Challenges to Use Response Time Standard in Assessing Emergency Medical Services in Iran: A Systematic Review


1 Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences,

2 Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences

3 1Safety Promotion and Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, 2Department of Health in Disaster and Emergency, School of Health Safety and Environment, Shahid Beheshti University of Medical Sciences

4 Antimicrobial Resistance Research Center, Rasoul-e-Akram Hospital, Department of Bio-Statistics, School of Public Health, Iran University of Medical Sciences, Tehran, IR Iran



Response time (RT) accounts as a common tool for emergency medical services (EMS) assessment. While the national standard RT has been
established in Iran since 2007, its application has hardly been put into scrutiny. This study aimed at investigating the use of RT standard in
assessing EMS in Iran. This systematic review included papers focusing on prehospital EMS assessment published in Google Scholar, Scopus,
Embase, PubMed, and the Persian databases of Magiran and SID. Selection criteria involved all English and Persian studies focusing on RT
as an assessment of prehospital EMS in the context of Iran. Repetitious papers and those presented in conferences were omitted, which left
21 papers published from 2007 to mid‑2016 for systematic review. A data collection form was designed. This provided both inclusive information
about the papers and indicators used to report RT in each paper (i.e., mean and percentages of RT below 8 min) as well as the use of these
indicators vis‑a‑vis that of the standard. From among the 21 papers focusing on RT, seven (33%) reported RT as percentages of operations
performed in the means of RT; nine studies compared mean and the national standard as expressed in percentage. Limited use of the national standard to
report RT was identified as a challenge to EMS assessment. Further, the inconsistency that exists when comparing RT in terms of means and
percentage is a challenge to the validity of judgments expressed in some previous studies. Employment of uniform methods to report and
evaluate performance based on the national standard will lead to greater transparency in emergency operation performance.


1. Tsai D, Choi B, Sullivan F, Williams KA. Quality improvement in EMS:
A unique and challenging necessity. R I Med J (2013) 2014;97:17‑9.
2. Al‑Shaqsi SZ. Response time as a sole performance indicator in EMS:
Pitfalls and solutions. Open Access Emerg Med 2010;2:1‑6.
3. El Sayed MJ. Measuring quality in emergency medical services:
A review of clinical performance indicators. Emerg Med Int
4. Fitch J. Response times: Myths, measurement & management. JEMS
5. Pons PT, Markovchick VJ. Eight minutes or less: Does the ambulance
response time guideline impact trauma patient outcome? J Emerg Med
6. Gonzalez RP, Cummings GR, Phelan HA, Mulekar MS, Rodning CB.
Does increased emergency medical services prehospital time affect
patient mortality in rural motor vehicle crashes? A statewide analysis.
Am J Surg 2009;197:30‑4.
7. Lim CS, Mamat R, Braunl T. Impact of ambulance dispatch policies
on performance of emergency medical services. IEEE Trans Intell
Transport Syst 2011;12:624‑32.
8. Carr BG, Caplan JM, Pryor JP, Branas CC. A meta‑analysis of prehospital
care times for trauma. Prehosp Emerg Care 2006;10:198‑206.
9. Blackwell TH, Kaufman JS. Response time effectiveness: Comparison
of response time and survival in an urban emergency medical services
system. Acad Emerg Med 2002;9:288‑95.
10. Bailey ED, Sweeney T, National Association of EMS Physicians.
Considerations in establishing emergency medical services response
time goals. Prehosp Emerg Care 2003;7:397‑9.
11. Trowbridge MJ, Gurka MJ, O’Connor RE. Urban sprawl and delayed
ambulance arrival in the U.S. Am J Prev Med 2009;37:428‑32.
12. National Highway Traffic Safety Administration. Emergency Medical
Services Performance Measures: Recommended Attributes and
Indicators for System and Service Performance. Washington, D.C.: U.S.
Department of Transportation; 2009. Available from: https://www.ems.
gov/pdf/811211.pdf. [Last accessed on 2017 Dec 09].
13. Price L. Treating the clock and not the patient: Ambulance response
times and risk. Qual Saf Health Care 2006;15:127‑30.
14. Shah MN, Bishop P, Lerner EB, Fairbanks RJ, Davis EA. Validation
of using EMS dispatch codes to identify low‑acuity patients. Prehosp
Emerg Care 2005;9:24‑31.
15. National Fire Protection Association. NFPA 1710: Standard for
the Organization and Deployment of Fire Suppression Operations,
Emergency Medical Operations, and Special Operations to the Public
by Career Fire Departments. National Fire Protection Association; 2010.
16. Institute of Medicine. Emergency Medical Services: At the Crossroads.
Washington: DC: Committee on the Future of Emergency Care in
the US Health System; 2006. Available from:
catalog/11629/emergency-medical-services-at-the-crossroads. [Last
accessed on 2017 Dec 09].
17. Nasiripur A, Bahadori M, Sh T, Gohari M. Prehospital emergency
performance in Iran view of comprehensive coverage plan. J Crit
Care Nurs 2010;2:3‑4. Available from:
dl/355bb22a-e709-11e6-9e28-b3f18273092c. [Last accessed on 2017
Dec 09].
18. Haghparast‑Bidgoli H, Saadat S, Bogg L, Yarmohammadian MH,
Hasselberg M. Factors affecting hospital length of stay and hospital
charges associated with road traffic‑related injuries in Iran. BMC Health
Serv Res 2013;13:281.
19. Akbari ME, Naghavi M, Soori H. Epidemiology of deaths from injuries
in the Islamic Republic of Iran. East Mediterr Health J 2006;12:382‑90.
20. Fazel MR, Fakharian E, Mahdian M, Mohammadzadeh M, Salehfard L,
Ramezani M, et al. Demographic profiles of adult trauma during a 5 year
period (2007‑2011) in Kashan, IR Iran. Arch Trauma Res 2012;1:63‑6.
21. Bahadori M, Ravangard R. Determining and prioritizing the
organizational determinants of Emergency Medical Services (EMS) in
Iran. Iran Red Crescent Med J 2013;15:307‑11.
22. Khorasani‑Zavareh D, Mohammadi R, Khankeh HR, Laflamme L,
Bikmoradi A, Haglund BJ, et al. The requirements and challenges in
preventing of road traffic injury in Iran. A qualitative study. BMC Public
Health 2009;9:486.
23. Mahdian M. Establishing an integrated trauma system in Iran: The time
of translating information into action. Arch Trauma Res 2015;4:e28117.
24. Modaghegh MH, Roudsari BS, Sajadehchi A. Prehospital trauma
care in Tehran: Potential areas for improvement. Prehosp Emerg Care
25. MacFarlane C, Benn CA. Evaluation of emergency medical services
systems: A classification to assist in determination of indicators. Emerg
Med J 2003;20:188‑91.
26. Khan KS, Kunz R, Kleijnen J, Antes G. Five steps to conducting a
systematic review. J R Soc Med 2003;96:118‑21.
27. 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 healthcare interventions:
Explanation and elaboration. BMJ 2009;339:b2700.
28. Safarabadi M, Pakniyat A, Darvishi A, Harorani M. The performance of
emergency medicine services for patients with suspected acute coronary
syndrome, Arak, Iran. J Iran Clin Res 2016;2:153‑7. Available from: [Last accessed on 2017 Dec
29. Delshad V, Shemshadi H, Moradian MJ, Ahmadi S, Malkyan L,
Sabzalizadeh S. The effect of applying global positioning system in
ambulances on response time of Tehran emergency medical service.
Health Emerg Disasters Q 2016;1:125‑8.
30. Mohammadi M, Nasiripour AA, Fakhri M, Bakhtiari A, Azari S,
Akbarzadeh A, et al. The evaluation of time performance in the
emergency response center to provide pre‑hospital emergency services
in Kermanshah. Glob J Health Sci 2015;7:274‑9.
31. Kazamneghad E, Pourshaikhian M, Vatankhah S. Quality survey of
pre‑hospital emergency services in Guilan province. J Guilan Univ Med
Sci 2015;23:50‑8. Available from:
920-en.pdf. [Last accessed on 2017 Dec 09].
32. Peyravi M, Khodakarim S, Örtenwall P, Khorram‑Manesh A. Does
temporary location of ambulances (“fluid deployment”) affect response
times and patient outcome? Int J Emerg Med 2015;8:37.
33. Paravar M, Hosseinpour M, Mohammadzadeh M, Mirzadeh AS.
Prehospital care and in‑hospital mortality of trauma patients in Iran.
Prehosp Disaster Med 2014;29:473‑7.
34. Aghababaeian H, Jamalpor M, Mosavi A, Ghanavati S, Rasoli S,
Haji‑araghi N. Investigation of causes, time indices, and results of
pediatric pre‑hospital emergency missions in emergency medical
centers affiliated to Dezful university of medical sciences, 2011‑2012.
Sadra Med Sci J 2014;2:289-298. Available from:
FileServer/JF/3004413930307. [Last accessed on 2017 Dec 09].
35. Bahrampouri S, Khankeh HR, Dalvandi A. Diagnosis and transfer
of stroke patients by emergency medical services: Case of Vali‑Asr
hospital, Arak. Health Emerg Disasters Q 2014;1:152‑60. Available
from: [Last
accessed on 2017 Dec 09].
36. Gholipour C, Vahdati SS, Notash M, Miri SH, Ghafouri RR. Success rate
of pre‑hospital emergency medical service personnel in implementing
pre hospital trauma life support guidelines on traffic accident victims.
Turk J Emerg Med 2014;14:71‑4.
37. Monsef V, Asadi P, Maleki Ziabari S. Investigating time
period and associated factors in delivering emergency services
Guilan (1390‑1392). J Guilan Univ Med Sci 2014;24:1-6. Available
from: [Last accessed on
2017 Dec 09].
38. Rahbar Taramsari M, Badsar A, Naghipour M, Dvam F, Shahrami H,
Saeidinia A, et al. Assessment of pre‑hospital emergency performance
in missions of 115 emergency bases of Rasht, Iran. Ann Biol Res
2013;4:75‑81. Available from: http://www.scholarsresearchlibrary.
of-115rnemergency-bases-of-rasht-iran-11460.html. [Last
accessed on 2017 Dec 09].
39. Peyravi M, Ortenwal P, Djalali A, Khorram‑Manesh A. An overview
of shiraz emergency medical services, dispatch to treatment. Iran Red
Crescent Med J 2013;15:823‑8.
40. Paravar M, Hosseinpour M, Salehi S, Mohammadzadeh M, Shojaee A,
Akbari H, et al. Pre‑hospital trauma care in road traffic accidents in
Kashan, Iran. Arch Trauma Res 2013;1:166‑71.
41. Hajinabi K, Riahi L, Gholipur Varaki H. The relationship between
prehospital time indices and on-scene death rate in traffi c accidents in
the 22 regions of Tehran. Health Inf Manage 2013;11:353-61. Available 
pdf. [Last accessed on 2017 Dec 09].
42. Moradian M, Peyravi M, Ettehadi R, Pourmohammadi K. Studying the
time of response and results of delay in emergency medical system.
J Rescue Relief 2013;5:30‑9. Available from:
152-fa.pdf. [Last accessed on 2017 Dec 09].
43. Soltani M, Asadi Manesh L, Rajabi Z. Predicting the time required for
Eslamshahr township emergency personnel to attend at the scene of a
disaster. J Rescue Relief 2012;4:67‑78. Available from:
article-1-131-fa.pdf. [Last accessed on 2017 Dec 09].
44. Bahrami MA, Maleki A, Ranjbar Ezzatabadi M, Askari R,
Ahmadi Tehrani GH. Pre‑hospital emergency medical services in
developing countries: A Case study about EMS response time in Yazd,
Iran. Iran Red Crescent Med J 2011;13:735‑8.
45. Bigdeli M, Khorasani‑Zavareh D, Mohammadi R. Pre‑hospital care time
intervals among victims of road traffic injuries in Iran. A cross‑sectional
study. BMC Public Health 2010;10:406.
46. Peyravi MR, Tubaei F, Pourmohammadi K. The efficiency of
motorlance in comparison with ambulance in Shiraz, Southern Iran. Iran
Red Crescent Med J 2009;11:330‑3. Available from:
FileServer/JE/88120090315. [Last accessed on 2017 Dec 09].
47. Panahi F, Mohebbi HA, Farahani MA, Vishteh HR, Assari S. Prehospital
emergency service for internal medicine problems in pediatrics; Causes,
time indices and outcomes. Iran J Pediatr 2007;17:179‑85. Available
[Last accessed on 2017 Dec 09].
48. Bidari A, Abbasi S, Farsi D, Saeedi H, Mofidi M, Radmehr M,
et al. Quality assessment of prehospital care service in patients
transported to Hazrat‑e‑ Rasoul Akram Hospital. Med J Tabriz Univ
Med Sci 2007;29:43‑6. Available from:
JF/58613860307. [Last accessed on 2017 Dec 09].
49. Pons PT, Haukoos JS, Bludworth W, Cribley T, Pons KA,
Markovchick VJ, et al. Paramedic response time: Does it affect patient
survival? Acad Emerg Med 2005;12:594‑600.
50. Sohn H, Reyes G, Escobar C. Optimizing the Performance of the Dona
Ana County Ambulance Service. 2014.
51. Roudsari BS, Nathens AB, Arreola‑Risa C, Cameron P, Civil I,
Grigoriou G, et al. Emergency Medical Service (EMS) systems in
developed and developing countries. Injury 2007;38:1001‑13.
52. Graham DH. Motivation for documentation. Emerg Med Serv
53. Dawson DE. National emergency medical services information
system (NEMSIS). Prehosp Emerg Care 2006;10:314‑6.
54. Rahman NH, Tanaka H, Shin SD, Ng YY, Piyasuwankul T, Lin CH,
et al. Emergency medical services key performance measurement in
Asian cities. Int J Emerg Med 2015;8:12.
55. O’Hagan J, Persaud D. Creating a culture of accountability in health
care. Health Care Manag (Frederick) 2009;28:124‑33.
56. Gunderson M. Principles of EMS system design. Emergency Medical
Services: Clinical Practice and Systems Oversight. 2nd ed. John Wiley &
Sons, Ltd; 2015. p. 1-16.
57. Fahimi Y. EMS and its role in disaster medicine. Resuscitation and Life
Support in Disasters, Relief of Pain and Suffering in Disaster Situations.
Springer, Berlin, Heidelberg. 1980. p. 265-7. Available from: https:// [Last
accessed 2017 Dec 09].