

call-out or to experience a fracture/laceration, head–neck injury, chest injury, or dizziness. Data for the

incident type ‘others’ was also statistically significant, but the lack of details provided in the EPRs on

this category makes any analysis attempts meaningless.

Differences in patient demographic data by location

The sample was deliberately composed of an equal number (n ¼ 400 each) of urban and rural

residents. The urban group was composed of 264 (66%) male EMS users and 136 (34%) female EMS

users, while the rural group included 295 (73.8%) male and 105 (26.3%) female EMS users. The mean

age of the urban group was 42.75 years, while this dropped to 39.72 years for the rural cohort.

The number of advanced treatments was small overall when considered by geographic location. In

total, 398 urban and 390 rural residents received basic treatment on scene, compared with just two

urban and 10 rural people who received advanced treatment. The number of deaths on scene (n ¼ 13)

was higher in rural areas than in urban ones (n ¼ 8), but the overall death rate was low. Medical

reasons were more common reasons for transportation to hospital for urban EMS users (259 medical

versus 141 trauma), which represents a ratio of 1.8 medical case for each one trauma case. However,

this difference was smaller in rural locations (212 to 188), with a ratio of 1.1 medical case to one trauma

case. Key demographic data are outlined in Table 2. Two significant differences were found between

urban and rural EMS users: rural residents were more likely to experience fractures/lacerations, while

urban residents were at greater risk of wounds/burns.

Clinical characteristics: urban versus rural

A further analysis was undertaken to examine differences in the clinical characteristics of urban versus

rural residents. Table 3 summarizes the difference in the presentation of body injury or illness

according to the patient’s geographic location. Head, face, and extremity injuries were more common in

rural areas, while chest, abdomen, and back injuries were more common in urban areas; however, no

significant difference was found between the groups, except for head injuries, which were higher in

rural than in urban areas ( p ¼ 0.018). Otherwise, no other significant differences were observed based

on injury type with respect to location.

The injury type, as opposed to the presentation of injury or illness, is outlined in Table 4. The patient

outcome, in terms of the length of stay either in a hospital or an intensive care unit, is also noted. The

lengths of stay for patients transported by EMS specifically into an ICU and generally in hospital are

both significantly shorter in urban than in rural areas (p , 0.001).

No significant difference was found between urban and rural patients in terms of the provided care

(Table 5) for airway treatment, breathing treatment, and extrication and immobilization treatment.

However, a significant difference was found for circulation treatment, with urban patients more likely to

receive this treatment.

Table 2. Key patient data for urban and rural areas

Variables Urban Rural Sig. (p values)

Patient taken from scene to hospital Yes 43 59 0.114 Incident type No medical care provided 15 9 0.214

Fracture/laceration 45 66 0.032* Head-neck injury 43 57 0.134 Chest injury 15 10 0.310 Dizziness 53 49 0.672 Wound/burn 31 15 0.015* Cardiorespiratory 17 15 0.718 Gastrointestinal 20 19 0.870 Neurological 15 12 0.557 Respiratory 27 26 0.887 Others 119 122 0.817

Page 4 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

DISCUSSION

Prehospital EMS are a critical element of modern health systems, and their performance is a vital

component of any care model designed to improve patient outcomes associated with traumatic

injuries and time-sensitive diseases. 1 However, there is still a significant need for current research to

provide information on the strengths and weaknesses of prehospital EMS and particularly in relation to

key demographic differences across rural and urban areas. A recent systematic review noted that

almost all research undertaken in this area has focused on the USA, Europe, or Australia. 5 The

likelihood of service discrepancies between rural and urban settings is arguably even higher in lower

resourced countries due to the inaccessibility of health services in rural areas, with identified key

factors potentially affecting patient outcomes. 13

The present study examined a random sample of 800 EMS users within the Riyadh region in the

Kingdom of Saudi Arabia. The purpose of this study was to establish a profile of both urban and rural

EMS patients and to compare key demographic variables so as to identify any differences in outcomes.

Table 4. Injury type and length of stay in hospital or intensive care unit

Variable Urban Rural Sig. (p values)

Length of stay in hospital (days) 9 15 ,0.001* Length of stay in ICU (days) 2 5 ,0.001* Problem type No medical care provided 15 9 0.214

Fracture/laceration 45 66 0.03* Head-neck injury 43 57 0.134 Chest injury 15 10 0.310 Dizziness 53 49 0.672 Wound/burn 31 15 0.150 Cardiorespiratory 17 15 0.718 Gastrointestinal 20 19 0.870 Neurological 15 12 0.557 Respiratory 27 26 0.887 Others 119 122 0.817

Table 5. Patients’ treatment and progression frequency

Items Frequency Frequency Sig. (p values)

Urban Rural

Provide airway treatment Yes 16 15 0.999 No 384 385

Provide breathing treatment Yes 169 167 0.943 No 231 233

Provide circulation treatment Yes 147 111 0.008* No 253 289

Provide extrication and immobilization treatment Yes 96 103 0.624 No 304 297

Table 3. Presentation of injury or illness

Variables Frequency Sig. (p values)

Urban Rural

Head injury/illness Yes 43 67 0.018* No 357 333

Facial injury/illness Yes 12 20 0.206 No 388 380

Chest injury/illness Yes 20 18 0.868 No 380 382

Abdominal injury/illness Yes 20 16 0.609 No 380 384

Back injury/illness Yes 40 35 0.628 No 360 365

Extremity injury/illness Yes 76 94 0.142 No 324 306

Page 5 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

Initial examination indicated a skew in data with respect to sex, so data analyses were performed

separately with respect to both sex and geographic location. The findings associated with these

analyses are discussed below.

Differences by sex

The reasons for transport from the scene were categorized as either medical or trauma. The data showed

nearly equal numbers for male EMS users, with 282 for medical reasons and 277 for trauma reasons.

However, this pattern was quite different for female EMS users, with 189 medical reasons and 52 trauma

reasons. The reasons for this skewness are not possible to determine accurately in a cross-sectional

study; however, it is consistent with a previous study in Turkey showing that men use EMS at a higher rate

than women, 14 although this finding contrasts with those in countries such as Australia and USA where

an equal number of men and women utilize EMS. 15 Compared with previous studies, the percentage of

using the ambulance according to sex were almost the same without huge differences. 16–18

The precise

reasons are impossible to determine definitively, but it is hypothesized that men in Saudi Arabia are

likely to have high exposure to potential traumatic events arising from high-speed vehicular accidents or

higher-risk workplaces. 19 In this study, there were 18 male deaths and three female deaths on scene, and

this difference was believed to be due to men’s higher risk for significant trauma.

A difference was found between men and women with respect to the reason of transport to a hospital

from the scene. For men, there was little distinction between those transported for medical reasons,

such as illness and injury arising from trauma. However, over 3.5 times as many women were

transported following a medical event than following a traumatic event. Men were also more likely than

women to be taken to hospital and to have fractures or lacerations, head–neck injuries, or chest

injuries. These differences are believed to arise from the fact that women have low exposure to

potential risk factors that may result in traumatic injury, and there is little that EMS could do to

proactively prevent the occurrence of such injuries in men. However, further research into these

observed differences is recommended to better understand whether EMS needs to change on-scene

management and transportation to address these issues.

Differences by geographic location

Our data showed that medical problems were nearly twice as common as trauma when considering the

reasons for transportation to hospital for urban EMS users. However, this difference was much smaller

in rural areas than in urban areas and was close to parity with 1.1 medical problems for every trauma. As

noted above in the section regarding sex differences, this difference was considered largely due to the

increased risks of experiencing traumatic injuries arising from high-speed vehicular accidents or from

farming or industrial workplaces. While there is limited research data from Saudi Arabia, studies

conducted in USA and Sweden indicate that rural trauma cases often result in more severe injuries than

urban cases. 20,21

The number of deaths on scene (n ¼ 13) was higher in rural than in urban areas

(n ¼ 8), but the overall numbers were low.

Although the numbers were low, rural residents were significantly more likely to have longer hospital

or ICU stay after being transported by EMS. This finding is inconsistent with those in other countries,

with studies in the USA and Europe not reporting any significant differences in ICU and hospital stay

between rural and urban EMS users. 22,23

It was not possible to determine the severity of injury or illness

from the EMR forms; therefore, comparisons of whether rural patients had more serious health issues

than urban patients could not be established. This issue requires additional exploration to consider

whether rural factors, such as workplace exposures, may explain this difference. However, rural EMS

may have lower levels of training and/or availability of equipment, 1–5

and this could account for some

of the variance; thus, further research is required to examine this issue in more detail.

Another issue recommended for follow-up research is to evaluate whether there are any differences

in response time and on-scene time for urban and rural EMS users, as this has been observed both in

Saudi Arabia and in other countries. 5 The present data showed that rural people were five times as

likely to receive advanced treatment, although the overall numbers were small. In other settings, any

delays to the commencement of life-saving treatments, such as those that are likely to occur after

significant trauma, may increase the need for advanced on-site treatment and lead to worse overall

health outcomes for patients. 1,2,6–8

In rural areas, geographic distances that will naturally result in

longer response times and longer subsequent transportation times to a major healthcare setting are

key factors that require more detailed analysis within Saudi Arabia.

Page 6 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

LIMITATIONS

This cross-sectional study examined a random sample of 800 cases in the final dataset. While this

sample size is sufficient with respect to the initial power calculation, it would have been desirable to

include every EMS case in the Riyadh region. As EMS records were not electronic, data were manually

extracted from original hard copies, and collating all such data was beyond the scope of this project.

CONCLUSIONS

Analysis of this cross-sectional dataset by both geographic location and sex identified a number of key

issues. One of the main differences was the greater likelihood of rural EMS users to experience trauma-

related incidents that necessitate EMS transportation, while medical reasons were more common

among urban EMS users. Moreover, men used EMS at much higher rates than women and were more

likely to be transported to hospital following a call-out. Exploring the reasons for these findings was

beyond the scope of the current study; thus, further investigation is required to better understand the

observed outcomes.

Conflict of interest

There were no conflicts of interest, perceived or otherwise. There is no funding to declare.

REFERENCES

[1] Chng CL, Collins J, Eaddy S. A comparison of rural and urban emergency medical system (EMS) personnel: a Texas study. Prehosp Disaster Med. 2001;16(3):159–165.

[2] Choo E, Newgard C, Lowe R, Hall M, McConnell KJ. Rural-urban disparities in emergency department intimate partner violence resources. West J Emerg Med. 2011;12(2):178–183.

[3] Fatovich DM, Phillips M, Langford SA, Jacobs IG. A comparison of metropolitan vs rural major trauma in Western Australia. Resuscitation, 2011;82(7):886–890.

[4] Mihalicz D, Phillips L, Bratu I. Urban vs rural pediatric trauma in Alberta: where can we focus on prevention? J Pediatr Surg. 2010;45(5):908–911.

[5] Alanazy ARM, Wark S, Fraser J, Nagle, A. Factors impacting patient outcomes associated with use of emergency medical services operating in urban versus rural areas: a systematic review. Int J Environ Res Public Health. 2019;16(10):1728.

[6] Jennings PA, Cameron P, Walker T, Bernard S, Smith K. Out-of-hospital cardiac arrest in Victoria: rural and urban outcomes. Med J Aust. 2006;185(3):135–139.

[7] Gonzalez RP, Cummings G, Mulekar M, Rodning CB. Increased mortality in rural vehicular trauma: identifying contributing factors through data linkage. J Trauma Acute Care Surg. 2006;61(2):404–409.

[8] Newgard CD, Fu R, Bulger E, Hedges JR, Mann NC, Wright DA, et al., Evaluation of rural vs urban trauma patients served by 9-1-1 emergency medical services. JAMA Surg. 2017;152(1):11–18.

[9] AlShammari T, Jennings P, Williams B. Evolution of emergency medical services in Saudi Arabia. J Emerg Med Trauma Acute Care. 2017; 4:1–11.

[10] General authority for statistics. Saudi Arabia health statistics. https://www.stats.gov.sa. Accessed April 12, 2020. [11] Saudi Red Crescent Authority. Saudi Red Crescent Authority Statistics. https://www.srca.org.sa/en/Statistics/open-

data. Accessed April 2, 2020. [12] Kadam P, Bhalerao S. Sample size calculation. Int J Ayurveda Res. 2010; 1(1): 55–57. [13] Aftyka A, Rybojad B, Rudnicka-Drozak E. Are there any differences in medical emergency team interventions between

rural and urban areas? A single-centre cohort study. Aust J Rural Health. 2014;22(5):223–228. [14] Sariyer G, Ataman, MG, Sofuoğlu T, Sofuoğlu Z. Does ambulance utilization differ between urban and rural regions: a

study of 112 services in a populated city. Izmir. J Public Health. 2017;25(4):379–385. [15] Weiss S, Ernst A, Phillips, J, Hill B. Gender differences in state-wide EMS transports. Am J Emerg Med, 2000;18(6):666–

670. [16] Toloo S, Fitzgerald G, Rego J, Tippett V, Quinn J. Age and gender differences in ambulance utilisation in Queensland.

https://eprints.qut.edu.au/40191/. Accessed 2 April, 2020. [17] Norman C, Mello M, Choi B. Identifying frequent users of an urban emergency medical service using descriptive

statistics and regression analyses. West J Emerg Med, 2016;17(1):39. [18] Knowlton A, et al., Patient demographic and health factors associated with frequent use of emergency medical

services in a midsized city. Acad Emerg Med, 2013;20(11):1101–1111. [19] World Bank. Gender Portal Data – Saudi Arabia – Labor Force. http://datatopics.worldbank.org/gender/country/saudi

-arabia. Accessed March 5, 2020. [20] Beillon L, Suserud B-O, Karlberg I, Herlitz J. Does ambulance use differ between geographic areas? A survey of

ambulance use in sparsely and densely populated areas. Am J Emerg Med, 2009;27(2):202–211. [21] Newgard C, et al., Evaluation of rural vs urban trauma patients served by 9-1-1 emergency medical services. JAMA

Surgery, 2017;152(1):11–18. [22] McCowan C, Swanson E, Thomas F, Handrahan D. Outcomes of blunt trauma victims transported by HEMS from rural

and urban scenes. Prehosp Emerg Care, 2007;11(4):383–388. [23] McGuffie A, et al., Scottish urban versus rural trauma outcome study. J Trauma Acute Care Surg, 2005;(3):632–638.

Page 7 of 7

Ahmed et al.. Utilization of prehospital emergency medical services in Saudi Arabia 2020:9

https://www.stats.gov.sa
https://www.srca.org.sa/en/statistics/opendata
https://www.srca.org.sa/en/statistics/opendata
https://eprints.qut.edu.au/40191
http://datatopics.worldbank.org/gender/country/saudi-arabia
http://datatopics.worldbank.org/gender/country/saudi-arabia