Cvetković, V. M., Tanasić, J., Renner, R., Rokvić, V., & Beriša, H. (2024). Comprehensive risk analysis of emergency medical response systems in Serbian healthcare: Assessing systemic vulnerabilities in disaster preparedness and response. Healthcare, 12(19), 1962.
Comprehensive Risk Analysis of Emergency Medical Response Systems in Serbian Healthcare: Assessing Systemic Vulnerabilities in Disaster Preparedness and Response
Vladimir M. Cvetkovic´ 1,2,3,4,*, Jasmina Tanasic´ 5, Renate Renner 4, Vanja Rokvic´ 1 and Hatiža Beriša 6
1 Department of Disaster Management and Environmental Security, Faculty of Security Studies, University of Belgrade, Gospodara Vucˇic´a 50, 11040 Belgrade, Serbia; vanjarokvic@fb.bg.ac.rs
2 Scientific-Professional Society for Disaster Risk Management, Dimitrija Tucovic´a 121, 11040 Belgrade, Serbia
3 International Institute for Disaster Research, Dimitrija Tucovic´a 121, 11040 Belgrade, Serbia
5 Standing Conference of Towns and Municipalities, Makedonska 22/VIII, 11103 Belgrade, Serbia;
* Correspondence: vmc@fb.bg.ac.rs or vladimir.cvetkovic@unileoben.ac.at
Citation: Cvetkovic´, V.M.; Tanasic´, J.; Renner, R.; Rokvic´, V.; Beriša, H. Comprehensive Risk Analysis of Emergency Medical Response Systems in Serbian Healthcare: Assessing Systemic Vulnerabilities in Disaster Preparedness and Response. Healthcare 2024, 12, 1962. https:// doi.org/10.3390/healthcare12191962
Academic Editor: Krzysztof Goniewicz
Received: 23 August 2024
Revised: 27 September 2024
Accepted: 29 September 2024
Published: 1 October 2024
Copyright: © 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).
Abstract: Background/Objectives: Emergency Medical Response Systems (EMRSs) play a vital role in delivering medical aid during natural and man-made disasters. This quantitative research delves into the analysis of risk and effectiveness within Serbia’s Emergency Medical Services (EMS), with a special emphasis on how work organization, resource distribution, and preparedness for mass casualty events contribute to overall disaster preparedness. Methods: The study was conducted using a questionnaire consisting of 7 sections and a total of 88 variables, distributed to and collected from 172 healthcare institutions (Public Health Centers and Hospitals). Statistical methods, including Pearson’s correlation, multivariate regression analysis, and chi-square tests, were rigorously applied to analyze and interpret the data. Results: The results from the multivariate regression analysis revealed that the organization of working hours (β = 0.035) and shift work (β = 0.042) were significant predictors of EMS organization, explaining 1.9% of the variance (R2 = 0.019). Furthermore, shift work (β = −0.045) and working hours (β = −0.037) accounted for 2.0% of the variance in the number of EMS points performed (R2 = 0.020). Also, the availability of ambulance vehicles (β = 0.075) and financial resources (β = 0.033) explained 4.1% of the variance in mass casualty preparedness (R2 = 0.041). When it comes to service area coverage, the regression results suggest that none of the predictors were statistically significant. Based on Pearson’s correlation results, there is a statistically significant correlation between the EMS organization and several key variables such as the number of EMS doctors (p = 0.000), emergency medicine specialists (p = 0.000), etc. Moreover, the Chi-square test results reveal statistically significant correlations between EMS organization and how EMS activities are conducted (p = 0.001), the number of activity locations (p = 0.005), and the structure of working hours (p = 0.001). Conclusions: Additionally, the results underscore the necessity for increased financial support, standardized protocols, and enhanced intersectoral collaboration to strengthen Serbia’s EMRS and improve overall disaster response effectiveness. Based on these findings, a clear roadmap is provided for policymakers, healthcare administrators, and EMS personnel to prioritize strategic interventions and build a robust emergency medical response system.
Keywords: risk; disaster; emergency preparedness; effectiveness; comprehensive survey; emergency medical response systems; vulnerabilities; Serbian healthcare
Healthcare 2024, 12, 1962. https://doi.org/10.3390/healthcare12191962 https://www.mdpi.com/journal/healthcare
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Introduction
Among various healthcare services, Emergency Medical Response Systems (EMRS) (Appendix B) are an important element serving for urgent needs of disasters, which refer to both natural hazards and man-made (technological disasters) [1–3]. Considering that, the effectiveness of these systems can have a profound impact on patient outcomes, especially in critical, life-threatening situations [4,5]. Also, it is important to mention that, in Serbia, the healthcare sector has encountered numerous obstacles, such as economic limitations, resource scarcity, and ongoing reform transitions, which influence the performance of its EMRS [6–9]. Following that, the evolution of emergency medical services (EMS) in Serbia has progressed alongside the country’s broader healthcare system, reflecting significant socio-economic and political shifts [10–12]. In that way, the EMS framework in Serbia has historically been shaped by the Yugoslavian healthcare model, which emphasized accessibility and comprehensiveness [13,14]. However, the disintegration of Yugoslavia and the ensuing conflicts in the 1990s caused substantial disruptions in healthcare delivery, including emergency services [14].
It is crucial to point out that reforms initiated post-2000 aimed to align Serbian EMS with European standards and have had varying degrees of success. Likewise, initial re- form efforts concentrated on restructuring organizational frameworks, boosting funding, and enhancing training programs for medical personnel [15–17]. Despite these reforms, ongoing issues such as inadequate infrastructure and an insufficient workforce continue to challenge the system’s ability to deliver timely and effective emergency care [18]. In addi- tion, Serbia’s EMRS is currently organized into several key components: pre-hospital care, hospital emergency departments, and specialized emergency units [12,19]. Pre-hospital care involves dispatch centres and ambulance services, which are crucial for ensuring rapid response times. According to the provisions of the Law on Healthcare (“Official Gazette of the Republic of Serbia”, No. 25 of 3 April 2019, 92 of 27 October 2023), one of the main priorities of healthcare workers and institutions at all levels of the healthcare system can be said to be the provision of EMS. In the treatment of emergency cases and conditions, the basic principles and methods of emergency medicine are applied). Furthermore, the organization of emergency medical services is based on two interconnected subsystems: pre-hospital emergency care and hospital-based emergency care. Pre-hospital emergency medical care is a continuous activity of primary healthcare institutions and includes pro- viding medical assistance at the site of the emergency or within a healthcare institution, medical transport of critically ill or injured patients to hospital facilities, with continuous monitoring and provision of assistance during transport. This assistance is provided as part of the regular activities of doctors and their associates, as well as through the work of on-call or emergency teams during the night, weekends, and public holidays. On the other side, in health centres that serve territories with more than 25,000 inhabitants, an emergency medical service can be organized for the continuous reception and care of emergency cases. On the other hand, hospital-based emergency medical care is provided through the work of specialized teams in the emergency departments of general hospitals, clinical-hospital centers, clinics, institutes, and university clinical centers, with the admission of patients for hospital treatment. Healthcare institutions that are unable to adequately care for patients are required to organize medical transport and provide appropriate professional assistance during the transport to the most suitable hospital facility.
Nonetheless, research indicates that response times in Serbia frequently surpass inter- national benchmarks due to logistical challenges and resource limitations [20]. One impor- tant aspect is that hospital emergency departments in Serbia grapple with issues such as overcrowding, understaffing, and outdated equipment [21]. These problems are exacer- bated by the limited presence of specialized emergency units, like trauma and cardiac care centres, particularly in rural regions [1,4,8,12,15,21]. The effectiveness of EMRS in Serbia is further hampered by the uneven distribution of healthcare resources and disparities in access to emergency care between urban and rural populations [22–24]. Several risk factors impact the performance of EMRS in Serbia, including systemic, organizational,
and operational challenges [25]. The Serbian healthcare system is plagued by chronic underfunding, affecting all levels of healthcare delivery, including emergency services [26]. Limited financial resources result in inadequate investment in infrastructure, technology, and human resources, leading to subpar EMRS performance [9,15,24,27]. An essential point to highlight is that operational risks include delays in response times, insufficient training for EMS personnel, and lack of access to advanced medical equipment. These fac- tors contribute to increased morbidity and mortality rates among emergency patients [28]. Additionally, emergency medical technicians and paramedics often experience high levels of occupational stress and burnout, which can adversely affect their performance and decision-making abilities [6,29].
The effectiveness of EMRS in Serbia is assessed through various indicators, includ- ing response times, patient outcomes, and system efficiency. Response time is a crucial indicator of EMRS efficacy, as it directly influences patient survival rates, especially in cases of cardiac arrest, trauma, and stroke [30]. Studies reveal that response times in Serbia often exceed recommended international standards, mainly due to logistical challenges and resource constraints [6,31,32]. System efficiency is influenced by resource allocation, coordi- nation among healthcare sectors, and the implementation of evidence-based protocols [33]. Efforts to improve system efficiency in Serbia have focused on enhancing communication systems, optimizing resource allocation, and implementing training programs for EMS personnel [1,2,21,34].
Addressing the risks and enhancing the efficacy of EMRS in Serbia requires a multi- faceted approach involving policy, organizational, and operational interventions [35–38]. Organizational strategies should aim to enhance service delivery by improving communica- tion systems, optimizing resource allocation, and implementing evidence-based protocols for emergency care [38]. Efforts to decentralize healthcare services and encourage regional collaboration can also help address disparities in access to emergency care [39]. Opera- tional measures should concentrate on improving response times, enhancing training and education for EMS personnel, and ensuring access to advanced medical equipment [40].
This study thus analysed the risk spectrum and efficiency level in the Emergency Medical Services (EMS) of Serbia by exploring possible implications of work organization, distribution, and preparedness for major incidents on wider disaster readiness. Also, the primary goal of this study is to scientifically predict and explain the key factors influencing EMS performance while also identifying specific strategies and procedures that can improve the system’s efficiency during mass casualty incidents and other critical emergencies.
Literature Review
It is important to mention that Emergency Medical Response Systems (EMRSs) world- wide have been extensively analyzed, providing valuable insights into their strengths, chal- lenges, and best practices across various regions [5,6,33,38,41–56]. Conversely, an important observation is that studies from outside Serbia have identified common themes, such as the necessity for well-organized protocols [39,57], efficient resource distribution [43,58–60], and ongoing EMS personnel training [61,62]. Moreover, research from countries like Germany and the United Kingdom highlights the significance of standardized national protocols in ensuring consistent, high-quality care [10,63,64]. In Germany, where we have a high-quality system of standardized preclinical protocols (POLYQUALY), coordination of the emergency services has been improved and response times for all patients have decreased, as well as improved patient outcomes [65]. On the other side, the UK’s National Health Service (NHS) emphasizes standardized training and procedures, which have contributed to high survival rates in critical emergencies like cardiac arrests [66,67].
Effective resource allocation and infrastructure are key to EMRSs’ success [19,68]. A study in the US showed that urban ambulance services with advanced medical technol- ogy and well-equipped ambulances had better response times than their less-resourced rural counterparts [63,69–71]. Conversely, in countries with weaker infrastructure, longer response times have been linked to lower survival rates in trauma and cardiac emergen-
cies [72]. Ongoing training is critical for effective EMS systems [70,73,74]. From the other perspective, Japan’s EMS training integrates disaster preparedness, which has proven effective in large-scale emergencies such as different disasters [75,76].
Technology has a crucial role in enhancing EMRS effectiveness [77,78]. So, advanced telemedicine systems allow EMS teams to provide real-time medical consultations, im- proving pre-hospital care quality [79]. Similarly, Scandinavian countries use GPS-based dispatch systems to optimize emergency vehicle deployment, reducing response times, particularly in rural areas [80]. In low–middle-income countries, resource limitations hinder EMRS efficiency [81]. However, community-based EMS models have shown promise in expanding access to care in remote areas [82]. Innovations like motorcycle ambulances have also helped overcome transportation challenges in urban areas with poor road infras- tructure [83]. Furthermore, the presence of written mass casualty plans has been shown to significantly improve the performance of EMRS [42,71,84,85]. However, in Serbia, only 46% of institutions have dedicated emergency departments, and many lack specialized units for trauma and cardiac care [12].
In the context of post-conflict and post-disaster settings, Nelson et al. [7] discuss how health-system reforms are often complicated by unforeseen obstacles, frequently arising from inadequate initial evaluations. Expanding on this, Nelson et al. [12] conducted a comprehensive multimodal analysis of Serbia’s emergency medical services, blending both quantitative and qualitative methods. Comparing EMRS in Serbia with those in other countries provides insights into potential areas for improvement [50,63,64]. Conversely, Serbia faces challenges related to the lack of standardized protocols, limited access to advanced training, and insufficient funding [54,64]. These systemic weaknesses are re- flected in Serbia’s Global Health Security Index (GHSI) rankings [86–89]. The World Bank’s Emergency Preparedness and Response Assessment [88] further illustrates the strain on Serbia’s medical response capabilities during disasters. The report highlights limited EMS capacity for advanced life support and the lack of prehospital mass casualty structures, including triage zones, medical costs, and transport staging areas [88–90].
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Methods
This research delves into the analysis of risk and effectiveness within Serbia’s Emer- gency Medical Services (EMS), with a special emphasis on how work organization, resource distribution, and preparedness for mass casualty events contribute to overall disaster pre- paredness (see Figure 1). Also, the primary aim of this study is to scientifically predict and explain the key factors influencing EMS performance while also identifying specific strategies and procedures that can improve the system’s efficiency during mass casualty incidents and other critical disasters. Regarding that, this study utilizes quantitative meth- ods, including Pearson’s correlation, multivariate regression analysis, and chi-square tests to identify key predictors of risk and efficacy in EMS performance. Additionally, it assesses how mass casualty plans and procedures impact the overall effectiveness of EMS, particu- larly during large-scale emergencies. The research was conducted from 2019/20 to 2022/23 in the areas of the mentioned local governments.
General Hypothesis—The organization of working conditions (e.g., working hours, shift schedules, etc.), disaster preparedness and response (presence of mass casualty plans and procedures), financial resources (insurance, budget, revenue allocation, etc.), and availability of specialized equipment have a statistical impact on the effectiveness of EMS in Serbia. Specific hypotheses are:
H1. The organization of working hours and shift schedules significantly improves EMS organization and performance in Serbia.
H2. Financial resourcesallocated to EMS play a critical role in enhancing the system’s preparedness and operational efficiency during disaster response.
H3. Theimplementationof mass casualty plans and procedures significantly strengthens EMS readiness and response capabilities in large-scale emergencies.
H4. The availability of ambulance vehicles and specialized equipment significantly enhances the overall effectiveness of EMS, particularly in handling mass casualty incidents.
Figure 1. Conceptual research design of the emergency medical response system in Serbian healthcare.
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This research delves into evaluating emergency medical response systems within Serbia’s healthcare sector. In Southeast Europe, Serbia occupies the heart of the Balkan Peninsula (see Figure 2). The country, home to around 7 million inhabitants, features a varied landscape that includes fertile plains in the north and mountainous terrain in the south, each posing distinct challenges to emergency medical services (EMS) [1,2]. Serbia’s healthcare system is a hybrid model that combines state-run public healthcare with private medical services. Public healthcare operates on three levels: primary, secondary, and tertiary care. Emergency medical services, essential to this system, are primarily handled by the public sector. These services are designed to deliver urgent care both before patients reach the hospital and once they are within the hospital setting. The effectiveness and promptness of these services become especially crucial during disasters, whether natural, such as floods or earthquakes, or human-made [6,13,16,17,25,30,38].
Figure 2. Map of Serbia showing districts and national borders. Subfigure (a) shows the scale in kilometers, indicating distances ranging from 0 to 90 km, while subfigure (b) illustrates Serbia’s location within Europe, providing a broader geographic context.
According to the Statistical Office of the Republic of Serbia (https://www.stat.gov.rs/, accessed on 24 September 2024), based on the 2022 population census, approximately
6.7 million people live in Serbia. It is important to note that the birth rate is around 9.2 per 1000 inhabitants, while, in contrast, the mortality rate is 14.6 per 1000 inhabitants. These figures clearly indicate a negative natural population growth of about −5.4. Additionally, the average life expectancy in Serbia is 74.2 years (71.6 years for men and 77.3 years for women). Around 56% of the population lives in urban areas, with Belgrade being the most populous city. In terms of ethnic composition, Serbs make up about 83% of the population, while other ethnic groups include Hungarians, Bosniaks, Roma, and Croats. From a religious perspective, 84.6% of the population belongs to the Serbian Orthodox
The study encompasses a broad range of regions across Serbia, including major urban centres like Belgrade and Novi Sad, as well as rural and isolated areas where access to emergency services might be more restricted. Moreover, this regional diversity facilitates a thorough evaluation of EMS across various environments, addressing the risks and evalu- ating the efficiency of the existing emergency preparedness and response strategies [7,12]. As well, considering Serbia’s recent experiences with natural hazards [92] and its ongoing efforts to enhance disaster readiness [90], the country serves as a significant case study for assessing the effectiveness of its emergency medical response systems.
According to the Law on Healthcare (“Official Gazette of the Republic of Serbia”, No. 25 of 3 April 2019, 92 of 27 October 2023), healthcare institutions can be established with funds from either public or private ownership. Furthermore, public healthcare institutions are established by the Republic of Serbia, autonomous provinces, or local government units, while private healthcare institutions can be established by legal or natural persons. On the other side, healthcare institutions can be established in the form of health centers, polyclinics, pharmacies, hospitals (general and specialized), health centers, institutes, public health institutes, clinics, institutes, clinical-hospital centers, and university clinical centers, as well as military healthcare institutions or sanitary units within the Serbian Armed Forces, following specific laws.
It is very important to mention that the healthcare network plan determines the number, structure, capacities, and spatial distribution of public healthcare institutions and their organizational units across levels of healthcare, as well as the organization of emergency medical services and other important issues related to the organization of the healthcare system in Serbia. The health centre is a primary-level healthcare institution that provides preventive care for all population groups, healthcare for children and women, general medicine, patronage services, home treatment, and palliative care. In public health centres, depending on the number of residents and their needs, emergency medical services are organized in accordance with the healthcare network plan. If emergency medical services are not provided by another public healthcare institution in the designated area, the health center is responsible for providing these services. At the secondary level of healthcare, inpatient and specialized services are provided by general and specialized hospitals (“Official Gazette of the Republic of Serbia”, No. 25 of 3 April 2019, 92 of 27 October 2023).
Based on the available data from 2020, according to [93] and the Regulation on the Healthcare Institutions Network Plan (“Official Gazette of RS”, Nos. 5/2020, 11/2020, 52/2020, 88/2020), in the AP Vojvodina region, there are currently 93 public healthcare institutions, including 10 pharmaceutical institutions operating 47 pharmacies, 284 private healthcare institutions, and 960 private pharmacies. In the Western Serbia region, there are 39 public healthcare institutions, organized into 26 legal entities, as well as 87 private healthcare institutions and 279 private pharmacies. The Šumadija and Central Serbia region has 55 public healthcare institutions, along with 196 private healthcare institutions and 564 private pharmacies. The Eastern Serbia region is the least developed in terms of private healthcare, with 31 public healthcare institutions, 90 private healthcare institutions,
Table 1. Number of healthcare institutions (2020). Source: adapted from [93].
Region
n
%
Belgrade Region
57
18.21%
Vojvodina Region
93
29.71%
Western Serbia Region
26
8.31%
Šumadija and Central Serbia Region
55
17.57%
Eastern Serbia Region
31
9.90%
Southern Serbia Region
51
16.29%
Total
313
100
Primary Healthcare Centers
121
38.66%
Institutes for Primary Healthcare
16
5.11%
General Hospitals
10
3.19%
Healthcare Centers
31
9.90%
Special Hospitals
33
10.54%
Tertiary Healthcare Institutions (Clinics, Clinical Centers, 32 10.22%
University Hospitals, Institutes)
Institutes for Multilevel Healthcare
34
10.86%
Pharmacies
36
11.50%
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Table 2. Demographic and institutional characteristics of participants involved in emergency medical response services in Serbia.
Variables Category n %
Medical personnel 23 13.37
Function in EMS
Leadership positions within a medical institution
Administrative medical personnel
140
7
81.4
4.07
Operational medical personnel
2
1.16
Public health center
122
70.93
Type of Institution EMS
Hospital
11
6.40
Private healthcare facility
39
22.67
Less than 5 years
45
26.16
Experience in EMS
5–10 years
85
49.42
More than 10 years
42
24.42
Gender Male
95
55.23
Female
77
44.77
Table 2. Cont.
Variables Category n %
High school 30 17.44
Education Level
Bachelor’s degree 100 58.14
Master’s degree 42 24.42
Participation in Training No participation in training
50
29.07
Participated in one or more training sessions
122
70.93
First responder
50
29.07
Emergency Response Role
Coordinator
80
46.51
Support staff
42
24.42
Mass Casualty
Yes, the institution has a plan
110
63.95
Plans/Procedures
No, the institution does not have a plan
62
36.05
Total
172
100
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In the first step, a communication was sent to the offices of all city mayors and municipal leaders, requesting that it be relayed to the appropriate healthcare institutions within their areas, specifically those responsible for providing Emergency Medical Services (EMS), such as EMS centres and health clinics. In response, 172 healthcare institutions (Public Health Centers and Hospitals) completed the survey.
The survey questionnaire (see Appendix A) has been carefully designed to collect in-depth insights into how emergency medical services (EMS) in Serbia are organized and operate. In addition to that, this extensive questionnaire is divided into seven primary sections, each targeting a different aspect of EMS, with a varying number of questions designed to extract precise information: (a) organizational structure and risk management of emergency medical services (27 questions); (b) resource allocation (staffing) and efficacy in emergency preparedness (10 questions); (c) communication systems and efficacy in coor- dinated response (17 questions); (d) reaction time for first-order emergencies (3 questions);
(e) training (education) and preparedness for disaster response (6 questions); (f) funding for emergency medical services (EMS) (12 questions); (g) ambulance vehicles and equipment (5 questions); (h) emergency response and efficacy in urgent interventions, mass casualties (8 questions).
Each section is meticulously designed to provide a holistic overview of EMS capa- bilities and challenges, ensuring that all critical aspects of emergency preparedness and response are comprehensively addressed. Also, before the study commenced, a dedicated group of experts conducted an in-depth review of all the questions in the questionnaire. Moreover, this panel comprised professionals from various fields pertinent to emergency medical services and disaster preparedness, including specialists in healthcare manage- ment, public health policy, and disaster risk management. On the other side, their analysis aimed to guarantee that the questions were not only comprehensive and relevant but also reflective of the current socio-economic and political landscape. The experts also advised updating the questions to align with recent changes in healthcare policies and practices, acknowledging the dynamic nature of disaster risk management.
After the expert review, a pilot study was undertaken to test the revised questionnaire. Additionally, this preliminary study engaged a small group of participants from various
healthcare institutions. Its goal was to evaluate the questionnaire’s functionality, uncover any issues with question interpretation, and assess the overall coherence and flow of the survey. The pilot study yielded valuable insights into the questionnaire’s practical application, highlighting areas where further refinement was needed. Feedback from participants was instrumental in enhancing the language and structure of the questions, ensuring they were clear and pertinent to the respondents’ experiences.
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The research utilized a range of statistical methods, such as Pearson’s correlation [94], multivariate linear regression [95], and chi-square tests [96], to analyze the data comprehen- sively. Initially, the analysis revealed a breach of the equal variance assumption, prompting the application of the Welch and Brown–Forsythe tests [97], which are well-suited for handling such deviations. To provide a clear overview of the dataset, descriptive statistical analysis was also conducted. The statistical tests were executed using a two-tailed approach with a significance level of p < 0.05, employing IBM SPSS Statistics (Version 26, New York, NY, USA). Additionally, the study assessed internal consistency across various subscales utilizing Likert scales, yielding promising outcomes. The study was conducted according to the guidelines of the Declaration of Helsinki [98] and approved by the Institutional Review Board of the Scientific–Professional Society for Disaster Risk Management and the International Institute for Disaster Research (protocol code 005/2024, 15 July 2024). Also, the authors acknowledge the use of Grammarly Premium (1.2.96) and ChatGPT 4.0 in the process of translating and improving the clarity and quality of the English language in this manuscript.
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Results
The results of the study are presented in three dimensions: the predictors of risk and efficacy analysis of emergency medical response systems in Serbian healthcare; correla- tions and influences of demographic and socioeconomic factors on the perception of risk and efficacy analysis of emergency medical response systems in Serbian healthcare; and descriptive analysis parts: organizational structure and risk management of emergency medical services; resource allocation and efficacy in emergency (disaster) preparedness; communication systems and efficacy in coordinated response; emergency response times and efficacy in urgent interventions; training and preparedness for disaster response; and financial resources and administrative efficacy in emergency medical services.
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The Predictors of Risk and Effectiveness Analysis of Emergency Medical Response Systems in Serbian Healthcare
The results from the multivariate regression analysis regarding the organization of EMS reveal that both the organization of working hours (β = 0.035) and shift work (β = 0.042) are the most significant predictors, together explaining 1.9% of the variance. Other factors, such as EMS teams working only in the clinic and financial resources, did not show statistically significant effects on EMS organization. This model (R2 = 0.019, Adj. R2 = 0.006, F = 2.78, t = 59.87, p < 0.05) explains 1.9% of the variance in the organization of EMS, considering all the independent variables included in the analysis (Table 3).
For the number of EMS points performed, the analysis indicates that the organization of shift work (β = −0.045) and working hours (β = −0.037) are significant predictors, accounting for 2.0% of the variance. In contrast, other variables like ambulance vehicles and financial resources did not contribute significantly to the model. This regression model (R2 = 0.020, Adj. R2 = 0.008, F = 3.15, t = 62.14, p < 0.05) explains 2.0% of the variance in the number of EMS points performed (Table 3).
When it comes to service area coverage, the regression results suggest that none of the predictors were statistically significant. Although the model (R2 = 0.027, Adj. R2 = 0.015, F = 3.50, t = 63.21, p ≥ 0.05) explains 2.7% of the variance in service area coverage, this relationship was not found to be statistically significant (Table 3).
Table 3. Results of a multivariate regression analysis concerning predictors for EMS organiza- tion, number of EMS points performed, service area coverage, EMS doctors, and mass casualty plans/procedures.
Predictor
Organization of EMS Number of EMS Points
Doctors
Service Area Coverage EMS
Plan/Procedures for Mass Casualty
Variable
Performed
B SE β B SE β B SE β B SE β B SE β
hours * *
0.032
0.038
0.012
0.042
0.041
0.013
0.045
work * *
0.043
*
0.047
0.015
0.048
0.049
0.016
0.051
shifts *
0.028
0.034
0.011
0.035
0.036
0.012
0.037
Organization of working Organization of
shift
0.03 0.01 0.035 −0.032 0.011 −0.037
0.04 0.012 0.042 −0.041 0.013 −0.045
0.029 0.012
0.039 0.014
EMS team working 0.065
0.015
0.062
−0.065
0.016
−0.063
0.067
0.017
0.064
0.072
0.018
0.07 *
0.075
0.019
0.073
Teams per day 0.058
0.014
0.058
−0.062
0.015
0.059
0.061
0.016
0.06
0.066
0.017
0.065 *
0.07
0.018
0.069
Teams per night 0.049
0.013
0.053
−0.051
0.014
−0.055
0.05
0.015
0.054
0.055
0.016
0.057
0.059
0.017
0.061
Teams per shift 0.034
0.01
0.038
−0.036
0.011
−0.039
0.035
0.012
0.037
0.041
0.012
0.043
0.044
0.013
0.046
Financial resources 0.023
0.009
0.029
−0.026
0.01
−0.028
0.025
0.011
0.027
0.031
0.012
0.031
0.033
0.013
0.033
Ambulance vehicles 0.06
0.012
0.06
−0.065
0.013
−0.065
0.067
0.014
0.067
0.072
0.015
0.072 *
0.075
0.016
0.075
Vehicle for mass 0.044
0.011
0.041
−0.048
0.012
−0.046
0.047
0.013
0.045
0.052
0.014
0.05
0.055
0.015
0.053
Plan/procedures 0.071
0.016
0.073
−0.071
0.017
−0.074
0.073
0.018
0.075
0.078
0.019
0.078
0.08
0.02
0.08
Organization of work in
only in the clinic shift for amb. tran. shift for amb. tran.
during weekends for the healthcare
0.027 0.009 0.029 −0.028 0.01 −0.031
0.026 0.011
casualties (disasters)
adj
R2 (R2 ) 0.019 (0.006) 0.020 (0.008) 0.027 (0.015) 0.035 (0.022) 0.041 (0.030)
* p ≤ 0.05; B: unstandardized (B) coefficients; SE: std. error; β: standardized (β) coefficients. Note: Note: EMS is organized as a separate institution (Institute for Emergency Medical Services), with multiple dislocated points for EMS, service area coverage of more than 1100 km2, higher total number of EMS doctors, the presence of a plan/procedure for mass casualties, shift work for working hours, shifts of 12 h, presence of an EMS team working only in the clinic, adequate financial resources for healthcare, ambulance vehicles functional for daily use, availability of a vehicle for mass casualties, availability and usage of triage tags, participation in exercises for responding to mass casualties, and joint exercises with other first responders have all been coded as 1. All other values have been coded as 0.
In the case of the EMS doctors, the presence of EMS teams working only in the clinic (β = 0.07) emerged as a significant predictor, explaining 3.5% of the variance. However, other factors, such as shift work and financial resources, did not show statistical significance. This model (R2 = 0.035, Adj. R2 = 0.022, F = 3.88, t = 64.45, p < 0.05) accounts for 3.5% of the variance in the total number of EMS doctors (Table 3).
Lastly, the regression analysis related to plans/procedures for mass casualties indi- cates that ambulance vehicle availability (β = 0.075) and financial resources (β = 0.033) are significant predictors, explaining 4.1% of the variance. Other variables, such as the organization of working hours, were not significant in this context. This model (R2 = 0.041, Adj. R2 = 0.030, F = 4.25, t = 65.72, p < 0.05) explains 4.1% of the variance in the presence of plans or procedures for mass casualties (Table 3).
These findings offer valuable insights into the essential factors driving the success of EMS organizations, particularly emphasizing the critical role of managing working hours and shift schedules, which have a direct impact on the efficiency of emergency medical interventions during disaster situations.
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Correlations and Influences of Demographic and Socioeconomic Factors on the Perception of Risk and Effectiveness Analysis of Emergency Medical Response Systems in Serbian Healthcare
Based on Pearson’s correlation results, there is a statistically significant correlation between the EMS organization and several key variables. These include the total number of EMS doctors (p = 0.000), the number of emergency medicine specialists (p = 0.000), the number of doctors in emergency medicine training (p = 0.000), the number of general prac- titioners in EMS (p = 0.001), the number of permanent EMS ambulance drivers (p = 0.000), the number of day shift teams on weekdays (p = 0.000), the number of night shift teams on weekdays (p = 0.000), the maximum distance from EMS headquarters to the hospital (p = 0.002), the gender distribution of male doctors (p = 0.000), the gender distribution of female doctors (p = 0.009), the number of male emergency medicine specialists (p = 0.000), and the number of female emergency medicine specialists (p = 0.000). On the other hand,
Table 4. Pearson’s correlation results for the relationship between various structural and operational characteristics of EMS and EMS organization, number of EMS points performed, and service area coverage (n = 172).
Variables
Organization of EMS
Number of EMS Points Performed
Service Area Coverage
Sig. r Sig. r Sig. r
Structural characteristics
Operational characteristics
Total number of EMS doctors 0.000 ** −0.340 0.139 0.199 0.190 −0.698
medicine
EMS doctors specialized in emergency 0.000 ** −0.424 0.135 0.213 0.909 0.072
EMS doctors in emergency medicine training 0.000 ** −0.430 0.139 0.203 0.857 0.112
EMS doctors specialized in general medicine 0.161 −0.125 0.042 0.702 0.750 0.197
EMS doctors practicing general medicine 0.001 ** −0.286 0.140 0.199 0.874 −0.126
Permanent EMS ambulance drivers 0.000 ** −0.344 0.128 0.244 0.905 0.074
Doctors with verified limited working capacity 0.068 −0.162 0.033* 0.762 0.981 0.015
Gender distribution of male doctors 0.000 ** −0.346 0.079 0.472 0.995 0.004
Gender distribution of female doctors 0.009 ** −0.231 0.103 0.343 0.866 0.105
Male emergency medicine specialists 0.000 ** −0.473 0.072 0.505 0.919 0.063
Female emergency medicine specialists 0.000 ** −0.338 0.066 0.404 0.435 0.460
Day shift teams on weekdays 0.000 ** −0.326 0.115 0.297 0.942 0.046
Night shift teams on weekdays 0.000 ** −0.409 0.124 0.257 0.992 0.006
Standby readiness for doctors 0.059 0.164 0.120 0.269 0.892 0.007
Standby readiness for nurses-techn. 0.088 0.149 0.113 0.299 0.321 0.08
Maximum diameter of the EMS service area 0.423 0.147 0.366 0.112 0.213 0.09
Max distance EMC to hospital 0.002 ** 0.275 0.132 0.228 0.163 0.837
Average time spent by medical teams (min) 0.817 −0.020 −0.057 0.597 0.232 0.654
Average time spent by transport teams (min) 0.732 −0.030 −0.060 0.582 0.338 −0.549
** p ≤ 0.01.
Additionally, a statistically significant correlation was identified between the number of EMS points performed and the variable “doctors with verified limited working capacity” (p = 0.033). However, no significant correlations were found with other variables (Table 4). Further analyses revealed that as the total number of EMS doctors grows, the organization of EMS services tends to become more structured and effective. A similar pattern is observed with the increase in emergency medicine specialists, where their presence boosts both specialization and the system’s ability to respond swiftly to emergencies. As more doctors enter emergency medicine training, the EMS organization gains strength, which signals a clear emphasis on preparing for the future. Additionally, having more general practitioners involved in EMS correlates with improved coverage and a more solid organizational structure, while a greater number of permanent EMS ambulance drivers leads to noticeable gains in operational efficiency and the overall organization of EMS.
Moreover, adding more day shift teams during weekdays results in better resource management and a more organized EMS system. Similarly, an increase in night shift teams enhances the system’s flexibility, allowing it to meet nighttime demands more effectively. Also, the analysis also pointed out that as the distance between EMS headquarters and the hospital increases, the organization becomes more structured to ensure a timely response and smooth patient transfer. Regarding gender distribution, a higher percentage of male doctors is linked to a more structured EMS organization, which might be influenced by staffing patterns. On the other hand, an increase in female doctors brings balance to the organization, possibly reflecting a more diverse range of roles within the staff. When the number of male emergency medicine specialists rises, the organization becomes more specialized, focusing on emergency care, and a similar effect is seen with female specialists, where their growing presence contributes to improved preparedness and organization
within EMS. In addition, the data indicate that as the number of doctors with verified limited working capacity increases, there is also an increase in the number of EMS points performed, suggesting that staffing adjustments have been made to accommodate these limitations.
Recognizing the significant correlations between demographic and socioeconomic factors and EMS organization paves the way for further exploration into optimizing hu- man resources and resource allocation. This research could ultimately enhance disaster response efforts.
The results of the Chi-square test highlight a statistically significant correlation be- tween the organization of emergency medical services (EMS) and several critical variables. Notably, there is a strong relationship between EMS organization and how EMS activities are conducted (p = 0.001), the number of points where these activities take place (p = 0.005), and the structure of working hours (p = 0.001). The organization of shift work (p = 0.001) and the presence of a dedicated EMS team working exclusively in the clinic (p = 0.004) also show significant correlations (Table 5).
Table 5. Chi-square test results examine the relationship between different variables and the organi- zation of EMS, employee (EMS) training, and plans/procedures regarding mass casualty.
Variable
Organization of EMS
Employees (EMS) Training
Plan/Procedures Mass Casualty
p
X2
p
X2
Conducting EMS activities
0.001 **
190.38
0.001 **
126.64
0.001 **
110.05
Number of points EMS
0.005 **
86.99
0.107
25.68
0.526
16.56
Organization of working hours
0.000 **
194.06
0.002 **
134.01
0.000 **
113.90
Organization of shift work
0.001 **
76.13
0.001 **
34.58
0.055
14.49
Organization of work in shifts
0.006 **
85.40
0.065
23.13
0.000 **
42.14
EMS team working only in the clinic
0.004 **
165.43
0.005 **
147.07
0.060
18.23
Teams per day shift for amb. transport
0.001 **
265.23
0.001 **
154.02
0.000 **
140.43
Teams per night shift for amb. transport
0.000 **
185.06
0.003 **
127.23
0.000 **
126.24
Teams per shift during weekends
0.000 **
223.92
0.001 **
143.07
0.000 **
124.43
Ambulance transport team
0.001 **
142.18
0.056
16.98
0.000 **
133.37
On-call duty, leave the territory
0.003 **
154.18
0.001 **
142.88
0.000 **
123.21
Regular shift workload
0.001 **
140.29
0.006 **
153.06
0.000 **
131.61
Number of doctors in EMC
0.006 **
236.17
0.007 **
160.02
0.000 **
138.07
Systematic medical examinations
0.002 **
126.85
0.285
53.05
0.313
52.24
Verified limited work capacity
0.005 **
115.26
0.320
68.18
0.000 **
148.73
Number of ambulance drivers
0.000 **
211.04
0.160
34.30
0.909
9.128
Separate phone number for amb. transport
0.007 **
129.06
0.000 **
179.29
0.875
35.75
Call identification capability
0.018 *
159.62
0.004 **
175.19
0.453
28.07
Protocol/procedure for receiving calls
0.023 *
116.4
0.000 **
176.43
0.000 **
154.63
Presence of a call recorder
0.003 *
169.14
0.001 **
174.02
0.000 **
150.10
Recording conversations
0.001 **
153.06
0.065
43.65
0.232
46.01
Communication with teams in the field
0.005 **
151.13
0.001 **
179.06
0.000 **
152.96
Presence of radio stations in ambulances
0.001 **
124.43
0.003 **
172.02
0.000 **
148.92
Condition of radio repeaters
0.008 **
134.18
0.204
34.01
0.000 **
18.56
Power supply device for the radio system
0.001 **
123.02
0.001 **
183.02
0.000 **
145.05
Dedicated communication: police
0.005 **
127.01
0.000 **
172.14
0.001 **
124.04
Monitoring reaction time of interventions
0.001 **
174.44
0.000 **
185.93
0.005 **
162.87
Dedicated communication firefighers
0.003 **
119.02
0.002 **
172.14
0.003 **
148.73
Training for emergency medicine doctors
0.004 **
105.01
0.001 **
187.01
0.005 **
139.01
Training for emergency medicine nurses
0.003 **
102.07
0.002 **
175.01
0.001 **
23.08
Financial resources for the healthcare
0.001 **
156.07
0.003 *
165.45
0.000 **
211.76
Ambulance vehicles
0.765
15.06
0.001 **
197.32
0.005 **
175.20
Vehicle for mass casualties (disasters)
0.005 **
130.52
0.001 **
159.67
0.000 **
172.45
Plan/procedure: mass casualties
0.001 **
110.30
0.005 **
149.32
0.000 **
215.65
Triage tags
0.003 **
118.01
0.002 **
150.2
0.045
35.53
Exercises for responding to mass casualties
0.001 **
103.32
0.001 **
149.01
0.000 **
178.34
Joint exercises with other first responders
0.003 **
109.11
0.005 **
139.04
0.000 **
160.14
* p ≤ 0.05; ** p ≤ 0.01.
In addition, the number of ambulance transport teams per shift during the day (p = 0.001), night (p = 0.001), and weekends (p = 0.001) is significantly tied to EMS or- ganization. Other relevant factors include the composition of the ambulance transport team (p = 0.001), on-call duties in cases where the team needs to leave the territory (p = 0.003), and whether the regular shift workload includes additional responsibilities (p = 0.001). Further significant correlations emerged regarding the number of doctors in EMS (p = 0.006), the regularity of annual medical examinations for doctors (p = 0.002), limited work capacity (p = 0.005), and the number of ambulance drivers (p = 0.001). Communication-related aspects such as having a separate phone number for ambulance transport (p = 0.007), call identification features (p = 0.018), the presence of a call recorder (p = 0.003), and recording calls on this system (p = 0.001) also demonstrated significant relationships (Table 5).
Moreover, the condition of radio repeaters (p = 0.008), the installation of radio stations in ambulances (p = 0.001), and having a power supply backup for the radio system in case of outages (p = 0.001) were all significantly correlated with EMS organization. Lastly, factors such as maintaining a dedicated communication channel with the police (p = 0.005) and firefighters–rescuers (p = 0.003), monitoring response times during interventions (p = 0.001), and training for emergency medicine doctors (p = 0.004) and nurses (p = 0.003) also showed significant associations (Table 5).
The results from the Chi-square test reveal statistically significant correlations between EMS employee training and a range of key variables. Notably, there is a strong correlation between EMS employee training and the conducting of EMS activities (p = 0.001), as well as with the organization of working hours (p = 0.002) and shift work (p = 0.001). Additionally, significant correlations were identified between EMS employee training and the number of ambulance transport teams working both day (p = 0.001) and night (p = 0.003) shifts, along with those working on weekends (p = 0.001). The data also shows significant relationships between EMS employee training and the organization of on-call duty when teams are outside their designated areas (p = 0.001), the implementation of protocols and procedures for receiving calls (p = 0.000), and the monitoring of response times during interventions (p = 0.000). Moreover, there are strong correlations with the availability of dedicated communication channels with the police (p = 0.000) and firefighters (p = 0.002), as well as with the financial resources allocated to healthcare (p = 0.003). EMS employee training also shows significant correlations with the presence of triage tags (p = 0.002), exercises for responding to mass casualty incidents (p = 0.001), and joint exercises with other first responders (p = 0.005). For the remaining variables, no statistically significant correlations were found (Table 5).
Further analysis shows that conducting EMS activities is notably more effective in institutions where employees have undergone formal training at recognized centers. These institutions exhibit a higher level of operational readiness, ensuring their staff is well- prepared to handle various medical emergencies. This preparation is evident in their ability to allocate tasks more efficiently, reducing the risk of errors during critical incidents. Also, when it comes to organizing working hours, institutions with formally trained staff are more likely to implement structured shifts (41.9%). This structured approach allows for better shift management, ensuring that trained personnel are available around the clock to handle emergencies. This leads to more consistent and dependable service delivery.
Similarly, institutions with trained EMS personnel are more likely to utilize shift work (42.4%), which supports continuous service provision. This systematic organization of shifts allows them to respond effectively to increased demand during peak periods, ensuring that qualified professionals are always present. For teams working exclusively in clinics, training in established centres correlates with better organizational efficiency (28.9%). Such institutions are more adept at handling clinic-based interventions, as their specialized training equips staff with the necessary skills to manage specific medical scenarios. Resource allocation during day shifts, particularly for ambulance transport, is more efficient in institutions with trained EMS staff (43.5%). This allows for more effective use of teams during busy hours, facilitating quicker responses to disasters.
At night, these institutions also excel in organizing shifts for ambulance transport (43.0%), ensuring adequate staffing during off-peak hours. This ability to maintain round- the-clock coverage helps meet emergency transport needs effectively. During weekends and holidays, institutions with trained staff are better equipped to manage ambulance transport
services (47.1%), ensuring they can handle high demand without sacrificing care quality. When it comes to on-call duties, particularly when teams need to leave their designated areas, institutions with trained EMS staff demonstrate better management (42.4%). These organizations can maintain sufficient coverage, even when on-call teams are deployed to other locations.
Regular shift workloads are more effectively managed in institutions with trained personnel (48.6%). This allows them to balance emergency response with routine medical tasks without overwhelming their teams. In terms of staffing, institutions with more trained EMS personnel tend to have a more balanced distribution of doctors across teams (42.4%), ensuring that medical expertise is available whenever needed, thereby enhancing the quality of care provided. Institutions with dedicated ambulance transport phone lines (55.0%) are also more common where staff have received formal training. This specialization enhances their ability to coordinate emergency responses and streamline communication. The implementation of call identification systems is more prevalent in institutions with trained EMS staff (45.3%), improving their ability to direct resources efficiently to where they are most needed, which shortens response times. Furthermore, institutions with trained personnel are more likely to have established protocols for handling emergency calls (53.2%). These protocols ensure standardized call handling, minimizing the risk of miscommunication or delays in critical situations. The presence of call recording devices
Reliable communication with teams in the field is another advantage seen in insti- tutions with trained personnel, where the use of radio systems is more frequent (46.6%). This ensures real-time coordination and response adaptability in the field. Ambulances in institutions with trained staff are more likely to be equipped with radio stations (58.4%), which facilitates continuous communication and improves the speed of coordination dur- ing emergency responses. Moreover, institutions with trained employees are more likely to have backup power systems for their radio equipment (42.4%), ensuring uninterrupted communication even during power outages, which is vital for maintaining service con- tinuity in emergencies. Dedicated communication channels with the police are another feature more commonly found in institutions with trained staff (56.7%). This enhances coordination during joint operations, ensuring effective collaboration between EMS teams and law enforcement during disasters.
Monitoring reaction times to interventions is also more common in institutions with trained EMS employees (47.9%). This practice enables these organizations to evaluate and improve their response times, enhancing overall service delivery. Dedicated communication lines with firefighters are prevalent in institutions with trained EMS personnel (56.7%), facilitating better coordination during fire-related emergencies and ensuring that medical support is promptly provided. Institutions that prioritize training for their emergency medicine doctors tend to have better-prepared staff overall (42.4%), with the latest medical skills and knowledge needed to address a wide range of emergency situations effectively. The same is true for institutions that invest in the training of emergency medicine nurses (42.4%). This ensures nursing staff is well-equipped to handle high-pressure situations and deliver high-quality care during emergencies.
Additional financial resources allocated to healthcare are more common in institu- tions with trained EMS personnel (40.7%). This funding supports investment in training programs, leading to an expanded workforce and improved service delivery. Ambulance fleets in institutions with trained EMS staff are more likely to be well-maintained (42.4%), ensuring their readiness for immediate deployment in emergency scenarios and enhancing the overall responsiveness of the institution. Specialized vehicles for mass casualty events are also more common in institutions with trained EMS personnel (34.7%). This training enables staff to effectively manage large-scale emergencies, particularly in terms of the logistics of transporting multiple patients.
Institutions with trained staff are more likely to have written plans and procedures in place for mass casualty incidents (48.8%). These protocols ensure that all personnel are well-prepared for large-scale emergencies, enhancing their readiness and response capabilities. Triage tags, used to prioritize patients in mass casualty situations, are more readily available in institutions with trained EMS personnel (34.7%). This ensures that patients in the most critical condition receive attention first, improving the overall efficiency of care during such events. Regular drills and exercises for responding to mass casualty situations are more common in institutions with trained staff (41.8%). These exercises help teams refine their procedures and ensure they are ready to act quickly and effectively in real emergencies. Joint exercises with other first responders, such as police and firefighters, are also more frequently conducted in institutions with trained EMS personnel (41.8%). These collaborative exercises improve the coordination between different emergency services, enhancing the overall effectiveness of joint responses during major incidents.
Similarly, the Chi-square test results demonstrate statistically significant correlations between plans and procedures for mass casualty events and several critical variables. These include conducting EMS activities (p = 0.001), the organization of working hours (p = 0.000), and the presence of ambulance transport teams working during both day (p = 0.000) and night (p = 0.000) shifts. Additionally, significant correlations were observed between mass casualty event planning and the organization of on-call duty (p = 0.000), as well as the existence of protocols and procedures for receiving calls (p = 0.000). There is also a strong correlation between the presence of radio communication equipment in ambulances (p = 0.000) and the monitoring of response times during interventions (p = 0.005). Finally, plans for mass casualty events are significantly associated with the availability of vehicles for such incidents (p = 0.000), the presence of triage tags (p = 0.045), and the organization of joint exercises with other first responders (p = 0.000). No statistically significant correlations were identified for the remaining variables (Table 5).
Furthermore, results show that institutions that have written plans and procedures for mass casualty events demonstrate greater success in conducting EMS activities. These institutions are more likely to provide services from multiple dislocated points (55.9% for 47 institutions with plans) compared to those without such plans (55.3% for 21 institutions). The structured approach afforded by these plans helps streamline operations across various locations, ensuring a broader reach and better preparedness for emergencies. The organiza- tion of working hours also benefits from the existence of mass casualty plans. Institutions with these plans are more inclined to implement shift work (52.4% for 44 institutions) com- pared to those without plans (60.5% for 23 institutions). This structure facilitates continuous service provision, allowing institutions to maintain operational efficiency and ensure staff availability at all times, particularly during high-demand periods.
When it comes to ambulance transport teams, institutions with mass casualty plans ex- cel in organizing both day and night shifts. These institutions effectively allocate resources during peak times (58.3% for day shifts and 51.2% for night shifts), compared to those without plans. Additionally, the existence of such plans enables better management of on-call duties (60.7% for 51 institutions with plans), especially when teams need to operate outside their designated territories, ensuring uninterrupted coverage.
Institutions with mass casualty plans are also more likely to have established protocols and procedures for receiving emergency calls (78.6% for 66 institutions). This formalized process enables them to manage critical situations more effectively than institutions without plans (39.5% for 15 institutions). Furthermore, these institutions are better equipped with radio communication systems in ambulances (79.8% for 67 institutions), which enhances coordination during interventions and ensures seamless communication between teams.
Monitoring response times is another area where institutions with mass casualty plans outperform. By tracking response times (63.1% for 53 institutions), they can evaluate their efficiency and make necessary adjustments to improve overall performance. Moreover, these institutions are more likely to have specialized vehicles for mass casualty incidents (10.7% for 9 institutions), making them better prepared to handle large-scale emergencies
compared to institutions without plans (2.6% for 1 institution). Lastly, the presence of mass casualty plans correlates with the availability of triage tags (40.5% for 34 institutions) and the organization of joint exercises with other first responder services (58.3% for 49 in- stitutions). These factors contribute to enhanced coordination and preparedness during emergencies, ensuring that all agencies involved are well-equipped to respond effectively to mass casualty events.
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Organizational Structure and Risk Management of Emergency Medical Services (EMS)
Table 6. Organizational and operation of emergency medical services (EMSs).
Variables Category n %
No organized emergency medical service 2
1.44
Special institution—Institute for Emergency Medical Services 5
3.60
Organization of EMS in Within a special Emergency Medical Service department of a health center 64
46.04
Facility
Within the general medical service (through regular work and duty of doctors and other health workers)
Within the general medical service, as a separate organizational unit for emergency medical services
47 33.81
21 15.11
Conducting EMS Activities
Number of points where EMS
From a single location 46 26.7
Within a healthcare facility 78 45.3
From multiple dislocated points 13 7.6
From 3 to 5 points
4
4.44
From 6 to 10 points
4
4.44
From 0 to 2 points 80 88.89
activities are conducted
From 11 to 50 points
1
1.11
From 51+ points
1
1.11
Organization of working
Shift work
95
55.2
hours
Rotating shifts
77
44.8
In shifts of 12 h
138
80.2
Organization of shift work
Other
14
8.1
In shifts of 8 h
20
11.6
Day shift—24 h off—night shift—48 h off
33
24.44
Organization of work in shifts
Day shift—24 h off—night shift—72 h off
70
51.85
Day shift—48 h off—night shift—48 h off
32
23.70
1 team (all variations)
87
50.6
Team configurations during
2 teams (all variations)
29
16.9
daytime shifts on weekdays
3 or more teams
6
3.5
Special configurations
48
27.9
Table 6. Cont.
Variables Category n %
0 teams
2
1.2
Team configurations during 1 team (all variations)
83
48.3
nighttime shifts on weekdays 2 teams (all variations)
28
16.3
3 or more teams
19
11.0
Special configurations
40
23.2
Healthcare Management Plan Yes
49
28.5
have a team that only works N/A
38
22.1
in the clinic No
85
49.4
Teams in the clinic during the 1 team (including various descriptions)
110
64.0
daytime on weekdays 2 teams
14
8.1
3 or more teams (special configurations)
12
7.0
Teams in the clinic during the 0 teams
26
15.1
nighttime on weekdays 1 team (including various descriptions)
124
72.1
Transport by a team of medical nurse-technician and driver
33
19.2
Clinic team configurations for daytime shifts predominantly involve one team (64.0%), optimizing resource allocation for clinic operations. A smaller segment employs two teams (8.1%) or three or more teams (7.0%), reflecting complex operational demands. At nighttime, 72.1% of clinics maintain operations with one team, whereas 15.1% report no teams, possibly relying on emergency services for critical care during these hours. Finally, transport by a team composed of a medical nurse-technician and driver accounts for 19.2% of facilities,
This examination of EMS structures highlights the importance of standardizing or- ganizational models and refining protocols, which could strengthen emergency response capabilities across various regions in Serbia.
Table 7. Comprehensive overview of emergency medical services (EMS) structure, operations, and geographical coverage.
Variables Category n %
No teams reported
9
5.2
1-team configurations
106
43.0
Medical transport teams during daytime shifts on 2-team configurations
39
14.0
weekdays 3-team configurations
7
4.1
4-team configurations
7
4.1
5-team configurations
2
1.2
More than 5-team configurations
3
1.7
Medical transport teams during nighttime shifts on No teams reported
34
19.8
weekdays 1 team (including all 1-team variations)
126
47.7
2 teams (including all 2-team variations)
10
5.8
Nurse-technician and vehicle driver
67
29.7
Composition of medical transport teams Other
31
13.4
Vehicle driver
74
33.1
Standard team (doctor, nurse/technician, driver)
65
37.8
Driver only or driver with occasional medical staff
29
16.9
Medical transport team configurations Teams formed based on specific needs
24
14.0
No specific team required for transport only
17
9.9
Variable teams depending on patient condition
36
20.9
Other unspecified configurations
1
0.6
Organization of preparedness for medical teams Yes
74
43.0
No
98
57.0
Organization of preparedness for vehicle drivers Yes
83
48.3
No
89
51.7
0–10
27
15.7
11–30
25
14.5
Average holding time of medical teams (in min) 31–60
27
15.7
61–120
31
18.0
121–240
22
12.8
241 min and above
16
9.3
Table 7. Cont.
Variables Category n %
Under 10
19
11.0
10–30
26
15.1
Average holding time of transport teams (in min) 31–60
32
18.6
61–120
30
17.4
121–240
19
11.0
241 min and above
6
3.5
Less than 100 km2
12
7.0
100–200 km2
18
10.5
200–300 km2
18
10.5
300–400 km2
35
20.3
400–500 km2
18
10.5
Area covered by health services (HMP) 500–600 km2
14
8.1
600–700 km2
14
8.1
700–800 km2
13
7.6
800–900 km2
10
5.8
900–1000 km2
1
0.6
1000–1100 km2
9
5.2
Other
8
4.7
The largest diameter of territory covered by health Under 30 km
32
18.6
services (HMP) 30–60 km
104
60.5
Over 60 km
37
21.5
0–25 km
50
29
Maximum distance from HMP headquarters to 25–50 km
53
31
corresponding hospital 50–75 km
28
16
Over 75 km
41
24
Under 30 km
27
15.7
Maximum distance from HMP headquarters to the 30 to 60 km
39
22.7
corresponding tertiary healthcare center 60 to 90 km
41
23.8
Over 90 km
49
28.5
Yes
45
26.2
Institutions cover part of the highway N/A
41
23.8
No
86
50.0
Under 25 km
40
23.3
Distances that institutions cover part of a highway 25 to 50 km
35
20.3
50 to 75 km
30
17.4
Over 75 km
22
12.8
Seasonal variations in the population numbers Yes
84
48.8%
within the HMP’s jurisdiction N/A
41
23.8%
No
47
27.3%
Under 1000
70
40.7%
Specific population increases reported during 1000 to 5000
64
37.2%
seasonal variations within the HMP’s jurisdiction 5001 to 10,000
18
10.5%
10,001 to 30,000
33
19.2%
Over 30,000
7
4.1%
Seasonal population increases reported by Short-Term (1–3 months)
92
53.5
institutions Mid-Term (4–5 months)
41
23.8
Long-Term (6 months)
39
22.7
Seasonal Tourism and Migration
65
37.8
Returnees and Temporary Residents
34
19.8
Reasons for the increase in the population or users of Local Events and Activities
25
14.5
HMP services Migrants
11
6.4
Regional Center
5
2.9
Tourist Center
32
18.6
Table 7. Cont.
Variables
Category
n
%
Regular shift’s workload, beyond the scope of Yes
112
65.1
managing urgent care, includes additional activities N/A
41
23.8
No
19
11.0
Extent of additional activities by staff type From On-Call Duty
43
25.0
From Regular Staff
129
75.0
Organization of transport teams during the night shift for urgent medical care
Transport by a team of medical nurse-technician and driver
Transport by a complete medical team (doctor, nurse-technician, driver)
33 19.2
127 73.8
Transport by a medical vehicle driver only 12 7.0
Transport by a team of medical nurse-technician and driver
33 19.2
Healthcare service coverage (HMP) ranges widely, with the most common area be- ing 300–400 km2 (20.3%). Many facilities cover areas between 100–200 km2 (10.5%) and 400–500 km2 (10.5%), demonstrating varying regional service demands. The typical terri- tory diameter is 30–60 km (60.5%), indicating broad reach within the healthcare system. Also, the maximum distance from HMP headquarters to hospitals is primarily 25–50 km (31%), suggesting strategic facility placement for timely patient transport. For tertiary centers, the most common distances are 60–90 km (23.8%), reflecting the distribution of specialized services. Institutions covering parts of a highway report mixed responses: 50.0% indicate no coverage, 26.2% confirm coverage, and 23.8% find it non-applicable. Highway access is crucial for efficient logistics and rapid emergency site access (Table 7).
-
Resource Allocation and Effectiveness in Emergency (Disaster) Preparedness
In emergency medical service (EMS) facilities, a significant number, precisely 25.58%, function with a moderate staffing model of 3 to 5 doctors. This configuration appears to be
Table 8. Distribution of doctors and specialists in emergency medical services.
Variables Category n %
0–2 doctors
20
11.63
3–5 doctors
44
25.58
Doctors in emergency medical 6–8 doctors
31
18.02
services 9–11 doctors
31
18.02
12–15 doctors
19
11.05
More than 15 doctors
15
8.72
0–2 doctors
89
51.74
3–5 doctors
27
15.70
Specialists in emergency 6–8 doctors
7
4.07
medical services 9–11 doctors
3
1.74
12–15 doctors
2
1.16
More than 15 doctors
4
2.33
0–2 doctors
116
67.44
Doctors in emergency medical 3–5 doctors
8
4.65
services (EMS) specialists who 6–8 doctors
2
1.16
are in training for emergency 9–11 doctors
1
0.58
medicine 12–15 doctors
1
0.58
More than 15 doctors
0
0.00
Doctors in emergency medical 0–2 doctors
100
58.14
services (EMS) who are 3–5 doctors
23
13.37
specialists in general medicine 6–10 doctors
4
2.33
More than 10 doctors
1
0.58
General medicine doctors in 0–4 doctors
74
43.02
emergency medical services 5–9 doctors
42
24.42
(EMS) 10–19 doctors
11
6.40
20 or more doctors
0
0.00
Institutions have other Yes
94
54.7
specialities Not Applicable
43
25.0
No
35
20.3
General medicine (general practitioners)
30
17.4
Medical specialities in institutions
Specialized medicine (all specialized fields like gynaecology, paediatrics, etc.) Diagnostics and lab (radiology, biochemistry, etc.)
Surgical specialities (surgery-related fields)
Other specialties (less common specialties)
85 49.4
40 23.3
10 5.8
7 4.1
Among doctors undergoing emergency medicine training, most EMS institutions (67.44%) have 0 to 2 doctors in training, pointing to opportunities for growth in workforce development. A smaller segment, 4.65%, reports 3 to 5 doctors in training, with even fewer institutions having 6 to 8 doctors at 1.16% and 9 to 11 doctors at 0.58%. Looking at EMS doctors who are specialists in general medicine, 58.14% of institutions are staffed with 0 to
- specialists, indicating a tendency toward employing generalists. Another 13.37% have
Among medical specialties, 49.4% of institutions are dedicated to specialized fields, in- cluding gynecology and pediatrics, showcasing the breadth of available expertise. General medicine makes up 17.4% of specialties, playing a crucial role in foundational healthcare. Diagnostics and laboratory services represent 23.3%, emphasizing their importance in medical facilities. Surgical specialties are found in 5.8% of institutions, with other less common specialties making up 4.1%, highlighting the varied medical landscape in these settings (Table 8). These findings underscore the diverse distribution of medical staff and specialties within EMS, with a strong focus on moderate-sized teams and generalists, while also identifying potential areas for specialist expansion and service diversification.
The findings suggest that the strategic readiness of EMS, particularly in resource allocation and team configuration, is vital for maintaining operational efficiency during high-demand periods and large-scale emergencies. Strengthening these areas could signifi- cantly improve EMS responsiveness and overall disaster preparedness.
Table 9. Distribution of doctors and nursing staff by gender and specialization.
Variables
Category
n
%
0–5 doctors
71
41.3
6–10 doctors
27
15.7
Gender distribution of male doctors
11–20 doctors
21
12.2
21–30 doctors
4
2.3
More than 30 doctors
5
2.9
0–5 Doctors
52
30.2
6–10 Doctors
33
19.2
Gender distribution of female doctors
11–20 Doctors
30
17.4
21–30 Doctors
7
4.1
More than 30 Doctors
6
3.5
Table 9. Cont.
Variables Category n %
0–2 doctors
107
62.2
3–5 doctors
16
9.3
Male specialists in emergency medicine 6–10 doctors
5
2.9
11–15 doctors
1
0.6
more than 15 doctors
1
0.6
0–2 doctors
113
65.7
Female specialists in emergency 3–5 doctors
10
5.8
medicine 6–10 doctors
2
1.2
11–20 doctors
1
0.6
more than 20 doctors
1
0.6
Male doctors in specialization for 0 doctors
97
56.4
emergency medicine 1–2 doctors
24
14.0
3–5 doctors
6
3.5
Female doctors in specialization for 0 doctors
93
54.1
emergency medicine 1–2 doctors
28
16.3
3 or more doctors
5
2.9
0 doctors
77
44.8
Male general medicine specialists 1–2 doctors
42
24.4
3 or more doctors
8
4.7
0 doctors
61
35.5
Female general medicine specialists 1–2 doctors
41
23.8
3–5 doctors
17
9.9
6 or more doctors
7
4.1
0–2 doctors
84
48.8
Male general medicine doctors 3–5 doctors
33
19.2
6–10 doctors
9
5.2
more than 10 doctors
1
0.6
0–2 doctors
50
29.1
Female general medicine doctors 3–5 doctors
35
20.3
6–10 doctors
24
14.0
11 or more doctors
17
9.9
Male nursing staff with higher 0–1
104
60.5
education 2–4
17
9.9
5 or more
5
2.9
Female nursing staff with higher 0–2
95
55.2
education 3–5
16
9.3
6 or more
16
9.3
0–5
76
44.2
Male nursing technicians with 6–10
22
12.8
secondary education 11–20
13
7.6
21 or more
16
9.3
0–5
76
44.2
0–5
35
20.3
Female nursing technicians with 6–10
41
23.8
secondary education 11–20
35
20.3
21–30
11
6.4
31 or more
5
2.9
Regarding female doctors, 30.2% of institutions have 0 to 5 doctors, marking the most common staffing range for women in the field. Meanwhile, 19.2% employ 6 to 10 female doctors, and 17.4% have 11 to 20, showing a somewhat more balanced distribution compared to male doctors. Only 4.1% of institutions have 21 to 30 female doctors, while
For male nursing technicians with secondary education, 44.2% of institutions employ 0 to 5 technicians, indicating a common staffing range. Meanwhile, 12.8% have 6 to 10,
with smaller percentages of 7.6% and 9.3% employing 11 to 20 and 21 or more technicians, respectively. Female nursing technicians with secondary education are less prevalent, with 20.3% of institutions having 0 to 5 technicians. A higher proportion, 23.8%, have 6 to 10, while 20.3% employ 11 to 20, and smaller percentages employ more, indicating a more even distribution of female nursing technicians across different staffing levels (Table 9). Overall, these data suggest that while gender distribution in EMS is generally balanced, opportunities exist to enhance specialization, particularly among male and female specialists in emergency and general medicine. Additionally, increasing the presence of both male and female nursing staff could further support comprehensive healthcare delivery.
For doctors under the age of 30, a substantial majority of institutions, about 61.0%, report having just 0 to 1 doctor. This suggests a relatively low presence of younger doctors within the workforce. A smaller portion, 11.0%, employs between 2 and 5 doctors, while only 1.2% have 6 or more, indicating challenges in recruiting or retaining young doctors. In
Table 10. Age distribution and work capability in medical and emergency services.
Variables Category n
%
0–1
105
61.0
Age structure data for doctors under the age of 30
2–5
19
11.0
6 or more
2
1.2
0–5
39
22.7
6–10
39
22.7
Doctors aged 30–55
11–20
48
27.9
21–30
14
8.1
31 or more
7
4.1
0–5
85
49.4
Doctors over the age of 55
6–10
19
11.0
11 or more
23
13.4
education
5 or more
10
5.8
0–5
29
16.9
6–10
33
19.2
Nursing technicians aged 30–55
11–15
24
14.0
16–20
11
6.4
21 or more
30
17.4
0–2
60
34.9
he age of 30 with secondary 0–1 89 51.7
2–4
27
15.7
Nursing technicians under t
Nursing technicians over the age of 55
3–5
6–10
37
18
21.5
10.5
11 or more
11
6.4
No limitation
106
61.6
Doctors with verified limited work capacity
Minor limitation
18
10.5
Significant limitation
3
1.7
Doctors comply with the legal requirement to undergo
Yes
81
47.1
annual systematic medical examinations
No
46
26.7
Medical nurses and technicians comply with the legal
Yes
78
45.3
requirement for annual systematic examinations
No
49
28.5
Ambulance drivers regarding compliance with the legal
Yes
111
64.5
requirement for annual systematic examinations
No
16
9.3
Medical nurses and technicians with verified limited work No Limitation
92
53.5
capacity Minor Limitation
31
18.0
Significant Limitation
4
2.3
0–5
77
44.77
Ambulance drivers per vehicle in the Emergency Medical 6–15
34
19.77
Service (HMP) 16–30
10
5.81
31–70
5
2.91
71+
1
0.58
Table 10. Cont.
Variables Category n %
0–16
115
66.9
Ambulance drivers in HMP service (permanent employees) 17–33
11
6.4
34–66
1
0.6
Ambulance drivers in the Emergency Medical Service by 0–1
89
51.7
contract type (Fixed-term Employees) 2–3
26
15.1
4–10
11
6.4
Ambulance drivers on fixed-term contracts with secondary 0–1
97
56.4
education 2–6
25
14.5
8–20
5
2.9
Ambulance drivers based on their shifts per month with 0
115
66.9
completed traffic school education 1–3
10
5.8
10
1
0.6
Ambulance drivers who have undergone special training 0
104
60.5
under the National Emergency Medicine Education 1–6
16
9.3
Program in the past two years 8–71
7
4.1
0–9
98
57.0
Male ambulance drivers 10–29
24
14.0
30–69
5
2.9
70 and above
1
0.6
0
123
71.5
Female ambulance drivers 1–2
2
1.2
6
1
0.6
0
86
50.0
Ambulance drivers under the age of 30 1–2
30
17.4
3–6
9
5.2
20
1
0.6
0–5
82
47.7
Ambulance drivers aged 30 to 55 6–15
33
19.2
17–33
10
5.8
50 and above
3
1.7
0–3
109
63.4
Ambulance drivers over the age of 55 4–10
15
8.7
12 and above
3
1.7
0
119
69.2
Ambulance drivers with verified limited work capability 1–3
7
4.1
6
1
0.6
Among nursing technicians under 30 with secondary education, 51.7% of institutions employ 0 to 1 technician, highlighting limited entry-level opportunities. Meanwhile, 15.7% employ 2 to 4 technicians, and only 5.8% have 5 or more, indicating a focus on retaining more experienced staff. Nursing technicians aged 30 to 55 show a diverse distribution. Around 16.9% of institutions have 0 to 5 technicians, while 19.2% have 6 to 10. Notably,
Among doctors, 61.6% report no verified limitations in work capacity, indicating a generally healthy workforce. However, 10.5% have minor limitations, and 1.7% have significant ones, suggesting areas for intervention to maintain productivity. Compliance with annual medical examinations is relatively high among doctors, with 47.1% meeting the requirements. However, 26.7% do not comply, revealing potential gaps in regulatory
adherence. For medical nurses and technicians, 45.3% comply with annual examinations, while 28.5% do not, indicating similar compliance challenges as seen with doctors (Table 10). Among ambulance drivers, compliance with annual medical examination require- ments is strong, with 64.5% adhering to standards. Nonetheless, 9.3% do not comply, highlighting areas for improvement. Regarding work capability, 69.2% of ambulance drivers report no verified limitations, indicating a robust workforce. However, 4.1% have minor limitations, and 0.6% face significant limitations, underscoring the need for ongoing health assessments. The age distribution of ambulance drivers shows that 50.0% are under 30, indicating a youthful workforce. However, 17.4% are aged 30 to 55, while 63.4% are
over 55, highlighting a significant proportion nearing retirement age (Table 10).
-
Communication Systems and Effectiveness in Coordinated Response
Table 11. Communication channels and call management in emergency services.
Variables Category n %
Phone number to call (from the territory under your HMP jurisdiction) in case of intervention
194 59 34.3%
Other 68 39.5%
The specific phone number for registering for Yes
40
23.3%
ambulance transport? N/A
45
26.2%
No
87
50.6%
Yes
78
45.3%
Capability to identify incoming calls
N/A
45
26.2%
No
49
28.5%
Doctor
24
14.0%
Who receives calls
Nurse/Technician
Nurse/Technician only with doctor consultation
24
18
14.0%
10.5%
Mixed model (nurse, doctor)
61
35.5%
Yes
93
54.1%
Protocol/procedure for receiving calls
N/A
45
26.2%
No
34
19.8%
The ability to identify incoming calls—a crucial factor in prioritizing emergency responses—is implemented in 45.3% of the units. This feature substantially boosts the responsiveness of services, facilitating the swift identification of repeat or critical calls. In contrast, the absence of this capability in 28.5% of the units might hinder timely responses, necessitating manual verification of calls.
Furthermore, protocols for managing calls, essential for the standardization and efficiency of operations, are in place in 54.1% of the units. This demonstrates a predominant compliance with structured communication protocols, which are critical for upholding
Our findings demonstrate that the efficiency of communication systems within EMS has a direct impact on the coordination and execution of emergency responses. Establishing strong communication protocols and infrastructure is crucial for enhancing collaboration between EMS teams and other emergency services during critical incidents.
Table 12. Technical equipment and recording capabilities.
Variables Category
n
%
Yes, functional
61
35.5%
Presence and condition of a dictation machine Yes, non-functional
16
9.3%
No
50
29.1%
Phone conversations with patients are recorded on a Yes
71
41.3%
dictation machine N/A
45
26.2%
No
56
32.6%
Radio communications recorded on a dictation Yes
15
8.7%
machine N/A
45
26.2%
No
112
65.1%
Special direct telephone line for communication with Yes
21
12.2%
the police N/A
45
26.2%
No
106
61.6%
Direct line for communication with the Alert and Yes
20
11.6%
Notification Center N/A
45
26.2%
No
107
62.2%
Both methods
14
8.1%
Communication conducted with teams in the field Via mobile phone
107
62.2%
Via radio
6
3.5%
Yes
27
15.7%
Ambulance vehicles have a radio station N/A
45
26.2%
No
100
58.1%
0–5
64
37.2%
Ambulance Vehicles Without a Radio Station 6–10
11
6.4%
11–15
1
0.6%
16–20
24
13.9%
Condition of the radio repeaters Operational
29
16.9%
Not Operational
98
57.0%
Table 12. Cont.
Variables Category
n
%
Device to power the radio communication system in Yes
30
17.4%
case of a power outage N/A
45
26.2%
No
97
56.4%
Special radio communication channel for direct Yes
3
1.7%
communication with the police No
124
72.1%
Special radio communication channel for direct Yes
3
1.7%
communication with firefighters-rescuers No
124
72.1%
Reaction time monitored during first-order Yes
68
39.5%
emergency interventions N/A
45
26.2%
No
59
34.3%
-
Emergency Response Times and Effectiveness in Urgent Interventions
An analysis of response times in different emergency medical service scenarios sheds light on how effectively and swiftly interventions are conducted. By categorizing these times into distinct ranges, we can better understand how well services are delivered across various operational contexts. The data indicate that a significant 20.3% of activation times fall within the 0-to-1 h range, demonstrating a quick response in a fifth of the cases.
Table 13. Analysis of response times in emergency medical services.
Variables Category
n
%
0 to 1 h
35
20.3
Activation times >1 to 3 h
11
6.4
>3 to 10 h
7
4.1
>10 h
15
8.7
0 to 1 h
15
8.7
Reaction time >1 to 10 h
40
23.3
>10 to 20 h
10
5.8
>20 h
3
1.7
0 to 10 h
27
15.7
Prehospital intervention time results 10 to 30 h
28
16.3
30 to 60 h
9
5.2
More than 60 h
4
2.3
A written plan/procedure known to workers in case Yes
84
48.8
of disasters N/A
50
29.1
No
38
22.1
Vehicle for mass casualty incidents equipped with Yes
10
5.8
stretchers and medical supplies? N/A
50
29.1
No
112
65.1
Yes
16
9.3
Availability of triage cards (either in vehicles or bags) N/A
50
29.1
No
106
61.6
Mass casualty response drills in the last 2 years at Yes
24
14.0
your institution N/A
50
29.1
No
98
57.0
Frequently drills for mass casualty incidentsh
One time per year or less
20 80.0
Twice a year 4 16.0
More than twice a year
1
4.0
Joint drills with other emergency services in the last Yes
27
15.7
2 years? N/A
50
29.1
No
95
55.2
This metric (prehospital intervention time) breaks down the responsiveness from the onset of an emergency to the point of medical intervention. About 15.7% of prehospital interventions occur within 0 to 10 h, reflecting quicker activation periods. The percentage rises to 16.3% for interventions taking 10 to 30 h, suggesting that many interventions fall within this range. Longer intervention times—between 30 and 60 h and those exceeding 60 h—are less common, at 5.2% and 2.3%, respectively, indicating areas where intervention delays are significant. These various timeframes—across activation, reaction, and prehos-
pital intervention—provide a detailed view of the operational dynamics in emergency medical services. The data reveal both the potential for rapid action and areas where delays impact overall emergency response effectiveness. Understanding these dynamics is essen- tial for pinpointing where improvements are needed, enhancing training and resources, and ultimately improving patient outcomes in critical situations such as disasters (Table 13). The study highlights that optimizing response times is crucial for improving patient outcomes during urgent interventions. Tackling logistical challenges and enhancing re- source distribution can greatly reduce delays and boost the overall efficiency of EMS
operations in emergencies.
In terms of mass casualty response drills, just 14% of institutions conducted these exercises in the past 2 years, with most of them doing so once a year or even less frequently. This lack of regular training could impact the readiness and ability of institutions to effec- tively manage disaster situations. Furthermore, only 15.7% of institutions participated in joint drills with other emergency services, such as the police, military, and fire departments, over the past 2 years (Table 13). This could hamper coordinated response efforts in real disaster scenarios.
-
Training and Preparedness for Disaster (Emergency) Response
Regarding training compliance and needs within an EMS system, results show that 32.0% of newly hired doctors and 30.8% of nursing technicians have undergone special- ized emergency medicine training soon after being hired, reflecting strong initial training programs for these essential staff members. However, there are notable gaps, as 41.9% of doctors and 43.0% of nursing technicians reported not receiving this training, highlighting a need to improve training coverage (Table 14). A closer look reveals that 42.4% of EMS personnel have received training at established centers, yet 31.4% have not, and 26.2% are marked as not applicable, indicating potential disparities in training access or inconsistent requirements across the organization. Alarmingly, while a significant 68.0% of respon- dents recognize the need for more training for all EMS staff, 5.8% do not see this necessity, pointing to a perception gap that could affect service delivery (Table 14).
When asked to prioritize training needs, 57.0% of respondents believe doctors re- quire the most training, compared to only 5.2% for nursing technicians and ambulance drivers. This suggests a focused need for advanced training for physicians who often handle the most complex medical emergencies (Table 14). Specific training needs identified include CPR and trauma management, prioritized by 26.2% of responses, underscoring the importance of these skills in emergency settings. Other areas such as urgent medical conditions, emergency protocols and equipment use, safety and operational training, and specialized medical fields like obstetrics and cardiology also receive significant attention. This indicates a broad spectrum of training needs that align with the diverse challenges faced in emergency medical services (Table 14).
Table 14. Training and compliance in emergency medical services.
Variables
Category
n
%
Newly hired employee doctors have undergone
Yes
55
32.0
special training in emergency medicine
No
72
41.9
Newly hired employee nursing technicians undergone
Yes
53
30.8
special training in emergency medicine
No
74
43.0
Employees in EMS service undergone training at any Yes
73
42.4
of the existing training centers N/A
45
26.2
No
54
31.4
Additional training is necessary for all employees in Yes
117
68.0
the EMS N/A
45
26.2
No
10
5.8
Doctor
98
57.0
Importance of who needs training the most
Nursing Technician
9
5.2
Ambulance Driver
9
5.2
CPR and Trauma Management (Cardiopulmonary resuscitation, trauma
45
26.2%
management, polytrauma handling) Urgent Medical Conditions (Emergency
response, urgent medical and pediatric
35
20.3%
care)
Emergency Protocols and Equipment
(Equipment use, triage, protocols,
32
18.6%
communication)
Safety and Operational Training (Safety
protocols, personal safety, psychological
30
17.4%
support)
Specialized Medical Training (Obstetrics,
30
17.4%
Categories of training needs
toxicology, neurology, cardiology)
Specification of norms for operations (equipment, Yes
98
57.0
staff, space, vehicles, education, etc.) as key area for N/A
45
26.2
enhancing EMC services No
29
16.9
Implementation and adherence to standards and Yes
81
47.1
procedures as key area for enhancing EMC services N/A
45
26.2
No
46
26.7
Continuous education as key area for enhancing EMC Yes
97
56.4
services N/A
45
26.2
No
30
17.4
Establishing new training centers as key area for Yes
59
34.3
enhancing EMC services N/A
45
26.2
No
68
39.5
Equipment renewal as key area for enhancing EMC Yes
106
61.6
services N/A
45
26.2
No
21
12.2
Additional Staff as key area for enhancing EMC Yes
102
59.3
services N/A
45
26.2
No
25
14.5
Our analysis underscores the critical role of continuous training and preparedness in improving EMS personnel’s effectiveness in disaster response. Institutions that emphasize training tend to show higher levels of readiness and competence when handling large-scale emergencies, highlighting the importance of regular drills and educational programs.
A significant majority, 57%, emphasized the importance of establishing clear norms for operations, including aspects like equipment, staffing, space, vehicles, and education. This
Similarly, 59.3% of respondents favor adding more staff, pointing to a recognized need for additional personnel to meet increasing service demands and ensure prompt emergency responses (Table 14). These perspectives collectively highlight a consensus on the need to improve operational standards, continuous professional development, and resource upgrades to advance the quality and efficiency of emergency medical services. However, the perceived value of expanding training facilities remains a point of contention.
-
Financial Resources and Administrative Effectiveness in Emergency Medical Services
Table 15. Funding sources and staffing in emergency medical services (EMSs).
nd (RFZO) resources: source Yes 119 69.2
N/A
46
26.7
Variables Category n %
No
7
4.1
Yes
67
39.0
Municipal/City Budget Resources: source of funding EMS
N/A
46
26.7
No
59
34.3
Yes
42
24.4
Own Revenue: source of funding EMS
N/A
46
26.7
No
84
48.8
Yes
35
20.3
Donations: source of funding EMS
N/A
46
26.7
No
91
52.9
National health insurance fu of funding EMS
No
55
32.0
0–5
86
50.0%
6–10
14
8.1%
Doctors in Emergency Medical Services
11–15
8
4.7%
16–20
8
4.7%
21+
9
5.2%
additional financial Yes
70
40.7
ment to employ additional staff N/A 47 27.3
Healthcare institution receive resources from local govern
Table 15. Cont.
Variables Category
n
%
0–5
83
48.3%
Medical Nursing Technicians in Emergency Medical 6–10
18
10.5%
Services 11–15
11
6.4%
16–20
8
4.7%
21+
5
2.9%
0–5
84
48.8%
6–10
16
9.3%
Ambulance Drivers in Emergency Medical Services 11–20
15
8.7%
21–30
7
4.1%
30+
3
1.7%
Doctors in Emergency Medical Services have credited Yes
56
32.6
service years No
66
38.4
Undecided
3
1.7
Doctors in Emergency Medical Services have paid night Yes
120
69.8
shifts? No
2
1.2
Undecided
3
1.7
Doctors in Emergency Medical Services have paid work on Yes
120
69.8
Sundays? No
5
2.9
Medical technicians/nurses in Emergency Medical Services Yes
57
33.1
and ambulance transport have credited service years? No
66
38.4
Undecided
2
1.2
Medical technicians/nurses in Emergency Medical Yes
120
69.8
Services and ambulance transport have paid night shifts? No
2
1.2
Medical technicians/nurses in Emergency Medical Services Yes
120
69.8
and ambulance transport have paid work on Sundays No
5
2.9
The findings indicate that sufficient financial resources are critical to the operational success of EMS. Securing adequate funding for personnel, equipment, and infrastructure is vital for upholding high standards of care and ensuring preparedness during emergencies. The assessment of the ambulance vehicle fleet shows a diverse range of ages. Notably, 18.6% of the vehicles were manufactured between 2011 and 2015, suggesting that part of the fleet is relatively modern. However, older vehicles from 1989 to 2000 and 2001 to 2005 make up smaller portions, 6.4% and 11.0%, respectively. This highlights a potential
need to update older vehicles to maintain reliability and efficiency in emergency responses (Table 16).
Table 16. Availability of medical equipment and emergency personnel in EMS.
Variables Category
n
%
1989–2000
11
8.15
2001–2005
19
14.07
Ambulance vehicles by year of manufacture 2006–2010
21
15.56
2011–2015
32
23.70
2016–2018
20
14.81
2019–2023
32
23.70
0–57,200
21
20.2
57,200–125,354
19
18.3
Medical vehicles—number of kilometres travelled
125,354–285,564
20
19.2
285,564–400,000
21
20.2
400,000–1,000,000
23
22.1
The presence of radio stations in medical vehicles
Yes No
38
70
22.0
40.7
Functionality of EKG machines for activities within
Does not exist
2
1.2
the healthcare service
Exists
122
70.9
Biphasic defibrillators with monitors for activities
Does not exist
13
7.6
within the healthcare service
Exists
110
64.0
Functionality of portable aspirators for activities
Does not exist
17
9.9
within the healthcare service
Exists
106
61.6
Portable mechanical respirator with oxygen tank
Does not exist
59
34.3
functionality in HMP activities
Exists
64
37.2
Table 16. Cont.
Variables Category n %
Functionality of portable mechanical respirators with oxygen tanks that have the CPAP mode
Does not exist 104 60.5
Exists 19 11.0
Availability of cardiopulmonary resuscitation sets Does not exist 17 9.9
Exists 106 61.6
Availability of 10-litre oxygen bottles for activities within the healthcare service
Vacuum mattresses for activities within the healthcare service
Does not exist 5 2.9
Exists 118 68.6
Does not exist 66 38.4
Exists 57 33.1
Cervical collars for spinal immobilization Does not exist 15 8.7
Exists 108 62.8
Kramer splints for activities within the healthcare service
Does not exist 39 22.7
Exists 84 48.8
Infusion solution heater functionality in HMP Does not exist activities Exists
122
1
70.9
0.6
Medications for thrombolytic therapy Does not exist
115
66.9
Exists
8
4.7
Emergency cricothyrotomy kits Does not exist
108
62.8
Exists
15
8.7
Availability of childbirth kits Does not exist
38
22.1
Exists
85
49.4
Protective helmets with lamps availability in HMP Does not exist activities Exists
122
1
70.9
0.6
Fixed radio station availability in ambulance Does not exist
80
46.5
Exists
43
25.0
Handheld radio availability Does not exist
107
62.2
Exists
16
9.3
Ultrasound device availability Does not exist
112
65.1
Exists
11
6.4
-
-
Discussion
This study identified the risks and levels of efficiency within the functioning of the Emergency Medical Service (EMS) under both regular and emergency circumstances, such as disasters. The primary focus of the research was on scientifically predicting and explaining the key factors that influence EMS performance, as well as identifying specific strategies and procedures that could improve system efficiency during mass casualty events, including emergencies and disasters. The research results highlight significant shortcomings within Serbia’s emergency medical services. This is particularly evident in how resources are managed, personnel are trained, and communication protocols are handled during both regular and emergency situations.
The results of the multivariate regression analysis revealed several areas important for the structure and functioning of EMS. It can be said that the overall structure of EMS and the total number of EMS points performed were influenced by working hours and shift patterns. On the other hand, it was found that financial resources and ambulance availability were not significantly associated with performance. These results suggest that the allocation of material resources alone may not optimize EMS outcomes [99]. Instead, it can be said that human resource management, particularly scheduling and shift work, has a greater impact [100]. Accordingly, operational factors such as shift scheduling should be prioritized to improve EMS services [101,102]. In contrast, when it comes to service area coverage, none of the variables were significant. Based on these results, it can be concluded that service coverage is likely influenced by more complex factors such as geographic structure
and population distribution [103]. Also, EMS teams based in clinics were a strong positive predictor for the number of doctors in EMS. Finally, it was found that for preparedness in the case of mass casualties, such as disasters, ambulance availability, and financial resources were significant predictors. Therefore, although the models explain a small portion of the variance in EMS organizations, they suggest that operational management and resource allocation are key to EMS performance [99,104,105].
The results of Pearson’s correlation provide insight into how certain variables affect the organization of Emergency Medical Services (EMS). The statistically significant correlation between EMS organizations and the number of emergency medicine specialists, doctors in training, and permanent ambulance drivers suggests that an increase in these key personnel improves the efficiency and operational organization of the system. Specifically, a larger number of specialists and trained doctors enhances the capacity of EMS to respond to complex emergencies, while permanent ambulance drivers contribute to continuous operational functionality. The more EMS teams work in shifts during the day and night, the more organized and flexible the system becomes. This finding is crucial for shift planning and staff distribution, as it allows for a better response to changing demands at different times of the day [106,107].
Additionally, the increase in distance between EMS headquarters and hospitals pos- itively correlates with better organization. These results indicate that as distances grow, the need for a more structured organization increases to ensure timely patient trans- port [108,109]. The findings highlight the importance of geographic coverage and logistical aspects that influence the quality of services provided. In terms of gender dimensions, the results show that a higher number of male doctors contributes to a structurally better organization. This outcome could be explained by potential traditional employment and leadership patterns [110]. In contrast, the increase in the number of female doctors brings balance and diversity to the roles within EMS.
One of the most interesting findings is the positive impact of the increased number of doctors with verified limited working capacity on the number of EMS points performed. This result indicates that institutions are able to efficiently adapt their staff to include doctors with limited working capacity, thereby maintaining operational capacity and ensuring continuity of services. Such findings underscore the significance of diverse inclusive employment policies and flexible resource management [111]. Additionally, it allows for better utilization of all available resources and retention of highly skilled personnel in the system, despite their physical limitations [112,113]. When considering the analysis of shift work, it is important to emphasize that an increase in the number of teams for day and night shifts significantly improves organization and allows for better resource distribution. This leads to a reduction in response time to emergency calls. On the other hand, this result highlights the need for a continuous increase in the number of teams depending on the time of day to ensure optimal coverage at all times [114].
The research results indicate the existence of diverse organizational structures within EMS in Serbian healthcare institutions. Approximately 46% of health centers have EMSs integrated into specialized departments. Also, such organizations can potentially lead to better patient outcomes, as emergency services become more efficient and organized, which is crucial in different disasters [46,115]. Nevertheless, resource requirements to implement this model are quite substantial and may not be sustainable for all facilities [116].
The research shows that in about 34% of centers, the emergency medical service oper- ates within general medical services. This means that existing medical teams are required to handle emergencies alongside their regular duties. Certainly, such an approach allows for maximum resource utilization, but it also raises the issue of balancing routine patient care with emergency demands, which can worsen the quality of emergency response [117]. This type of institution may also require additional staff training to adequately prepare for emergencies [118,119]. A smaller 15% of institutions have established EMS as separate units dedicated solely to emergencies. This structure can increase the efficiency and ef- fectiveness of response through specialized training and equipment [120]. However, this
small percentage of units applying this approach suggests that there are barriers, such as financial and administrative obstacles, preventing its wider implementation [62,121].
When it comes to specialized institutions, such as the Institute for Emergency Medical Services, it was found that they exist in only 3.6% of cases. These institutions are specialized, skilled, and equipped with resources for emergency response. They could be recognized as centers of excellence, providing advanced emergency medical care and serving as a model for best practices [122]. On the other hand, nearly 1.44% of facilities do not have an organized emergency medical system. This indicates a lack of emergency healthcare coverage and the necessity for political interventions and investments to expand emergency services [46].
Emergency transport and other emergency healthcare activities are primarily cen- tralized, with 88.89% of operations conducted at one or two locations. While centralized operations can be efficient due to economies of scale, they limit access to remote areas and can pose challenges for rural and less developed regions [85,123]. In some cases, institutions attempt to improve coverage through limited decentralization (4.44% have 3 to 10 locations, and 1.11% have more than 11 locations). However, further decentralization is required to ensure equal access to emergency services across the country [69]. Centralized operations can also lead to excessive demand during high-need periods, highlighting the need for resource planning to increase capacity and responsiveness [124].
In this latter case, it can be said that ambulances are staffed by a combination of rotating shifts and adopted shift work models, with most operations (55.2%) adopting a shift-based approach. This provides the impression that this method is less disruptive to daily life than rotating shifts and provides continuous 24/7 emergency medical care coverage. With 80.2% of institutions using 12 h shifts, work efficiency and staff well-being are high, although this can lead to fatigue and performance decline over time. Other new models, such as 8 h shifts and flexible schedules, may also reduce burnout rates and increase employee satisfaction [125,126]. It was also found that most shifts (50.6% during the day and 48.3% at night) operate with a single team. This certainly simplifies operations but may lead to problems in the event of a sudden surge in demand or complex emergencies [127]. This may indicate the need for institutions to use multiple teams (16.9% during the day and 16.3% at night) or special configurations (27.9% during the day, 23.2% at night), as these models could be adapted to demand-based needs, which could improve EMS efficiency [53].
The results show that the variability in the composition and deployment of medical transport teams is pronounced, with 43.0% of centers conducting daytime transport opera- tions using a single team. This “lean” system, which emphasizes resource efficiency [128], may have limited capacity for handling complex cases or multiple emergency interventions simultaneously [43]. The teams consist of doctors, medical technicians/nurses, and drivers, ensuring complete patient care but utilizing more human resources (37.8%). Although healthcare facilities cover an average area of 350 km2, the lack of highway access in 50.0% of institutions indicates potential problems with the timely arrival of ambulances and the provision of rapid response [129]. Improved accessibility and EMS performance re- quire strategic facility deployment and infrastructure development (including roads and communication systems) [68,130].
The study also highlights several serious weaknesses in strategic preparedness, the most alarming of which is the fact that 57.0% of institutions do not have detailed disaster management plans. This indicates an opportunity for improved planning and coordinated actions to enhance EMS performance [131,132]. Where preparedness plans are lacking, responses are likely to vary and may be less effective in large-scale emergencies or disas- ters [133,134].
Reported seasonal population changes among 48.8% of respondents further emphasize the need for flexible and adaptive strategies within EMS. Adjusting resources and staffing to account for tourism, migration, or temporary residents is crucial in such situations [56,135]. Additionally, the study identifies several distinctive features in staffing models across Emer-
gency Medical Service (EMS) facilities in Serbia. Specifically, one out of every four facilities has a staffing model that includes three to five doctors, adopting a balanced strategy. Of course, this ensures a balance between cost-effectiveness and operational capacity, with enough medical personnel to handle typical emergency cases [41,136]. On the other hand, problems arise in some facilities where 11.63% of units have only 0–2 doctors. Such limited staffing can cause serious issues in providing timely and comprehensive care, especially in high-demand situations or complex emergencies and disasters [42]. Conversely, facilities with larger team sizes—12 to 15 doctors (11.05%) or more than 15 doctors (8.72%)—suggest the ability to manage more complex cases, likely as a result of strategic investments in areas with higher emergency needs or larger populations [45].
Furthermore, it was found that EMS facilities generally employ minimal numbers of specialists, with 51.74% of institutions employing only 0–2 specialists. This shortage further emphasizes recruitment and retention issues, which may affect the quality of care for high- risk or specialized emergency patients [58]. Facilities with three to five specialists (15.70%) can provide more comprehensive care, but the scarcity of a larger number of specialists points to systemic obstacles, such as funding constraints or insufficient opportunities for specialization [71].
It was also found that training for doctors in emergency medicine is sparse, with 67.44% of institutions reporting only 0–2 doctors in training. This situation presents a significant workforce development opportunity [137], highlighting the need for dedicated training programs to enhance specialization and emergency care capacity [60,138]. The trend toward employing general practitioners (58.14% with 0–2 specialists in general medicine) shows a pragmatic approach to staffing but underscores the need for increased specialization to better address diverse medical emergencies.
Further results show that although the representation of female doctors in EMS clinics is relatively good (e.g., 41.3% have 0–5 male and 30.2% have 0–5 female doctors), the distribution of specialists predominantly shows more men (32.7%) compared to female specialists in the same groups. Certainly, these results indicate a relatively balanced gender representation in smaller teams, but larger teams with female doctors are rarer [139]. On the other hand, although women work in EMS, there remains significant room for growth in their representation, particularly at higher levels of specialized roles [48].
Further results show that many medical institutions have very few or no younger doctors under 30 years old. Around 61.0% of institutions employ only 0 to 1 doctors in this age group, indicating challenges in attracting and retaining young doctors, which could affect workforce sustainability [52]. Conversely, the age profile of doctors aged 30 to 55 shows a more stable mid-career workforce, while the significant proportion of doctors over 55 suggests upcoming retirements, requiring active recruitment and succession planning [140].
The part of the research related to communication infrastructure in Emergency Medical Service (EMS) facilities examined their readiness and protocol adherence, which are crucial for successful disaster management [141]. It was found that having a designated phone number for emergency responses, present in 34.3% of institutions, enables faster responses and improves system efficiency [142]. However, when 39.5% of units use multiple phone numbers, inefficiencies in call handling can lead to delays in emergencies. Therefore, estab- lishing a single direct line for emergencies across all institutions could reduce confusion and improve response times in stressful situations [49]. Additionally, the ability to screen incoming calls is available in 45.3% of institutions, which certainly improves responsiveness by enabling the quick identification of key or repeat calls, a crucial feature for prioritizing emergencies [143]. On the other hand, the absence of this feature in 28.5% of units indicates a gap that could lead to delays, suggesting a need for technological upgrades to support real-time call identification [144].
in 14.0% of cases, either nurses or technicians handle the calls, while doctors perform this task in another 14.0% of cases, showing flexibility depending on facility resources. However, requiring doctor consultations in 10.5% of cases may slow down decision-making [145]. Empowering nurses and technicians with additional training could streamline operations and improve response times [146].
The results show that in 54.1% of units, the existence of protocols for handling calls indicates good performance regarding structured communication frameworks. That is essential for maintaining an optimal service standard in a disaster [5,53,69,144]. On the other side, given the lack of standardized protocols in 19.8%, inconsistent call management and delayed responses to emergencies may occur. This must be improved as soon as possible to avoid more serious problems.
Additionally, promoting standardized call-handling practices and widespread pro- tocol implementation across all facilities are necessary approaches to achieving greater operational consistency and service quality [147]. It should be noted that in the EMS environment, communication devices and response protocols, which are an essential part of disaster management, require technological infrastructure [35,36,148,149]. All of the above is important to ensure proper recording of facts, as it is noted that dictaphones function in 35.5% of services, and they should be used for appropriate documentation and accountability.
The study also noted challenges in communication with other emergency services, including limited direct communication channels between emergency departments and the police (only 12.2%) and the Alert and Notification Center (11.6%). It is believed that limiting social scanning can slow down responses in situations where coordination with the police or central alarm services is needed [150]. This is a clear signal indicating the importance of integrated communication systems that enable seamless exchange between various emergency services [151]. It can be emphasized that reliance on mobile phones for field communication in 62.2% of cases reflects a shift towards more accessible and reliable technology in practical operations [152,153].
It is crucial to note that response times in various EMS environments provide important insights into the efficiency and resilience of these services during disasters [55]. Activation time, defined as the period from receiving an emergency call to the start of an emergency response, is another important system readiness indicator [155]. It was found that only 20.3% of activation times fall within the time frame of 0 to 1 h, indicating significant room for improvement in many cases, but on the other hand, it shows an impressive ability to respond quickly where necessary. This finding suggests that if the environment supports it, services can indeed be deployed rapidly [156].
However, it was also found that longer activation times occur (6.4% between 1 and 3 h, 8.7% over 10 h). This could be explained by the fact that in some units, there are improvised emergency teams that only provide transport. Certainly, and as expected, in a system with such limited resources, administrative delays point to bottlenecks—possibly in
logistics, financial issues, or the complexity of the disaster itself [15–17]. This is important for reducing response times and overall EMS efficiency [157].
Another important aspect related to responsiveness is reaction time, which measures the period between activation and the arrival of the emergency service on-site [20,150]. It was found that 8.7% of services achieve a reaction time of one hour. The variability in how efficiently different services and scenarios are handled suggests that the largest share of cases, 23.3%, falls within the reaction time range of 1 to 10 h [68,130]. Relatively slower response, where 5.8% of cases take 20 h, and 1.7% take more than 20 h, indicates serious operational or logistical challenges. These delays could be the result of traffic congestion problems [158] geographical constraints, or insufficient staffing during high- demand periods [42,85]. It can be noted that solving these problems requires a systematic approach, from infrastructure improvements and faster resource allocation and deployment to enhanced communication systems for quicker response.
It is very important to mention that the prehospital intervention time, or the interval from the onset of an emergency to medical intervention, provides a complete picture of the performance of Emergency Medical Services (EMS) [159]. According to the research results, it was found that 15.7% of interventions occur within 0 to 10 h, which supports rapid mobilization and reaction. On the other hand, it was found that 16.3% of interventions occur within the range of 10 to 30 h, clearly indicating the need for improvement. Also, exceptionally long intervention times, where 5.2% of cases take between 30 and 60 h, and 2.3% exceed that timeframe, suggest the need for strategic adjustments in EMS opera- tions [69]. These delays may result from complex emergencies, limited resources [160], or coordination problems. All of this together highlights the clear need for continuous evaluation and improvement of EMS processes to reduce intervention time and improve patient outcomes [57].
Training for mass casualty incidents, such as disasters, is crucial for EMS preparedness, especially in disaster preparation [161]. According to the research results, around 48.8% of institutions have written plans or procedures for disaster response, indicating moderate preparedness. However, the fact that only 9.3% of institutions have vehicles for mass casualties and triage cards points to shortcomings in preparedness. Such deficiencies can cause delays and inefficiencies during disasters, emphasizing the need for better planning and resource allocation. Additionally, the results indicating the rarity of mass casualty drills, where only 14% of institutions conducted such drills in the past two years, may point to a lack of regular training [61]. Furthermore, it was found that only 15.7% of agencies participate in joint drills with other emergency services, suggesting barriers to coordinated responses. This underscores the importance of improving cooperation and training for an effective disaster response [162].
Further results show that many newly hired employees in Emergency Medical Services (EMS) start with on-the-job training. Specifically, around 32% of new doctors and 30.8% of medical technicians receive emergency medicine training shortly after being hired, reflecting the enhancement of core team members from day one [163]. However, when examined more closely, gaps remain, as 41.9% of doctors and 43% of medical technicians do not receive this training. This highlights the need for broader training programs to ensure comprehensive coverage for all new hires [163]. Consistent training for all new EMS employees is crucial for maintaining high standards of emergency medical care [157]. On the other hand, around 42.4% of EMS staff receive training at established centers, but 31.4% do not have access, and for 26.2%, the training is deemed inapplicable, indicating differences in access to training or inconsistent requirements throughout the EMS system [80]. It is also important to note that 68% of staff recognize the need for more training, while 5.8% do not. If this issue is not addressed, this difference in perception could affect service quality [61,62]. It was found that training priorities are clear, with 57% of respondents stating that doctors require the most training, compared to 5.2% for medical technicians and ambulance drivers. This highlights the need for advanced training for doctors, who often handle complex emergencies and disasters [164]. Key areas of training include
cardiopulmonary resuscitation (CPR) and trauma management (26.2%), which are vital skills for disaster response [60,149,157]. Other important areas include emergency medical conditions, emergency protocols, equipment use, and specialized fields such as obstetrics and cardiology, reflecting the wide range of challenges EMS faces [60,149,157].
A significant majority of respondents (57%) support clear operational standards cov- ering equipment, personnel, space, vehicles, and training. This emphasizes the value of standardized guidelines for improving EMS operations [165]. Similarly, 47.1% emphasize the importance of strict adherence to standards and procedures, highlighting the role of compliance with regulations and structured protocols in disaster management. Continuous education is considered vital by 56.4% of respondents, ensuring that EMS personnel stay up to date with the latest practices and techniques [166].
In contrast, opinions on expanding physical training capacities are divided, with only 34.3% seeing it as beneficial, while 39.5% do not. This raises concerns about the effectiveness and resource allocation for such initiatives [59]. However, 61.6% support equipment renewal, believing that modern and efficient equipment is key to improving EMS functionality. Additionally, 59.3% support increasing staff to meet growing service demands and ensure rapid responses to disasters [119,148].
The Emergency Medical Services (EMS) system largely relies on the National Health Insurance Fund (RFZO), which funds 69.2% of its services, emphasizing its critical role. In contrast, only 39% of EMS services receive support from municipal budgets, and 34.3% receive no funding from local governments, indicating significant regional differences in financial support. All of this together highlights the need for greater municipal involvement to ensure consistent service quality [167]. It was found that self-generated income and donations account for only 24.4% and 20.3% of EMS unit funding, respectively, indicating potential financial vulnerabilities [168]. Of course, such results also emphasize the need for diversified funding sources to maintain stable operations [169]. Many EMS units operate with minimal staffing, with around half employing only 0–5 doctors, and a similar trend is seen in the number of medical technicians and ambulance drivers. These staffing levels could affect the quality of emergency responses and highlight the need for more personnel to meet growing service demands [170].
The workforce includes a combination of experienced and newer employees, reflecting both staff retention and turnover. The results show that compensation for night shifts and weekends is provided, with 69.8% of medical staff receiving additional pay, highlighting the demanding nature of EMS work and the importance of fair compensation. The ambulance fleet includes a modest proportion of modern vehicles (18.6% from the period 2011–2015), while many vehicles are outdated, suggesting an urgent need for upgrades to ensure reliability [77]. High mileage in 22.1% of vehicles indicates heavy usage, which could affect efficiency and reliability.
Most EMS units are equipped with basic tools such as EKG machines (70.9%) and defibrillators (64.0%), but there is a significant lack of advanced equipment such as portable respirators (11.0%). The limited availability of communication tools, such as fixed radio stations (25%) and handheld radio devices (9.3%), highlights the need to improve com- munication capacities [51]. It was also found that there are significant shortages in critical supplies, such as thrombolytic medications (4.7%) and cricothyrotomy kits (8.7%), indicat- ing gaps in preparedness. This underscores the need for better inventory management to support comprehensive emergency response [44].
By identifying these key areas, the research unequivocally presents a clear strategy and recommendations for improving the functioning of the Emergency Medical Service (EMS). Also, the implementation of such recommendations will undoubtedly lead to better disaster response and improved patient care. Additionally, by identifying the key organizational and operational factors that influence EMS efficiency during disasters, it significantly contributes to the overall improvement in the field of EMS. Based on all findings, the foundation is set for improving EMS management practices, including more efficient
management of work hours, shift assignments, resource allocation, and the implementation of formal mass casualty response plans.
The study faced several limitations, which are outlined below: (a) the participant sample was drawn exclusively from healthcare institutions within Serbia, limiting the ability to generalize the findings to other countries or healthcare systems; (b) since the research depends on participants’ self-assessments, there is a possibility of subjectivity in their responses, which could introduce bias into the results; (c) the absence of longitudinal data makes it challenging to monitor changes in the efficiency of the emergency medical response system over time, thus potentially obscuring long-term trends; (d) resource and equipment shortages in certain institutions may have influenced the depth of the data collected, especially in facilities with smaller capacities; (e) differences in emergency preparedness levels across healthcare institutions could make it more difficult to compare results from different regions or organizations; (f) the lack of standardized national protocols might have affected the uniformity and reliability of the collected data, posing difficulties for accurate analysis of the system’s overall efficiency.
-
Recommendations
The recommendations in Table 17 are designed to tackle critical areas within Emer- gency Medical Services (EMS) that need strategic improvements. It can be said that by concentrating on elements like organizational structure, resource allocation, communica- tion systems, response times, training, and financial resources, these strategies lay out a detailed plan for boosting the effectiveness and preparedness of EMS operations.
Table 17. Strategic recommendations for enhancing emergency medical services: addressing struc- tural, resource, and operational challenges.
and Risk Management
units
Aspect Recommendations Term
Feasibility
Cost
Priority
Standardize risk assessments across all EMS Short
High
Low
High
Introduce dynamic updating protocols for Short
High
Medium
High
Organizational Structure Establish a centralized authority for EMS Long
Medium
Medium
High
Integrate new technology platforms for Long
Low
High
High
Develop inter-agency agreements for risk Long
Medium
Medium
Medium
Conduct targeted resource audits in Short
High
Low
High
Deploy mobile resource units in underserved Short
Medium
High
High
Resource Allocation and Establish a fund for state-of-the-art EMS Long
Medium
High
Medium
Develop partnerships with technology Long
Low
High
Medium
Implement a resource-sharing protocol Long
High
Low
Low
Upgrade to digital radio systems and secure Short
High
Medium
High
Establish regional communication centers Short
Medium
High
High
Communication Systems Create redundant communication channels Long
Medium
High
High
and Efficacy Launch training programs for Long
Medium
Medium
Medium
Invest in AI-driven communication tools. Long
Low
High
Medium
emergency response strategies management
real-time risk management management best practices
Efficacy
high-demand locations areas
equipment providers
among EMS agencies
networks
communication technologies
Aspect Recommendations Term
Feasibility
Cost
Priority
Enhance GPS and dispatch technologies Short
High
Medium
High
Develop rapid deployment strategies Short
Medium
High
High
Invest in infrastructure improvements at
Emergency Response Long
Medium
High
High
Times and Efficacy Expand the network of emergency Long
Low
High
Medium
Implement performance tracking for Long
High
Medium
Medium
Increase frequency and complexity of Short
High
Medium
High
Develop specialized units for specific Short
High
Medium
High
Training and Preparedness Collaborate with international disaster Long
for Disaster Response response agencies
Medium
High
Medium
Create a digital training hub for disaster Long
Medium
Medium
High
Mandate disaster preparedness Long
High
Medium
High
Optimize financial planning for Short
High
Low
High
Streamline administrative processes to Short
High
Low
High
Financial Resources and Develop strategic financial partnerships Long
Medium
Low
Medium
Administrative Efficacy Use big data analytics for predictive Long
Medium
Medium
Low
Lobby for increased governmental and Long
Low
Low
High
Table 17. Cont.
EMS stations medical facilities response times
disaster response simulations disaster scenarios
response certifications
high-priority needs reduce overhead
funding needs international funding
Each recommendation is evaluated based on factors like duration, feasibility, cost, and priority to ensure that the actions taken are well-suited to the varied needs and challenges faced by EMS units. Through these focused efforts, the aim is to strengthen EMS capabilities, make better use of resources, and ensure a strong response to emergencies.
-
Conclusions
The analysis of the Emergency Medical Response System (EMRS) in the Serbian healthcare system reveals numerous deficiencies and serious challenges that require the implementation of urgent short-term and long-term measures for improvement. This study is one of the few in Serbia that comprehensively examines multiple indicators of the efficiency and effectiveness of such a system. The extensive study results point to significant and widespread variations in the organization and functioning of EMRS across the country. It can be assumed that these variations are a result of both historical and economic changes, as well as regional specificities. Although certain segments of the system, such as specialized emergency departments, function efficiently, the organization in many areas is inconsistent, leading to inadequate access to emergency medical assistance in some regions of the country. On the other hand, this diversity underscores the need for standardized procedures and more centralized management to improve coordination and optimize efficiency. Certainly, all identified weaknesses must be addressed in the shortest possible time, and the organization and functioning of the system must be improved.
Besides the mentioned facts, the study identified several key weaknesses that signifi- cantly affect the efficiency of the system. Among these, outdated infrastructure, a chronic lack of staff, and inadequate logistics stand out, all of which together slow down response times in emergencies, including various disasters. Although reforms aimed at aligning with European standards have been initiated, their implementation is often limited by a lack
of financial resources and capacity. The results also show that many emergency services rely on minimal resources and improvisations, while some units operate with insufficiently trained personnel and outdated equipment. Moreover, dependence on the National Health Insurance Fund (RFZO) as the main source of funding further burdens the system, while local budgets and self-generated revenue are insufficient for the stable development and sustainability of EMRS.
Thus, a critical step in improving the system is conducting targeted resource audits and establishing funds for the procurement of modern equipment for emergency med- ical services. All of these identified weaknesses become particularly evident under the difficult conditions caused by disasters. Therefore, the introduction of mobile units and strategic partnerships with technology providers can significantly improve the distribution of resources, especially in less developed and rural areas. Additionally, sharing resources among EMRS agencies and increasing intersectoral cooperation would optimize the use of available capacities, resulting in greater efficiency.
A particularly important area that requires attention is the various aspects of commu- nication system organization and functionality. In the study, communication was identified as one of the most critical points in the functioning of EMRS. The results clearly indicate significant gaps in communication systems, including a lack of standardized protocols and limited connections with key services such as the police and firefighting–rescue services. The introduction of digital radio systems, regional communication centers, and artificial intelligence to improve inter-agency communication is recommended as an urgent and essential measure. In addition, training on the use of communication technologies is neces- sary to ensure that EMRS staff is adequately prepared for complex emergency situations, including disasters.
Conversely, the analysis of response times revealed significant variations compared to international standards, indicating the need for additional infrastructure investments and process optimization to reduce response times and improve patient outcomes. For these reasons, focusing on accelerating responses, training personnel, and expanding emergency medical assistance capacity is key to improving system performance.
In light of these findings, it is clearly recommended to establish new training cen- ters and digital hubs for disaster response, as well as to introduce continuous education and specialized training for emergency personnel. Such training is especially significant in areas such as cardiopulmonary resuscitation (CPR), trauma management, and other specialized medical fields. Through intensified cooperation with international agencies and the integration of simulation-based training, Serbia can increase the preparedness and resilience of its emergency medical response system in disaster situations. The results of this study provide a clear roadmap for policymakers, healthcare administrators, and EMRS personnel to define priorities for strategic interventions, strengthen the system, and achieve alignment with international standards, which would significantly improve the health and safety of Serbian citizens.
The conducted research has unequivocal scientific and societal implications in the area of emergency medical services improvement, as well as in disaster management and response. The scientific implications are reflected in enriching the existing literature in these fields and enhancing the understanding of key factors influencing the efficiency of emergency medical services (work organization, resource distribution, logistical challenges, etc.). A rich repository of data with empirical evidence is created, which can be used for comparison with other countries. Moreover, the study clearly identifies the need for standardization of procedures, protocols, and management within emergency medical services. This creates a foundation for future research on how standardization can con- tribute to improving response times and reducing regional disparities in access to such services. Additionally, through the use of statistical methods such as Pearson’s correlation, multivariate regression analysis, and chi-square tests, the study provides a methodological framework for further investigation into the organizational and operational aspects of emergency medical services.
Regarding societal implications, the study offers concrete recommendations for health- care sector reform for policymakers in Serbia and other countries facing similar challenges. Certainly, the results contribute to creating recommendations for increasing the capacity of emergency services and improving response times in medical emergencies, directly affecting the health and safety of the population. The study also highlights the need for better coordination between different sectors, as well as for improving communication systems and logistical capacities. These proposed changes can enhance the resilience of communities in cases of emergencies, disasters, and mass accidents, contributing to the improvement of population safety.
Author Contributions: V.M.C. and J.T. conceived the original idea for this study and developed the study design and questionnaire. V.M.C. and J.T. contributed to the dissemination of the ques- tionnaire, while V.M.C. analyzed and interpreted the data. R.R. made a significant contribution by drafting the introduction; V.M.C., J.T., and V.R. drafted the discussion, and V.M.C., R.R., and J.T. composed the conclusions. V.M.C., and H.B. critically reviewed the data analysis and contributed to revising and finalizing the manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by the Scientific–Professional Society for Disaster Risk Manage- ment, Belgrade (https://upravljanje-rizicima.com/, accessed on 18 August 2024) and the International Institute for Disaster Research (https://idr.edu.rs/, accessed on 18 August 2024), Belgrade, Serbia.
Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of the Scientific–Professional Society for Disaster Risk Management and the International Institute for Disaster Research (protocol code 005/2024, 15 July 2024).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are contained within the article.
Acknowledgments: The authors acknowledge the use of Grammarly Premium and ChatGPT 4.0 in the process of translating and improving the clarity and quality of the English language in this manuscript. The AI tools were used to assist in language enhancement but were not involved in the development of the scientific content. The authors take full responsibility for the originality, validity, and integrity of the manuscript.
Conflicts of Interest: The authors declare no conflicts of interest.
Appendix A. Questionnaire About Risk and Effectiveness Analysis of Emergency Medical Response Systems in Serbian Healthcare: A Comprehensive Survey on Disaster Emergency Preparedness
ORGANIZATIONAL STRUCTURE AND RISK MANAGEMENT OF EMERGENCY MEDICAL SERVICES (EMS)
-
How is emergency medical service organized in your institution?
O No organized emergency medical service
O Within the general medicine department (through regular work and on-call duties of doctors and other healthcare workers)
O Within the general medicine department as a separate EMS organizational unit
O Within a separate EMS department of the health center
O Separate institution—Institute for Emergency Medical Services
-
Is EMS performed from:
O A single location → Proceed to Question 4
O Multiple dislocated points
O Within the health center
-
How many points perform EMS?
O Enter the number of points:
-
What is the work time organization?
O Shift work
O Rotation work → Proceed to Question 6
-
What is the organization of shift work?
O Shifts of 12 h
O Shifts of 8 h
O Other, specify:
-
What is the organization of rotation work?
O Day shift—24 h off—night shift—72 h off O Day shift—48 h off—night shift—48 h off O Day shift—24 h off—night shift—48 h off O Other, specify:
-
Specify the number of teams per shift (consisting of: doctor, nurse-technician, ambulance driver) working:
O On weekdays: Day shift: Night shift:
O During weekends and holidays: Day shift: Night shift:
-
Does EMS have a team working exclusively in the clinic (doctor, nurse/technician)?
O No
O Yes
-
Specify the number of teams in the clinic (consisting of: doctor, nurse-technician):
O On weekdays: Day shift: Night shift:
O During weekends and holidays: Day shift: Night shift:
-
How many teams are available for ambulance transport per shift?
O On weekdays: Day shift: Night shift:
O During weekends and holidays: Day shift: Night shift:
-
Who forms the team for ambulance transport?
O Nurse-technician and ambulance driver
O Ambulance driver
O Specify other:
-
Is there an on-call duty organized in case the team needs to leave the territory for which it is responsible?
O No for doctors
O Yes for doctors
O No for nurse-technicians O Yes for nurse-technicians O No for ambulance drivers O Yes for ambulance drivers
-
What is the average time (in minutes) that the medical team stays at higher-level centers?
O minutes
-
What is the average time (in minutes) that the transport team stays at higher-level centers?
O minutes
-
Provide data on the territory where EMS services are provided:
O (a) Area of the territory:
Less than 100 km2
100–200 km2
200–300 km2
300–400 km2
400–500 km2
500–600 km2
600–700 km2
700–800 km2
800–900 km2
900–1000 km2
1000–1100 km2
More than 1100 km2 (specify km2)
O (b) The widest diameter (the greatest distance between two end points) of the territory for which EMS is responsible:
10 km
15 km
20 km
25 km
30 km
35 km
40 km
45 km
50 km
55 km
60 km
65 km
More than 65 km (specify km)
O (c) The greatest distance from the EMS headquarters to the competent hospital (secondary level of health care):
Up to 10 km
Up to 20 km
Up to 30 km
Up to 40 km
Up to 50 km
60 km
More than 60 km (specify km)
O (d) The greatest distance from the EMS headquarters to the competent center (tertiary level of health care):
Up to 10 km
Up to 20 km
Up to 30 km
Up to 40 km
Up to 50 km
60 km
Up to 70 km
Up to 80 km
Up to 90 km
Up to 100 km
Up to 110 km
Up to 120 km
Up to 130 km
Up to 140 km
Up to 150 km
More than 150 km (specify km)
-
Does the institution cover part of the highway?
O No
O Yes
-
If yes, specify the length covered:
-
Specify the official number of inhabitants for the territory for which EMS is respon- sible according to the latest data from the Republic Institute for Statistics:
O inhabitants
-
Are there seasonal variations in the number of inhabitants on the EMS responsible territory annually?
O No
O Yes
-
If yes, specify:
O For which the largest number of inhabitants increased:
O The period for which the seasonal variation of the increase:
1 month
2 months
3 months
4 months
5 months
6 months
Other:
-
Select the reason for the increase in the number of inhabitants/users of EMS services:
O Tourist center
O Regional center
O Migrants
O Other:
-
Specify the data source by which the number of inhabitants of the city/municipality is increased/decreased:
-
Does the volume of work from the regular shift composition, besides responsibili- ties from the domain of urgent conditions, include additional activities?
O No
O Yes
-
If yes, what are they?
O House visits from the field service domain (therapy, dressing)
O The job of a medical doctor to professionally determine the time and cause of death outside the health institution and issue a death certificate
O Both mentioned options
O Other (specify):
-
Are the activities mentioned in the previous question performed from:
O Regular composition
O On-call duty
-
During the night shift, in case of the need to transport a patient to a higher-level healthcare institution for urgent care:
O The entire medical team (doctor, nurse-technician, and ambulance driver) performs the transport
O The team consisting of nurse-technician and ambulance driver performs the transport
O The ambulance driver performs the transport
-
If the entire medical team accompanies the patient:
O The team comes from home (on-call duty)
O The doctor and nurse-technician from the clinic accompany the patient
O One of the teams from the shift accompanies the patient
RESOURCE ALLOCATION (STAFFING) AND EFFECTIVENESS IN EMERGENCY PREPAREDNESS
-
State the number of doctors in EMS:
Doctors Number Total
Emergency medicine specialists
In specialization for emergency medicine General medicine specialists
General medicine
Other specialties (specify):
-
Gender and age structure:
- Gender structure of the total number of doctors:
Male:
Female:
- Age structure of the total number of doctors (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of emergency medicine specialists:
Male:
Female:
- Age structure of emergency medicine specialists (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of doctors in emergency medicine specialization:
Male:
Female:
- Age structure of doctors in emergency medicine specialization (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of general medicine specialists:
Male:
Female:
- Age structure of general medicine specialists (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of general medicine doctors:
Male:
Female:
- Age structure of general medicine doctors (expressed in years, enter the num- ber of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of doctors with other specialties:
Male:
Female:
- Age structure of doctors with other specialties (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of the total number of doctors:
-
State the total number of doctors with verified limited work capacity:
1.
-
Are annual systematic examinations performed according to legal obligations?
- For doctors:
No
Yes
- For nurse-technicians:
No
Yes
- For ambulance drivers:
No
Yes
- For doctors:
-
How many doctors over the age of 55 have invoked the collective agreement and signed an annex stating that after 55 years they have the right not to work with the field team?
1.
-
State the number of nurse-technicians in EMS:
Nurse-Technicians Number Total
With higher/university education With secondary education
- Gender structure of nurse-technicians with higher/university education:
Male:
Female:
- Age structure of nurse-technicians with higher/university education (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of nurse-technicians with secondary medical education:
Male:
Female:
- Age structure of nurse-technicians with secondary medical education (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
Over 55:
- Gender structure of nurse-technicians with higher/university education:
-
State the number of nurse-technicians with verified limited work capacity:
1.
-
State the number of ambulance drivers in the EMS service:
Ambulance Drivers Number Total
Permanently employed Employed for a fixed term With 2nd level of education With 3rd level of education With 4th level of education
With completed traffic school (3rd level) With completed traffic school (4th level) With completed traffic school (5th level)
-
How many drivers have undergone special training according to the National Education Program in Emergency Medicine for Ambulance Drivers in the last 2 years?
-
- Gender structure of the total number of ambulance drivers:
Male:
Female:
- Age structure of ambulance drivers (expressed in years, enter the number of persons in squares):
Up to 30:
From 30–55:
From 55–65:
Over 65:
-
-
State the number of ambulance drivers with verified limited work capacity:
1.
COMMUNICATION SYSTEMS AND EFFECTIVENESS IN COORDINATED RESPONSE
-
Which phone number should be called (from the territory for which your EMS is responsible) in case of intervention if the call is made from a mobile phone to reach your EMS?
O 194
O Or area code: phone number:
-
Which phone number should be called from the territory for which your EMS is responsible in case of intervention if the call is made from a landline phone to reach your EMS?
O 194
O Or area code: phone number:
-
Is there a separate phone number for reporting ambulance transport?
O No
O Yes
If yes, enter the area code: and phone number:
-
Is there an option to identify an incoming call?
O No
O Yes
-
Who receives the calls?
O Doctor
O Nurse/technician
O Nurse/technician only in consultation with a doctor
O Mixed model (nurse and doctor)
-
Is there a protocol/procedure for receiving calls?
O No
O Yes
-
Is there a recorder?
O No
O Yes, but not working
O Yes, working
-
Are phone conversations with patients recorded on the recorder?
O No
O Yes
-
Are conversations via radio recorded on the recorder?
O No
O Yes
-
Is there a separate direct phone line for communication with the police?
O No
O Yes
-
Is there a direct line for communication with the Alert and Notification Center?
O No
O Yes
-
How is communication with teams in the field conducted?
O By radio
O By mobile phone
O Both
-
Do all ambulances have a radio station?
O No
O Yes
-
How many ambulances, out of the total number, do not have a radio station?
O Enter percentage: %
-
What is the condition of the radio repeaters?
O Working
O Not working
-
Is there a power supply device for the radio system in case of a power outage?
O No
O Yes
-
Is there a special radio channel for direct communication with:
O Police: No/Yes
O Firefighters-rescuers: No/Yes
REACTION TIME FOR FIRST ORDER EMERGENCIES
-
Is reaction time monitored during first-order emergency interventions?
O No
O Yes
-
If yes, provide results for the year 2023:
O Activation time:
O Reaction time:
O Pre-hospital intervention time:
TRAINING (EDUCATION) AND PREPAREDNESS FOR DISASTER RESPONSE
-
Does every new employee undergo special training in the field of emergency medicine according to their job description before independent work in the last 2 years:
O Doctor: No/Yes
O Nurse-technician: No/Yes
O Ambulance driver: No/Yes
-
Have the employees in your EMS service undergone training in any of the existing training centers?
O No
O Yes
-
Do you consider additional training necessary for all employees in the Emergency Medical Services?
-
If yes, select the importance on a scale from 1–3 (1-most needed, 2-medium needed, 3-least needed) for whom the training is most necessary:
O Doctor:
O Nurse-technician:
O Ambulance driver:
-
Specify the areas where you believe there is the greatest need for employee educa- tion:
-
Select the areas you think would most affect the improvement of work within the EMS services (multiple answers possible):
O Specification of standards for EMS work (equipment, staff, space, vehicles, education, etc.)
O Introduction and adherence to standards and procedures
O Continuous education
O Establishment of new training centers
O Equipment renewal
O Additional staff
O Other (specify):
ADDITIONAL FUNDING EMERGENCY MEDICAL SERVICES (EMS)
-
From which sources is the funding of EMS services carried out (multiple answers possible):
O From RFZO funds
O From the city/municipality budget O Own funds of the health institution O Donations
O Other (specify):
-
Does the healthcare institution receive additional financial resources from local government for the employment of additional staff?
O No
O Yes
-
If yes, specify the number of staff for the emergency medical services by structure:
O Doctor:
O Nurse-technician:
O Ambulance driver:
Do EMS doctors have:
O Beneficial work experience: No/Yes/Partially
O Paid night work: No/Yes/Partially
O Paid Sunday work: No/Yes/Partially
Do EMS and ambulance transport nurse-technicians have:
O Beneficial work experience: No/Yes/Partially
O Paid night work: No/Yes/Partially
O Paid Sunday work: No/Yes/Partially
Do EMS and ambulance transport drivers have:
O Beneficial work experience: No/Yes/Partially
O Paid night work: No/Yes/Partially
O Paid Sunday work: No/Yes/Partially
AMBULANCE VEHICLES AND EQUIPMENT
-
Ambulance Vehicles:
No. Vehicle Type
Year of Man- ufacture
Mileage (km)
Drive Wheels
Radio Station Installed
Air Condi- tioning
Functional for Daily Use
If not, Specify Reason
-
A-van A-front
-
B-van (8 + 1 seats) B-rear
-
C-station wagon C-all four
-
D-passenger car
-
J-jeep
-
-
Is the ambulance vehicle functional for everyday work?
O No
O Yes
-
The ambulance vehicle was purchased:
O From the budget of the Government of Serbia/MZ (specify number):
O From the city/municipality budget (specify number):
O Foreign donation (specify number):
O Other:
Equipment
Present
Not Present
Need for New (Specify
Number)
EKG device
Yes/No
Yes/No
Biphasic defibrillator with monitor
Yes/No
Yes/No
Biphasic defibrillator with monitor and transcutaneous pacemaker
Yes/No
Yes/No
Biphasic defibrillator with monitor, transcutaneous pacemaker, and capnography Yes/No Yes/No
-
List the functional equipment for EMS activities:
option
Aspirator—portable
Yes/No
Yes/No
Portable mechanical respirator with oxygen cylinder
Yes/No
Yes/No
Portable mechanical respirator with oxygen cylinder with CPAP mode option
Yes/No
Yes/No
Set for cardiopulmonary resuscitation (laryngoscope with at least 3 blades of different
sizes, endotracheal tubes min. 5 different sizes, self-expanding resuscitation bag,
Yes/No
Yes/No
oronasal masks min. 3 different sizes, oropharyngeal tubes min. 3 different sizes)
10-L oxygen cylinder
Yes/No
Yes/No
Portable oxygen cylinder
Yes/No
Yes/No
Trauma care set (bandaging material, straight and curved forceps, Esmarch’s bandage of greater length, scissors for cutting clothes)
Yes/No
Yes/No
Vacuum mattress
Yes/No
Yes/No
Vacuum splints
Yes/No
Yes/No
Collars for immobilization of the cervical spine
Yes/No
Yes/No
Kramer splints
Yes/No
Yes/No
Vest for immobilization and extraction of the injured (KED)
Yes/No
Yes/No
Long spinal board with head immobilizers and body fastening straps
Yes/No
Yes/No
Longitudinally collapsible scoop stretcher for spinal injuries and polytrauma (“Ferno
stretcher”)
Yes/No
Yes/No
Infusion solution warmer
Yes/No
Yes/No
Refrigerator for cooling infusion solutions
Yes/No
Yes/No
Transport refrigerator for therapeutic hypothermia equipment
Yes/No
Yes/No
Thrombolytic therapy medications (Streptokinase/Metalyse/Actilyse)
Yes/No
Yes/No
Urgent conicotomy set
Yes/No
Yes/No
Set for intraosseous medication administration
Yes/No
Yes/No
Birth set
Yes/No
Yes/No
Pulse oximeter
Yes/No
Yes/No
Central vein puncture set
Yes/No
Yes/No
Chest decompression set
Yes/No
Yes/No
Burn dressings
Yes/No
Yes/No
Reflector lamp
Yes/No
Yes/No
Protective helmet with forehead flashlight for each team member
Yes/No
Yes/No
Protective reusable gloves
Yes/No
Yes/No
Protective glasses
Yes/No
Yes/No
Fixed radio station in the ambulance
Yes/No
Yes/No
Handheld radio station
Yes/No
Yes/No
Ultrasound
Yes/No
Yes/No
-
Do the stretchers in the ambulance have straps for securing the patient on the stretcher?
O No
O Yes
O Need (specify):
EMERGENCY RESPONSE AND EFFECTIVENESS IN URGENT INTERVENTIONS, MASS CASUALTIES
-
Do you have a vehicle for mass casualties (prepared with a larger number of stretchers, medical supplies, and other equipment)?
O No
O Yes
-
Do you have a written plan/procedures that workers are familiar with in case of a mass casualty event?
O No
O Yes
-
Do you have triage tags? (in the car or bag)
O No
O Yes
-
If yes, do you use triage tags?
O No
O Yes
-
Have you had exercises for responding to mass casualties within your institution in the last 2 years?
O No
O Yes
-
If yes, how often have you had exercises in the last 2 years?
O Specify:
-
Have you had joint exercises with other rescue services (police, military, firefighters) in the last 2 years?
O No
O Yes
-
If yes, how often have you had such exercises in the last 2 years?
O Specify:
COMPLETED BY:
- Name and surname:
- Function:
- Name and address of the healthcare institution:
- Phone number:
- Mobile phone number:
- Email:
- Municipality:
- District:
- Date:
Appendix B. Nomenclature (Terms and Abbreviations)
-
Mitigation—the lessening or limitation of the adverse impacts of hazards and related disasters [171];
-
Risk—the combination of the probability of an event and its negative consequences [171];
-
References
- Emergency Medical Services (EMS)—the organized medical response systems that provide care during emergencies;
- Emergency Medical Response Systems (EMRS)—a broader system that encompasses various emergency medical services;
- Mass casualty preparedness—the readiness and ability of EMS systems to handle incidents involving multiple casualties simultaneously;
- Shift work—a scheduling method where EMS staff work rotating shifts to provide 24-h emergency coverage;
- Pre-hospital care—medical care provided before the patient reaches a hospital, typi- cally by EMS teams at the emergency site or during transport;
- Pearson’s correlation—a statistical method used to measure the strength of a relation- ship between two variables;
- Chi-square test—a statistical test used to determine if there is a significant association between categorical variables;
- R2—coefficient of determination, indicating how well the regression model fits the data;
- B—beta coefficient, representing the standardized regression coefficient in the multi- variate regression analysis;
-
p-value—statistical significance level, used to determine whether the results are statistically significant.
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