Prehospital emergency care for trauma victims in Nepal: a mixed-methods study

Article history

The contractual start date for this research was in July 2017. This article began editorial review in February 2023 and was accepted for publication in March 2024. The authors have been wholly responsible for all data collection, analysis and interpretation, as well as for writing up their work. The Global Health Research editors and publisher have tried to ensure the accuracy of the authors’ article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.

Copyright statement

Copyright © 2024 Banstola et al. This work was produced by Banstola et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

2024 Banstola et al.

Study design

This case study used mixed methods (secondary data analysis and qualitative semistructured interviews). The use of quantitative and qualitative approaches, in combination, provides a better understanding of the research problem than either approach alone.

Study setting

The NAS was selected for the case study because it is the largest prehospital emergency care provider in the country, providing services in three out of the seven provinces in Nepal – Bagmati Province (Kathmandu Valley and Bharatpur/Chitwan); Gandaki Province (Pokhara); and Lumbini Province (Butwal). The Kathmandu Valley is the most developed and populated (2.5 million population) area of Nepal, which includes the city of Kathmandu (capital), Lalitpur, Bhaktapur, Kirtipur and Madhyapur Thimi. Chitwan (579,984 population) is a lowland plain region, while Pokhara (414,141 population) is a hilly region, and Butwal (118,462 population) is a combination of hills and plains. The NAS provides fully equipped ambulances via a central dispatch facility with radio communication between area hospitals and ambulances, along with medical care by trained EMTs on the way to the hospital. 18–20 In addition, the NAS has established a three-digit emergency phone number (102) which could, in the future, form the basis of a national phone number to summon assistance following acute illness or injury. Therefore, the NAS has the scale of organisation and workload to explore our research questions.

Study participants

For the qualitative component of the study, we interviewed a diverse group of staff employed by the NAS, including ambulance drivers, EMTs, dispatch officers and service managers. The number of participants was based on the concept of information power proposed by Malterud et al. 27 We asked the gatekeepers of NAS to help us identify potential participants and to reassure potential participants that they have permission from NAS to participate in the study. The participants were selected purposively using a sampling frame to ensure participation across the breadth of roles within the organisation.

Data collection

Written permission from NAS was obtained to access its call records and interview the staff.

Data management

Data analysis

Patient and public involvement

The study was supported by a prehospital care stakeholder advisory group. The group did not involve patients or members of the public.

Quantitative findings

A total of 9182 callouts were handled between May 2019 and May 2020. Of these, 1408 (15.3%) were trauma calls (including calls to transport trauma victims between hospitals). Of the 1408 trauma calls, 682 (48.4%) were trauma callouts for which prehospital care or EMS were provided for injured patients before they reached a hospital. Of the total 682 prehospital trauma cases, 60.7% were male and 39.3% were female, with a median age of 43 (interquartile range; 27–65 years). People aged over 60 years old were the largest group of service users (32.0%), followed by those aged between 18 and 29 years old (24.2%) (Tables 1 and 2).

Falls were the most common injury mechanism (35.8%), followed by road traffic crashes (19.1%). The mechanism of injury was unspecified in 31.4% of cases (see Table 1).

Fractures accounted for 33.1% of cases, followed by suspected spinal injury (10.1%). The type of injury was not specified in 27.6% of cases (see Table 2).

Table 3 shows the mean values of different time intervals in handling trauma cases by the prehospital care providers. On average, ambulances were dispatched within 2 minutes of the call being received, and the ambulance arrived at the scene in an average of 15 minutes (range 3–68 minutes). EMTs spent an average of 10 minutes at the scene providing care before taking an average of 17 minutes to transport the patient to the hospital (range 2–285 minutes). The total mean prehospital time interval from receiving a call to arrival at the hospital was 48 minutes.

Qualitative findings

We invited 18 staff employed in the NAS to participate in the qualitative study. Seventeen participants agreed to participate and were interviewed in February and March 2021; eight worked as EMTs, five worked as ambulance drivers, two as dispatch officers and two worked in managerial positions. One staff member declined to participate because he was unavailable during the data collection period. Participants ranged in age between 24 and 62 years. All EMTs had a mandatory vocational degree as either a community medicine assistant or an auxiliary nurse midwife. Participants in the managerial positions had a master’s degree, while the dispatch officers had bachelor’s degrees in management. Four out of five ambulance drivers had not completed their secondary education. Further demographic information of the participants is presented in Table 4. Interviews lasted an average of 42 minutes.

Thematic analysis of the transcript data led to the identification of a framework through which to describe factors affecting prehospital care. Participants’ narratives identified issues during four key periods of provision of care which were presented as themes: (1) Getting to the scene, (2) Action at the scene, (3) Getting to hospital and (4) Arrival at hospital. Within each of these themes, two or three subthemes were identified (Figure 1).

FIGURE 1.

A diagrammatic representation of themes and subthemes.

The term ‘accident’ is no longer used in injury prevention research. 29 However, the study participants used the word ‘accident’ to describe road traffic crashes and injuries. Hence, the word appears in participants’ quotes.

Actions of patients, their relatives and public affecting access to the scene

The dispatch officers in the head office of NAS receive calls from the public. They take details of the patient, such as name, age, location and chief complaint. They then forward the details to EMTs through a walkie-talkie, and the EMTs follow up on the patient’s call to get more detailed information. Most EMTs and dispatchers reported that the callers were sometimes anxious about their relatives and did not provide detailed patient information. Some EMTs reported that people at the scene would call several ambulance providers and use whichever one arrived first. Such actions sometimes meant that when they arrived on scene, the patient had already left and hence they were not required to provide treatment or transportation.

We call them before we leave, and they [the public] instruct us to come, but upon reaching the specified location, people tell us they went in another ambulance.

P4 – EMT

Emergency medical technicians and dispatch officers expressed concern about the hoax calls they received. They reported that hoax calls blocked telephone lines from people who needed an ambulance. In addition, the EMTs complained that when they arrived at the given location and found nothing, the original caller had their phone turned off or the line was busy. One dispatch officer described how threatened she felt when she received hoax calls or heard unacceptable language from the caller.

These fake calls make things very difficult for us. Some people say whatever they want, they use unacceptable language that gives us goosebumps, and yet we still have to respond to the call. We have previously discussed this matter with senior managers, but nothing has been done. Even the police acknowledge that such cases occur everywhere and it cannot be resolved.

P13 – Dispatch officer

Delay in reaching scene

The EMTs and the drivers reported several factors, such as heavy traffic, poor road conditions and public protests, which led to delays in reaching the scene. Ambulance drivers said they use the siren to help navigate through the traffic and are supported by the traffic police in normal circumstances. However, some EMTs and ambulance drivers felt that when there are protests or delays due to traffic being held back to allow very important persons (VIPs) to travel, the police do not prioritise the ambulance getting through. Three of the EMTs suggested that there should be a separate lane designated for ambulances, with one participant suggesting a separate lane could allow all emergency vehicles to travel, including ambulances, fire engines, police vans or hearses. Other EMTs suggested having a single national emergency number so that the traffic police can promptly get the message and manage traffic before the arrival of an emergency vehicle. One EMT said that road users should show empathy towards the victim by allowing ambulances to move through a traffic jam.

Regarding traffic control, it would be beneficial to have a single hotline number for all emergency services, similar to those used abroad.

P1 – EMT

In addition to congestion, most of the EMTs and the drivers reported that the poor road conditions, including potholes, meant that ambulances needed to drive slowly, hence creating a delay in reaching the scene. One of the EMTs complained that most of the time, information about road blockages due to construction was poorly communicated, causing them to have to look for alternative routes when trying to reach the patient. Because of the delays in reaching the patients, many EMTs and drivers found that the patient’s family or relatives had found alternative means to get to the hospital such as taxis as they are readily available. Some EMTs shared incidences where these delays led to the patient’s death, to which they expressed feeling helpless for not being able to save the patient.

If the patient’s family does not inform us about the condition of the road and only provides us with the location, instructing us to reach there, then we have to find an alternative way to reach the location, which takes time.

P7 – EMT

Some EMTs and one driver reported they sometimes have difficulty identifying the location of the emergency. They think that this is due to the caller being unsure of their location, putting this down to the high influx of people into Kathmandu valley from other districts. In addition, one EMT advised that the situation worsened when there was poor phone network coverage, as they could not communicate with the patient’s family or relatives over the phone. Hence, he suggested that the availability of global positioning system (GPS) devices inside an ambulance would make it easier to identify the location of the call, especially at night when there are fewer people on the streets who can direct the ambulance to the patient’s house.

We can identify the area from the place’s name, but it is challenging to identify the home. Most of our patients are from outside the valley, and some live in huts or tin sheet houses, which can make it difficult for us [to locate them]. Nevertheless, they can identify us, so we ask people to come to the road and wave to us when they see our vehicle.

P5 – Driver

Systems in place within Nepal Ambulance Service to aid in getting to the scene

One of the dispatch officers talked about the systems used by the NAS that eased work. She said that using a walkie-talkie had enabled her to communicate easily with the ambulance drivers and EMTs at different stations. She added that the availability of a navigation system (e.g. GPS tracker) at the central office helps understand where the ambulances are heading and provides real-time information on their location. The system allowed the dispatch officers to assign a new case to the ambulance staff on that particular route.

A GPS tracker allows us to monitor the real-time location of our ambulances and the direction they are heading. In case of an emergency call, we use GPS to track all the ambulances and assign the case to the ambulance on that particular route.

P11 – Dispatch officer

The same dispatch officer also highlighted the need to use criteria-based dispatch when prioritising ambulance calls. Patients can request an ambulance to take them to the hospital for a follow-up appointment. She reported the practice of prioritising ambulance services to emergency cases when the service is receiving multiple calls.

We determine whether a case is an emergency or a regular follow-up. Sometimes, regular follow-up cases may coincide with an emergency case, so we ask those who are going for a follow-up visit to wait.

P11 – Dispatch officer

Low awareness about the role of prehospital care among public and police

The EMTs and the drivers perceived that many of the public and police were unaware of NAS’s prehospital care service, believing that the role of NAS was just limited to transporting patients. Most EMTs and a few drivers reported that when attending road traffic crashes, patients’ families, the general public and police rush to transport the victims without appropriate stabilisation or first aid. One driver reported that the public and police transfer road crash victims in a way that people pack their things in a sack. The study participants (EMTs and drivers) claimed the public lacked awareness of the importance of carefully handling the patient at the scene. The EMTs provided numerous incidents where the victims could have died had they not been provided with prehospital care.

Patients may experience internal bleeding, bleeding from head injuries, or any other wound. These patients require bleeding control and fluids, which may cause a slight delay, but it is better for their long-term health. However, sometimes the public transfers patients in vehicles without controlling bleeding or providing fluids. By the time the patient reaches the hospital, they may have died due to blood loss.

P1 – EMT

In most accident cases, things happen too fast. Victims are taken [to hospital] in a taxi or any available vehicle, by bystanders. For the public, saving a life means taking victims to hospital quickly. However, that is wrong because they do not transfer the patient in a stable position and take them in a hurry. Due to this, they may cause more harm, including bleeding.

P6 – Driver

Confidence and enablement of Nepal Ambulance Service staff

Apart from the dispatch officers, most of the staff (EMTs and drivers) reported receiving regular training, every 6 or 12 months for at least 3–7 days. One of the participants shared his experience of receiving training opportunities in Switzerland. He expressed how the international training exposure boosted his confidence in his current EMT role.

The EMTs reported several trauma-related incidents and the care they provided to trauma victims. One of the senior managers in the study emphasised that all the EMTs and the dispatch officers are required to follow specific protocols when providing prehospital care. He described how the EMTs needed to call senior doctors working with NAS if they wanted to use medicines that were not mentioned in the protocol.

We have a protocol for all staff or dispatch officers who work for our ambulance service. After the patient is placed inside the ambulance, the EMTs should follow a specific protocol.

P12 – Senior manager

One EMT explained how they handle mass casualties in road traffic crashes. She explained the triage system, which involved a colour-coding scheme using black, yellow, green and red. Red tags require immediate treatment and hence are the first priority.

The EMTs and drivers reported working as a team. All drivers described how they support EMTs to deliver prehospital care. The drivers reported how they felt respected in their roles.

We have only one EMT, and our driver supports us in measuring the [blood] pressure, setting up the saline [drip] lifting the patient, and using the C-collar. They also help us with bandaging and opening the bandage. They are familiar with the location of all the equipment, including the type of board used for backbone fractured patients, wheelchairs for asthma patients, and the position to keep them in. They assist us with everything.

P4 – EMT

I have experience driving other vehicles, but I prefer driving this one. Unlike other vehicles, we are not insulted while driving the ambulance.

P3 – Driver

Having supplies of appropriate equipment and medicines enabled the staff to provide effective care. One EMT described a cupboard inside the ambulance where equipment and medicines were stored, while a ‘red bag’ or ‘Go-bag’ was packed with essential medicines and equipment for immediate use. After handling an emergency case, each EMT replaces the equipment and medicines they have used from the red bag with supplies from the cupboard. All the EMTs perceived that they were provided with adequate medicines and equipment.

The equipment will be stored in that cupboard. The equipment I used from the red bag will be replaced from the cupboard into the red bag.

P14 – EMT

Actions of patients and their relatives influence care in the ambulance

Some EMTs and drivers described how the behaviour of some patient’s families and relatives affected their ability to provide optimal care. For example, they described occasions where they were scolded by relatives while performing first aid as it was perceived to be wasting time. They described how some families were reluctant to answer questions asked by EMTs on their route to hospital, and in anger, they ask for them to be just rushed to hospital.

The patient’s family instructs us to move quickly and not ask any questions.

P1 – EMT

The patient is experiencing excessive bleeding, and our EMT is working to control it. They do everything possible to help the patient, even if it takes 5–7 minutes. However, the patient’s family may ask ‘why we are delaying in reaching the hospital?’.

P10 – Driver

All the EMTs described the challenges of deciding which hospital to take the patient to. They emphasised that most of the time, it was negotiated between the patient’s representatives and the EMTs. However, a few EMTs reflected that sometimes the victim’s family insist on visiting a particular hospital without understanding the availability of services and beds. The EMTs expressed their frustration when the patient was not able to be accepted, and they then had to search for another hospital for the same patient.

If the patient requires immediate medical attention, we will take them to the nearest health centre. We will explain to the patient’s family or friends that we are taking the patient to this health facility due to their condition, and they should not worry. After stabilizing the patient, we will take them to any hospital of their choice.

P14 – EMT

Sometimes, the patient’s families disagree with us on the hospital we select, which can be challenging and stressful for us. Although we advise the patient’s family or friends to confirm the availability of an ICU bed in a government hospital [before travelling], they believe they know best and do not listen to us. When we reach the hospital, we find that the ICUs are packed, and we have to move to another hospital.

P4 – EMT

None of the EMTs had been accused of wrongful treatment by a victim’s family. However, news reports of families blaming doctors for the death of their relatives led two of the EMTs to observe that they feared receiving such allegations in the future. All the EMTs expressed a need for a law to protect themselves from such prosecution.

When something happens to the patient, what if they attack us inside the vehicle? Who will be responsible for it? For instance, if the patient dies, the patient’s family may become angry and attack us. Who would take responsibility? Therefore, there should be a law to protect us.

P15 – EMT

Low awareness among the public about the role of prehospital care providers

Both the EMTs and the drivers perceived that the public and police had limited awareness of the role of prehospital care providers. The participants described examples where the victim’s family were surprised to see the EMTs providing treatment inside the ambulance or at the scene. Many of the public they engaged with assumed that the ambulance services only transferred patients to hospital. Many EMTs and drivers suggested that awareness campaigns, such as demonstrations and mock scenarios, could help make people aware of their services and how to contact them. They recommended such campaigns in schools, businesses and community groups.

We have heard patients say, ‘Wow, this type of treatment is available in this ambulance.’ We provide the best possible care to our patients.

P5 – Driver

A ‘video’ should be made for the public, showing how patients are received and treated when a road accident has occurred. Awareness should be spread through small groups such as mothers and loan-saving groups, as well as in offices and schools.

P7 – EMT

Delay in reaching a health facility

Participants described how they were often delayed when transferring the patient to the hospital. They explained that vehicles bounced up and down on the bumpy road, and the EMTs described having to pull the ambulance to the side of the road due to the poor road conditions to provide treatment to the patient.

Some EMTs were more concerned about traffic congestion, especially on long journeys that led to delays reaching the hospital. They described how the delay due to traffic congestion could lead to running out of oxygen en route to the hospital. On such occasions, they would call another ambulance with oxygen and transfer the patient to the new vehicle.

Sometimes, if the oxygen supply runs out or the vehicle breaks down … and there is a shortage of oxygen …, we will contact 102 ambulances from Kathmandu’s central office to transfer the patient.

P15 – EMT

Delay in receiving care

Two EMTs and a dispatch officer complained that the hospital sometimes refused to treat unidentified patients, which delayed receipt of care. In a road traffic crash, the victim’s identity is often unknown, and the hospital prefers not to receive road traffic victims without their families or relatives, as it does not want to take financial responsibility for those patients. Most participants acknowledged the support provided by the traffic police to hospitalise unidentified road crash victims.

If we are taking a patient to a government hospital, if we do not have police with us, the hospital will ask us who will look after the patient and who will be responsible if the patient dies?

P14 – EMT

Two EMTs and a driver described how they had more equipment (such as trollies, wheelchairs or spine boards) than the hospital. This led to difficulties when trying to handover patients in the emergency department.

We carefully transport patients to hospital on spine boards, and using C-collars. However, government hospitals do not have spine boards.

P1 – EMT

Three EMTs and a driver described the challenge of finding vacant beds, particularly intensive care unit (ICU) beds in government hospitals. They offered examples of where they had to support patients for several hours while searching for a hospital. Therefore, one EMT suggested there should be a system that provides updates on beds, ventilators and ICU availability so that they could make informed decisions about where to take the patient and patients could receive timely treatment.

After arriving at hospital, we discovered that there were no available beds or ICU beds, and they [the patient] could not afford a private hospital. We tried moving from one government hospital to another, but the beds were all occupied. At that moment, we felt helpless and unsure of where to take the patient. We have encountered situations where ambulances have been on the move for 3–4 hours searching for a hospital.

P1 – EMT

Processes after handover of patient

The participants described their actions to ensure that a good service was provided to trauma patients. For example, one EMT described how they used a checklist at the end of their shift to indicate the equipment and medicines they had used during their duty. This system ensured that the ambulance was always fully stocked.

I have to fill up out a request form [checklist] and list the equipment that I have used from the drawer [present inside the ambulance]. Then, I need to replace the equipment and submit the form to the main office. The office will immediately provide replacements.

P8 – EMT

Both the dispatchers in the study explained the patient surveys they undertook to understand better the service they provided. The survey was conducted with every third case admitted to hospital.

We follow up on cases by asking patients about their experience with our EMTs, our ambulance service, our charges, and whether they would be interested in using our service again. We conduct surveys either a day later or 2–3 days after the patient has been admitted to hospital.

P11 – Dispatch officer

Equality, diversity and inclusion

Injuries are known to be socially patterned, with males sustaining more injuries than females, and with injuries being more prevalent in communities experiencing greater disadvantage. Children, the elderly and those living with a disability are at increased risk of injury overall, and may be at risk of specific types of injury. In a country such as Nepal where the patient needs to pay at the point of care, household income influences health-seeking behaviour following an injury. Considering these inequalities, we analysed the callout data by age and sex, but we were unable to conduct analyses by other indicators of inequality because of the data available. In the qualitative component of our study, we purposively sought male and female participants from all four roles; however, due to the predominance of men in such roles, the number of female participants was lower than that of men.

Future research

This study has indicated a number of issues that could be researched to further develop the prehospital care system in Nepal. Further qualitative research to understand the perceptions and experiences of trauma victims, road users, emergency department staff, police officers, members of other organisations involved in prehospital care, firefighters and health policy-makers would complement the findings from this study and may identify ways forward. A range of specific barriers to care needs further exploration, for example, factors affecting the handover of trauma patients between ambulance and emergency department staff.

Lessons learnt

This study has indicated ways in which the NAS can strengthen its routine data collection, including the need to minimise missing data and the advantages of collecting and classifying data on the circumstances of an injury event. Both would enable the provider to continually monitor and develop their service. The study shows how a lack of public understanding of the need to stabilise injuries prior to transfer to a hospital can lead to conflict between service providers and service users. Only a proportion of EMS providers currently employ staff trained in prehospital care; therefore, there needs to be a co-ordinated roll-out of training of EMTs alongside public awareness raising of the need for first aid prior to transfer to hospital. Training greater numbers of the public in first aid would enable bystanders to both support victims and enable prehospital care providers to utilise their skills without reproach.

Implications for practice and policy

The findings from this study provide policy-makers with examples of how the existing EMS system could be improved through policy and legislation. The study illustrated how, for example, the current EMS system with multiple providers and lack of co-ordination results in inefficiencies in care provision. Bystanders and relatives call multiple ambulances to identify one that is readily available to take the injured person to the hospital. Poor road conditions and congested traffic that do not give way to the ambulance lead to delays in arriving at the scene and transferring to the hospital. EMTs describe receiving verbal abuse from the public who do not understand the importance of stabilising injuries prior to, or during, transfer. Importantly, they fear physical abuse and prosecution from the relatives of injured patients, should the patient’s injuries prove fatal. Promulgation of a ‘good Samaritan law’, as exists in many countries, would protect service providers seeking to save lives.

Strengths and limitations of the study

The main strength of this study was the use of a mixed-methods design with the qualitative interviews providing insights into the factors influencing the patient and time interval data analysed. We analysed data from one of Nepal’s largest and most established prehospital care providers. A further strength is that we interviewed a diverse group of prehospital care provider staff (ambulance drivers, EMTs, dispatch officers and service managers), which enabled the collection of broader perspectives and a more rounded overview.

In the analysis of callout data, we chose a 1-year period to provide a focused and comprehensive examination within a manageable and funded time frame. We found that for some data fields more than a quarter of the data were missing, limiting the ability to accurately determine the patient needs and response times. We managed this by having a member of NAS staff as part of the study team to maximise the utility of the available records and we introduced ‘unspecified’ categories for both the mechanism and nature of injury to present the findings in a clear and organised manner. Table 5 (see Appendix 2) details the components included within the unspecified category for the mechanism of injury and Table 6 (see Appendix 3) for the nature of injury. Interpretation of the findings of the study therefore needs to take the degree of missing data into consideration. Some data fields that would have been particularly helpful to further understand patients’ needs, such as the part of the body injured, injury severity scores or the care provided, were not routinely captured. Studies from other countries have shown that prehospital care times vary between urban and rural areas, with increased delays in response in rural areas. 31,32,38–40 Our study was not able to conduct such an analysis due to the data available. The qualitative component of this study may have been subject to responder bias if the participants felt uncomfortable reporting something that may have reflected badly on their employer. We managed this risk by making participants aware of the agreement of their managers to their participation in the study and by emphasising that their responses would not be identifiable in any outputs from the study. The participants’ managers were not present during the interviews.

Key learning points

• Falls and road traffic crashes were the commonest causes of trauma requiring an ambulance, with fractures and suspected spinal injuries being the commonest types of injury.

• The mean interval from a call being received to arriving with the patient at a hospital was 48 minutes, although this could be much longer.

• High standards of prehospital care were facilitated by the availability of care protocols, regular refresher training, good stocks of medicines and equipment, availability of GPS software, radio contact between the base and crews and good teamwork between ambulance drivers and EMTs.

• Traffic congestion and poor road maintenance, the expectations of patients, relatives and bystanders and lack of awareness of EMT’s knowledge and skills were barriers to providing prehospital care.

Acknowledgements

We acknowledge the support of the NAS for providing access to its data sets and for allowing interviews with its staff. We are thankful to all the participants of our study who consented to participate and share their experiences. We want to acknowledge the support of researchers at the NIHR Global Health Research Group on Nepal Injury Research and the administrative support of Kathmandu Medical College.

CRediT contribution statement

Amrit Banstola (https://orcid.org/0000-0003-3185-9638): Conceptualisation (equal), Formal analysis (equal), Investigation (equal), Methodology (equal), Project administration (lead), Visualisation (equal), Writing – Original draft (lead), Writing – reviewing and editing (lead).

Preeti Gautam (https://orcid.org/0000-0002-2040-5000): Conceptualisation (equal), Formal analysis (equal), Investigation (equal), Methodology (equal), Project administration (supporting), Visualisation (equal), Writing – Original draft (supporting), Writing – reviewing and editing (supporting).

Gary Smart (https://orcid.org/0000-0002-8578-0661): Conceptualisation (equal), Formal analysis (equal), Methodology (equal), Supervision (co-lead), Writing – reviewing and editing (supporting).

Sunil K Joshi (https://orcid.org/0000-0002-2704-5060): Conceptualisation (equal), Formal analysis (equal), Funding acquisition (co-lead), Methodology (equal), Supervision (co-lead), Writing – reviewing and editing (supporting).

Julie Mytton (https://orcid.org/0000-0002-0306-4750): Conceptualisation (equal), Formal analysis (equal), Funding acquisition (co-lead), Methodology (equal), Supervision (co-lead), Writing – reviewing and editing (supporting).

Furba Sherpa: Conceptualisation (equal), Formal analysis (equal), Methodology (equal), Resources, Writing – reviewing and editing (supporting).

Disclosure of interests

Full disclosure of interests: Completed ICMJE forms for all authors, including all related interests, are available in the toolkit on the NIHR Journals Library report publication page at https://doi.org/10.3310/TMTG2437.

Primary conflicts of interest: Amrit Banstola, Preeti Gautam and Gary Smart have no conflicts of interest to declare. Julie Mytton was a member of HTA MNCH Panel from 2008 to 2015. Sunil K Joshi is an Editorial Board Member of BMJ Injury Prevention.

Data-sharing statement

All data requests should be submitted to the corresponding author for consideration. Access to anonymised data may be granted following review.

Ethics statement

Ethical approval was obtained from the Nepal Health Research Council on 13 January 2021 (Reference number 769/2020) and the UWE Bristol, Faculty of Health and Applied Sciences Research Ethics Committee on 26 January 2021 (Reference number HAS.21.01.089).

Information governance statement

The University of the West of England, Bristol (UWE Bristol), as sponsor for this study, is committed to ensuring that all personal information is handled in line with the UK Data Protection Act (2018) and the General Data Protection Regulation (EU GDPR) 2016/679. Under Data Protection legislation, UWE Bristol is the Data Controller and the Nepal Injury Research Centre is the Data Processor, who process personal data in accordance with their instructions. The data governance strategy applied in this study used the ‘five safes’ framework. This is a systematic approach to good data governance, commonly used in government data management systems. The framework breaks data management and governance into five broad issues which need to be addressed: (1) Safe projects, (2) Safe people, (3) Safe settings (which are all amenable to managerial controls), (4) Safe data and (5) Safe outputs (which are amenable to statistical controls). More information on the data governance strategy used in this study is available from the authors on request.

Department of Health and Social Care disclaimer

This publication presents independent research commissioned by the National Institute for Health and Care Research (NIHR). The views and opinions expressed by the interviewees in this publication are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, MRC, NIHR Coordinating Centre, the Global Health Research programme or the Department of Health and Social Care.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Global Health Research programme as award number 16/137/49 using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Research is published in the NIHR Global Health Research Journal. See the NIHR Funding and Awards website for further award information.

About this article

The contractual start date for this research was in July 2017. This article began editorial review in February 2023 and was accepted for publication in March 2024. The authors have been wholly responsible for all data collection, analysis and interpretation, as well as for writing up their work. The Global Health Research editors and publisher have tried to ensure the accuracy of the authors’ article and would like to thank the reviewers for their constructive comments on the draft document. However, they do not accept liability for damages or losses arising from material published in this article.

This article was published based on current knowledge at the time and date of publication. NIHR is committed to being inclusive and will continually monitor best practice and guidance in relation to terminology and language to ensure that we remain relevant to our stakeholders.

Copyright

Copyright © 2024 Banstola et al. This work was produced by Banstola et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This is an Open Access publication distributed under the terms of the Creative Commons Attribution CC BY 4.0 licence, which permits unrestricted use, distribution, reproduction and adaptation in any medium and for any purpose provided that it is properly attributed. See: https://creativecommons.org/licenses/by/4.0/. For attribution the title, original author(s), the publication source – NIHR Journals Library, and the DOI of the publication must be cited.

Research study: prehospital emergency care for trauma victims in Nepal

Providing high-quality prehospital care to injured persons followed by good medical treatment can save lives, reduce the severity and prevent disability. We want to know what prehospital care is provided to injured persons by EMS in Nepal and what are the opportunities and challenges of providing care?

Introduction (10 minutes)

• First, thank the participant for joining the interview.

• Give a brief introduction of yourself, the purpose of the study.

• Explain the approximate time required (audio-recording, handwritten notes).

• Encourage participants to speak clearly.

• Explain that there will be no right or wrong views.

• Assure anonymity and confidentiality of participant and their views.

• Explain how participants will not be identifiable from any record or report arising from the interview.

• Explain that the participant does not have to talk about anything they feel uncomfortable with and can stop at any time for any reason.

• Sign the consent form (check that the interviewee has signed and s/he is happy for the interview to be audio-recorded).

Warm-up

Introduction by participant with a brief background.

Definition (for reference if needed)

Injured persons: Injured persons are defined as those who had one of these injuries – transport injuries (road injuries and other transport injuries), falls, drowning, burns, poisonings, animal-related, natural disaster, self-harm, interpersonal violence, conflict and terrorism.

Discussion

Now we shall begin our interview. For this, I will be asking you about your experience of providing prehospital care for injured persons. Particularly, I will be interested in your views on the opportunities and challenges of providing prehospital care for injured persons.

[To organise the interview, use the following questions].

For emergency care providers

1. Please tell us what role you do in NAS. What does that role involve? Can you describe your role? How long have you been in your role?

2. Can you tell me what training you have received? How long was that training? What topics were covered in your training? Have you had any refresher training?

3. What is your experience of providing prehospital emergency care to people with injuries?

4. What is/are the best thing(s) about your role?

5. What do you think is the most difficult or challenging part of your role?

6. What is the most discouraging part of your role?

7. What changes could be made to make your role easier?

8. Are there any changes that could be made at a national level that would improve EMS in Nepal?

9. Do you think there is a need for a law which protects prehospital emergency care providers from being prosecuted?

For service managers

1. Please tell us what role you do in NAS. What does that role involve? How long have you been doing that role? Did you receive any training for your role? How long was the training?

2. Can you tell me about the training you provide to the staff? Have your staff received training to support different types of emergency cases including trauma victims? Is there Continuing Professional Development support for the staff?

3. What is your experience of providing prehospital emergency care service?

4. What is/are the best thing(s) about your role?

5. What do you think is the most difficult or challenging part of your role?

6. What is the most discouraging part of your role?

7. What changes could be made to make your role easier?

8. Are there any changes that could be made at a national level that would improve EMS in Nepal?

9. Do you think there is a need for a law which protects prehospital emergency care providers from being prosecuted?

10. Do you have a way of finding out the disposition (admission, discharge, transfer) of the person you have treated and handed over to the hospital?

Wrap-up (10 minutes)

Ending the discussion by saying: Thank you for your time today. We have been discussing this for about an hour. Do you think we missed anything that needs to be discussed?

Interview recording details