The specialization of emergency medical services in Iran: A qualitative study

Abstract

BACKGROUND:

The specialization of emergency medical services (EMS) in the areas of cardiac and neurological disorders, accidents, and toxicology has emerged as a recent challenge. The provision of these specialized services enhances patient care quality and outcomes. This study was conducted with the aim of examining the opinions and insights of experts, technicians, and policymakers involved in these services.

MATERIAL AND METHODS:

This qualitative research was undertaken across Isfahan, Tehran, Yazd, Kerman, and Shiraz from February to August 2023. Data were gathered through purposive sampling via semi-structured interviews with 30 participants. The data were subsequently analyzed using a content analysis methodology with the aid of MAXQDA 20 software.

RESULTS:

The analysis yielded four primary themes: 1. Infrastructure, encompassing key categories such as Ambulance Services, Specialized Bases, Access Routes, and Communication Systems; 2. Human Resources, including key categories related to Employment and Remuneration; 3. Medical Specialization, comprising key categories of Specialized Medical Services and Specialized Medical Equipment; and 4. Management, including key categories of Education, Personnel, Motivation, Functionality, and Interdepartmental Cooperation.

CONCLUSION:

The participants opined that the provision of specialized services necessitates a multifaceted approach. The policymakers are advised to employ a specialized team consisting of physicians, trained nurses, and experienced technicians with the support of logistical facilities, equipment, and communication systems. Ultimately, effective management and coordination within this system are crucial to achieving EMS specialization.

Introduction

Emergency medical services (EMS) constitute a pivotal component of healthcare services, tasked with the provision of patient care within the health system until hospital admission.[1,2] These services span a range of specialized areas, including burns, cardiac and cerebrovascular events, obstetric emergencies, toxicological incidents, trauma, and accidents. As a fundamental organization within the healthcare system, the EMS plays a crucial role in mitigating disease complications through its optimal and swift response.[3]

The specialization of these services for optimal treatment and quality enhancement is a critical step toward improving patient prognosis. Existing evidence underscores the significance of specialized care for patients. The increasing contribution of cardiovascular diseases to disability prevalence is noteworthy, with a majority of deaths resulting from misdiagnosis, particularly within the initial four hours. The efficacy of a specialized cardiac team in mitigating these complications is well-documented. Studies indicate a 20% reduction in disabilities attributable to an increase in emergency personnel capacity and significant enhancements in their training and specialized skills.[4] Several studies have identified the causes of EMS failures as insufficient knowledge and skills of personnel, a lack of trained medical personnel, the presence of a nonspecialist workforce in the EMS, or the absence of a specialized workforce in certain situations.[5,6,7]

In recent times, specialized emergency services have been established to cater to diverse accidents, needs, and expectations of the populace. The specialization of EMS can alleviate disease burden and enhance patient satisfaction.[1,4] Occasionally, the absence of specialized obstetric services has led to premature childbirth in an ambulance or obstetric complications. In cases of myocardial infarction (MI) and stroke, the “golden time” is critical for implementing life-saving measures.[8] Victims of traffic accidents necessitate specialized care and equipment.[9] In instances of burns, poisonings, and dyspnea, initiating specialized care from the onset of the incident has proven effective in reducing disabilities.[10] Studies suggest that the final outcomes of specialized treatment teams are significantly improved in these cases, benefiting patient prognosis.[10,11]

Martin Ebinger in Berlin (2015)[12] reported enhanced treatment adequacy in specialized ambulances equipped with a stroke emergency mobile unit. Crawford Mechem (2020),[13] through the development of Alternative Response Units and the segregation of ordinary and specialized tasks, concluded that the technical team exhibited improved performance, cost-effectiveness, and timely response. The UK’s National Health Service advocates for the development of specialist care and service specialization within EMS. Since 2018, the U.S. military has allocated a medical force to respond to obstetric emergencies, equipped with Advanced Trauma Operative Management (ATOM) training, resulting in improved performance in obstetric management.[14] Following the September 11 incidents, a special operations unit was established to provide rapid response to Washington County patients with heart diseases, deploying specialized teams to the scene as per guidelines.[15] Kurt Huber (2020),[16] investigating the impact of COVID-19 on the treatment of heart disease patients due to hospital visitation fears, underscored the role of a specialized emergency unit capable of effectively diagnosing, treating, and transporting these patients to the hospital. Some studies consider the diagnosis of infectious diseases such as sepsis in the ambulance by the specialized staff to be effective in optimal treatment.[17] Tae Han Kim (2019),[18] examining the effect of utilizing a specialized intensive care unit in Seoul named SMICU, demonstrated a significant reduction in casualties among critically ill patients within the first 24 hours. In Iran, with over 17,000 fatalities and 367,000 injuries annually due to accidents alone, there is a pressing need to enhance care to reduce mortality.[2] Safdari in Tehran proposed the triage of specialized care to reduce casualties and adopted a multifactorial approach in response to its management.[19] Khosrow Shakeri[20] has proposed the establishment of specialized bases and hiring capable physicians and even a dedicated women’s emergency team in ambulances.

Considering the efforts made in the above countries, and in order to determine the fields of emergency care that require specialization, a comprehensive review was needed. Therefore, the researcher decided to conduct this qualitative study. This study addressed all aspects of these services by obtaining the opinions of emergency experts on how to specialize in emergency services. Also, in this study, the prerequisites considered in various specialized medical fields that should be provided for the target patients have been examined and discussed. In fact, this study analyzes the recommendations and insights of interviewees including experts, technicians, and policymakers involved in specialized emergency services. These recommendations will be used to specialize the EMS.

Material and Methods

Study Design and Setting: A qualitative investigation serves as a powerful tool for elucidating individuals’ genuine comprehension of their daily life phenomena.[21] In this study, we draw upon the rich experiences of emergency technicians and experts across the metropolitan areas of Isfahan, Tehran, Yazd, Kerman, and Shiraz. Our research endeavors involve in-depth interviews, conducted between February and August 2023, which delve into the participants’ firsthand encounters with specialized services required within the EMS context. These interviews were skillfully administered by participants possessing practical expertise in EMS operations.

We employed conventional content analysis to meticulously dissect and interpret the collected data. This analytical approach allowed us to uncover the latent phenomena underlying EMS practices, thereby contributing novel insights and knowledge to the field.[22] Through rigorous textual analysis, we discerned emergent themes, organizing them into a coherent and systematic categorization.[22]

Participant Selection: Our study cohort comprised 30 carefully selected participants, drawn via purposive sampling. These participants represent a diverse spectrum, including technicians, managers, policymakers, and emergency faculty members, all of whom boast substantial experience in emergency management. The eligibility criteria necessitate a minimum of 15 years of professional work experience, a keen interest in participating in the interviews, and direct involvement in EMS-related activities. Demographic characteristics are meticulously documented in Table 1, while detailed profiles of the participants are presented in Table 2. The interviews continued until data saturation was achieved.

Table 1.

Demographic characteristics of participants

Demographic	Quantity (%)
Gender
Male	27 (90%)
Female	3 (10%)
Work experience (year)
Below 10	3 (10%)
Between 10 and 20	21 (70%)
Above 20	6 (20%)
Degree
Fellowship	3 (10%)
PhD/Expert	15 (50%)
Master’s Degree	3 (10%)
Bachelor’s Degree	9 (30%)

Table 2.

Demographic profile of participants

Row	Organization	City	Current Position
1	Emergency organization	Isfahan	Emergency center manager
2	Emergency organization	Isfahan	Emergency center manager
3	Emergency organization	Tehran	Emergency center manager
4	Emergency organization	Tehran	Emergency center manager
5	Emergency organization	Kashan	Emergency center manager
6	Emergency organization	Yazd	Chief Executive Officer
7	Emergency organization	Shiraz	Chief Executive Officer
8	Faculty of Emergency Medicine	Isfahan	Head of Department
9	Faculty of Emergency Medicine	Isfahan	Head of Department
10	Faculty of Emergency Medicine	Yazd	Head of Department
11	Faculty of Emergency Medicine	Isfahan	Responsible for the province’s EMS
12	Faculty of Emergency Medicine	Yazd	Responsible for the province’s EMS
13	Faculty of Emergency Medicine	Tehran	Responsible for the province’s EMS
14	Faculty of Emergency Medicine	Mashhad	Responsible for the province’s EMS
15	Emergency medicine specialist	Isfahan	Hospital emergency ward
16	Emergency medicine specialist	Isfahan	Hospital emergency ward
17	Emergency medicine specialist	Kerman	Hospital emergency ward
18	Emergency medicine specialist	Yazd	Hospital emergency ward
19	Emergency medicine specialist	Mashhad	Hospital emergency ward
20	EMS Technician	Isfahan	Urban emergency manager
21	EMS Technician	Isfahan	Urban emergency manager
22	EMS Technician	Isfahan	Urban emergency manager
23	EMS Technician	Tehran	Urban emergency manager
24	EMS Technician	Isfahan	EMS base technician
25	EMS Technician	Yazd	EMS base technician
26	EMS Technician	Qom	EMS base technician
27	EMS Technician	Tehran	EMS base technician
28	EMS Technician	Tehran	EMS base technician
29	EMS Technician	Mashhad	EMS base technician
30	EMS Technician	Kashan	EMS base technician

Data Collection: In accordance with written authorization from Isfahan University of Medical Sciences (IUMS), we embarked on data collection endeavors. Prior informed consent was meticulously obtained, adhering to the principles outlined in the Declaration of Helsinki. Participants were afforded the autonomy to select an interview environment conducive to their comfort, a quiet, convenient, and undisturbed setting. Commencing with a succinct presentation of the project objectives, the interviews proceeded with a series of initial inquiries, subsequently tailored based on the participants’ responses.

Our data acquisition methodology centered on semi-structured interviews, characterized by open-ended questions. To delve deeper and extract data of greater richness, we posed in-depth queries. The participants’ verbal responses were meticulously captured using a voice recorder and subsequently transcribed post-interview. These textual records were then subjected to rigorous analysis within the MAXQDA 20 software.

The primary interview framework was thoughtfully predetermined. Our line of inquiry commenced with the fundamental question: “Does the Emergency Medical Services (EMS) necessitate specialized services?” Additional probing questions are meticulously documented in Table 3. The participants’ statements were transcribed verbatim and subsequently shared with them for validation. The interview sessions extended over a duration of 50–60 min, with iterative reviews conducted to achieve a state of immersion.

Table 3.

Interview questions

Number	Question
1	Does the EMS need to provide specialized services?
2	Do recipients demand specialized services from the EMS?
3	What specialized services are needed in the EMS?
4	What are the human resources requirements for EMS specialization?
5	What are the equipment requirements for EMS specialization?
6	What are the ambulance requirements for EMS specialization?
7	What is your advice in this regard?

Data Analysis: The recorded interviews underwent meticulous review and transcription. Multiple readings of the text were undertaken to foster a shared understanding. Subsequently, we derived codes and meticulously categorized them based on thematic similarities. Redundant codes were judiciously eliminated, and convergent codes were harmonized. The resultant categories were systematically compared, leading to the emergence of overarching themes. The researcher diligently endeavored to mitigate personal biases, opinions, and attitudes throughout this analytical process.

Validity of Data: To bolster the trustworthiness of our data, we applied the Cuba and Lincoln criteria.[23] Transcribed interviews, presented in both their original form and coded representations, were shared with participants to solicit their additional insights. Based on their invaluable feedback, the codes underwent thoughtful modification. In our pursuit of robustness, we further bolstered credibility and data confirmability through two key strategies:

Sampling Diversity and Member Checking: By engaging a diverse array of participants, including emergency technicians, managers, policymakers, and faculty members, we ensured a multifaceted perspective. The iterative process of member checking allowed us to validate the accuracy and fidelity of our interpretations.

Expert Verification: Three esteemed faculty members meticulously examined and verified the codes and categories. Their expertise and discernment contributed to the rigor of our analysis. Additionally, we meticulously curated a conducive interview environment, fostering participant comfort, and openness. Allocating sufficient time for each interview session further contributed to the credibility of our findings.

Ethical Considerations: This study received ethical approval from Isfahan University of Medical Sciences (IUMS) under the code IR.MUI.NUREMA.REC.1400.143. Participants were accorded complete autonomy, with the freedom to withdraw from the interview process at any juncture.

Results

Following the conduct of 30 interviews, our dataset achieved saturation, brimming with rich insights. Among the participants, three were women, while twenty-seven were men. Notably, 90% of the participants boasted over 10 years of experience. Their educational backgrounds spanned from bachelor’s degrees to fellowships. Importantly, 19 participants (63%) held managerial responsibilities within the emergency domain.

Our rigorous data analysis yielded 551 distinct codes, which were meticulously classified into 43 subcategories, further coalescing into 13 main categories. These categories converged to form 4 overarching themes, encapsulating the major challenges inherent in EMS specialization. These themes encompassed infrastructure, human resources, medical specialization, and management, as meticulously detailed in Table 4.

Table 4.

Themes, categories, subcategories, and codes of data of Specialization of Emergency Medical Services (EMS) in Iran

Themes	Main categories	Subcategories
Infrastructures	Ambulances	Increasing the quality of ambulances
		Buying different types of ambulances
		Use of the types of ambulances (A, B, C)
		Provision of ambulance equipment
	specialized bases	Increasing the number of specialized bases
		Proper arrangement of specialized bases
	Access paths	Repair of public roads
		Determining dedicated paths
	Communications	Communication between dispatch and ambulances
		Communication between specialized teams and hospitals
		Communication between ambulances
		Use of telemedicine
Human Resources	Employing	Providing specialized human resources
		The presence of a physician in the ambulance
		Providing nonspecialist human resources
	Salary	Provision of adequate salaries and benefits
		Anticipate appropriate job benefits
Medical specialization	Medical specialized services	Providing specialized cardiac services (Code 247)
		Providing specialized stroke services (Code 724)
		Providing specialized trauma services
		Providing specialized obstetrics services
		Providing specialized burn services
		Providing specialized poisoning services
		Providing specialized psychiatric services
		Providing specialized services for CBRNE accidents
	Medical Specialized Equipment	Provision of specialized ambulance medical equipment
		Provision of specialized medical equipment for bases
Management	Education	Providing specialized medical training
		Providing specialized nonmedical training
		Providing Individual and group training
		Providing in-service specialized training
	Personnel	Improving the composition of the specialized team
		Predicting the succession of specialized technicians
	Motivation	Improving the internal motivation of the person
		Improving the external motivation of the person
		Compilation and implementation of protective laws
	Function	Improve personal performance
		Improving organizational performance
		Monitoring the performance of the specialized team
	Cooperation between departments	Cooperation with upstream officials
		More cooperation with hospitals
		Cooperation with the Red Crescent
		Cooperation with social welfare emergency

In the following, the main categories and subcategories of interviews are reviewed.

Theme 1: Infrastructures

Ambulances: Providing a special ambulance with specialized facilities was considered by most of the interviewees. They mentioned the quality of ambulances and considered their role in providing optimal services very important. The use of types of ambulances such as A, B, and C in the EMS was also emphasized. To provide specialized services, ambulances must have equipment and facilities that were mentioned by the interviewees. Participants mentioned different challenges of the current position and agreed that special ambulances had a great influence on the quality of EMS. Just as two interviewers expressed:

“I want to tell that a good ambulance should be bought firstly. Specialized services cannot be well- equipped with current ambulances. They are all old and broken. Give this issue priority. We are afraid to transfer our patients with them.” (P. 24).

“Even with a specialized team, the service will fail without specialized ambulances. We had an incident where an ambulance broke down on the highway. The main problem of the EMS is the ambulance. You need to establish the foundation of the system first, then consider the other aspects. “(P. 20).

Finally, the interviewees agreed on the quality, number, type, size, and types of ambulances.

Specialized Bases: Requirements should be considered for the specialization of EMS bases. These bases should be placed in different places based on the needs of each district of the city. Additionally, these places must be equipped with specialized equipment. This equipment helps the above teams fulfill their specialized role and achieve the desired goals. Electroshock, ventilator, syringe pump, capnograph, and specialized drugs can be mentioned among this equipment. It should be mentioned that this equipment should be installed in that center following the role that the base plays in providing specialized services.

“Now, we do not have many facilities on emergency bases. If we want to be more advanced, we need devices in which only one is located in each center, and we have a severe shortage. Some bases do not even have electroshock. We went to a scene where many measures could have been taken if there was an AED device. Unfortunately, the patient died. “(P. 29).

“If there are more facilities and specialized equipment in the base, the quality of our work will be higher. The equipment is old and needs to be updated. We have a monophasic electroshock, while we should have a biphasic model. For the specialized base, you need more advanced devices.” (P. 7).

Access Paths: Urban roads are one of the indicators of the societies’ development. Safe access paths are required to reach the patients timely. Normally, ambulances use the usual urban paths. Reducing the time to reach the accident scene is one of the benefits of designing a specialized path for EMS. The most emphasis on dedicated paths was given by EMS technicians:

“With current traffic, the specialized team cannot be useful, at least make a special line for us, so we do not lose time. Assuming that our performance is excellent, but if we get stuck in traffic, the result will not be successful.” (P. 27).

Communications: Communication can be considered one of the basic factors of any system for optimal performance. In EMS, to accomplish a mission, we need communication between all system components. Today, EMS departments use different communication tools to exchange information between their units. The participants of this study mentioned this a lot.

“I recommend that you pay more attention to communications. We have problems communicating with dispatch or other ambulances. Once the address was obtained from dispatch, the connection was lost. If I did not know the location of the incident before, could not do anything until the connection was reconnected.” (P. 30).

Communication between EMS and dispatch centers, hospitals, ambulances, and emergency operation centers (EOCs) is necessary in various ways. Wireless communication through telemedicine has replaced usual communication. Telemedicine plays a vital role in the exchange of information in the emergency system. This topic was not overlooked by the interviewees:

“Wireless communication should be expanded in ambulances so that any information can be easily provided between technicians and other parts such as physicians, EOC, dispatch, etc., Without communication, how can you provide specialized services? I think telemedicine is very important if you want to specialize in the EMS.” (P. 1).

Telemedicine was suggested by one of the emergency managers to exchange information between the patient and the physician. Thus, the patient’s information can be transmitted immediately, and treatment decisions can be made quickly.

Theme 2: Human resources

Employing: Human resources, one of the basic elements of any organization, are the driving engine of that system. To specialize in EMS, first, special attention should be given to human resources. Interviewees considered the recruitment of human resources as the first prerequisite for the specialization of the EMS.

“We do not have personnel now. I recommend that you hire a technician first; otherwise, you will be in trouble. Occasionally, we have two personnel, and during the mission, we have to close the door of the base. This is the problem of all provinces.” (P. 19).

“We have a shortage of manpower to adjust the monthly personnel schedule. We expect you to give priority to this issue. We also need a physician on the specialized team. “(P. 5).

Salary: Paying salaries and benefits according to the duties of the specialized EMS is an important factor in guaranteeing and continuing to provide those services. Employees on specialized teams have higher academic degrees and more complex tasks. Therefore, they expect higher benefits.

“After creating the specialized team, problems are shown because they want more benefits and have higher expectations for the specific tasks they perform. Therefore, it is necessary to ask for more funds.” (P. 3).

“The ministry has a financial problem, and the creating of these teams imposes an additional financial burden. You must be prepared to solve these problems. “(P. 1).

Theme 3: Medical specialization

Medical Specialized Services: The purpose of creating specialized teams is to provide better services and separate the duties. The interviewees mentioned several specialized medical fields in which it is necessary to provide a specialized team. The specialized MI team, which is currently working as code 247, or the specialized stroke team, is called code 724. In addition, some recommended midwifery, burn, poisoning, and trauma teams.

“You should work in some fields where you have a lot of patients, now there are more myocardial infarctions or strokes, which are more common.” (P. 8).

“The midwifery team is justified because recently there has been a lot of emphasis on the health of mothers and babies and population growth. A burn team should also be established because now the technicians just bring the patient without any special action.” (P. 12).

“A team should be created to deal with chemical, biological, radiologic, nucleic, and explosive (CBRNE) incidents in a specialized manner. This team should be located near vital centers, factories, and industries.” (P. 3).

Medical Specialized Equipment: The provision of specialized equipment suitable for each specialized team was highly emphasized. This equipment helps team members in the specialized treatment of patients. Equipping ambulances and specialized bases with advanced medical equipment was proposed as a prerequisite for the creation of teams.

“To start, tools and equipment must be taken from the ministry. Even specific drugs are needed by the team for every disease. It is mandatory to have a Reteplase for the MI team and an Alteplase for the stroke team. I recommend starting these medicines from the patient’s home.” (P. 16).

Theme 4: Management

Education: Education was mentioned in two types of academic and in-service training as supplementary training. The participants stated that nonmedical training, such as problem-solving, anger management, and critical thinking, is necessary along with medical training. The participants believed that necessary training in the field of EMS should be provided in universities.

“We do not learn everything in university. Additional training must be in-service. You cannot find the experiences and in-service training that I felt in these years anywhere. Train specialized teams to become experts.” (P. 10).

Individual training and teamwork were emphasized by some participants.

“A technician may be very good as an individual, but when he works in a team, he can be judged. Teamwork training is very important.” (P. 15).

Personnel: The composition and arrangement of technicians in the team were also discussed. Competently managing the specialized team and placing expert people in each work shift is effective in achieving the team’s goals. The replacement of personnel in case of illness or absence must be managed.

“When someone is absent or sick, a replacement must be provided. This replacement should be with an expert person so that the team can perform the task.” (P. 22).

Motivation: The specialized team must have sufficient motivation to serve in the team. This motivation can be internal or external, both of which are complementary. The approved protective laws to defend the team personnel in the specialized treatment of patients can be effective in increasing their motivation.

“We want the necessary guarantees to protect ourselves in case of complications for patients. Who will support me if I do a specialized treatment that causes problems for the patient?” (P. 27).

The interviewees emphasized that choosing individuals with motivation and work conscience was one of the basic characteristics that was necessary in creating a specialized team.

“If your technician is more motivated, the quality of the team’s work will also increase. Unmotivated personnel cannot work well. They are not compassionate.” (P. 14).

Function: The performance of the specialized team should be regularly monitored by the EMS manager, and then its deficiencies should be checked and corrected. Additionally, the technical performance of the team should be checked to determine the percentage of achieving the goals. The performance of the specialized team should be reviewed periodically. Both managers and technicians made this suggestion.

“How can you make sure that the specialized team works well? If you do not supervise, this team will be similar to the general team. Monitor the performance of the team.” (P. 21).

“Results monitoring of the specialized team activities will help you to ensure the correct implementation of medical guidelines. We had technicians who did not follow these instructions. They did whatever they wanted. They even prescribed drugs!” (P. 14).

Cooperation: Cooperation between colleague and supporter organizations, hospitals, Red Crescent, welfare organizations, and upstream officials is one of the tasks that coordinates all efforts to achieve goals and makes the EMS specialized team more capable.

“The Red Crescent has ambulances and advanced equipment that can be used. The social medical team of the welfare organization has good experiences with mental patients and drug addicts.” (P. 6).

“If you do not cooperate with the emergency department of hospitals, it will be difficult for the team to continue functioning. You have to take the patients to the specialized hospital of the city, so it is necessary to cooperate with them.” (P. 7).

“You can use Red Crescent facilities to equip the EMS. They have advanced facilities. The welfare organization also has special facilities.” (p. 9).

Discussion

This study was conducted with the aim of obtaining the opinions of experts, technicians, and policymakers in the field of prehospital emergency regarding how to specialize medical services. In the current landscape of EMS in Iran, there is a notable absence of specialization. The public’s growing demand for specialized EMS is evident, yet the efforts to meet this demand remain insufficient. Recent initiatives have seen the implementation of Code 247 for MI and Code 724 for stroke in select hospitals. However, these specialized services are initiated at the hospital level, bypassing the critical prehospital phase where timely intervention is most crucial.

This study delves into the managerial hurdles faced when establishing specialized services within EMS. The findings reveal that a successful implementation hinges on several key factors: robust infrastructure, competent human resources, and effective management. Infrastructure emerges as a pivotal element, with participants highlighting the necessity for high-quality ambulances, adequately equipped and in sufficient numbers.

Some studies support these findings. Ebinger M et al.[24] demonstrated that ambulance thrombolysis can significantly reduce treatment times without compromising patient safety. Furthermore, specialized prehospital stroke care has been shown to enhance thrombolysis rates, shorten alarm-to-treatment durations, and decrease prehospital mortality rates.[25] The importance of dedicated and unobstructed access paths is also underscored, particularly in densely populated urban centers during peak traffic. This concern was expressed by Wenyan Hu et al.[26]

Another challenge identified is the recruitment and retention of skilled personnel, compounded by the need to offer competitive compensation. Blau G et al.[27] report that inadequate pay and benefits are the primary factors driving professional emergency workers to leave their positions, leading to decreased motivation of personnel. Low income has led to a decrease in motivation, reluctance, and leaving the job. Specialized services are provided to patients in various medical fields, which most of the interviewees mentioned. Currently, patients with MI by code 247 and stroke by code 724 receive specialized services, but the treatment does not start at the patient’s home. Receiving services without wasting time and from home can be effective in reducing complications of diseases. Studies confirm this.[10,28,29]

The provision of specialized services extends beyond MI and stroke care, encompassing areas such as burns, poisonings, trauma, midwifery, and CBRNE (Chemical, Biological, Radiological, Nuclear, and Explosives) incidents. In the United States, specialized teams like ATOM cater to the medical needs of pregnant patients, a model worth considering for adaptation within the Iranian military context.[30]

Globally, the deployment of mobile stroke units represents a progressive step toward enhancing prehospital care.[31] Effective resource and facility management, coupled with competent human resource management, are essential for the success of any project. This sentiment is shared among emergency operations managers, who stress the importance of proper management in achieving organizational goals.

The study also emphasizes the significance of academic and in-service training for specialized team members, advocating for continuous updates and enhancements to these programs. The optimal composition of the specialized team is crucial, ensuring precise and scientifically sound patient care. The presence of a physician, a practice adopted in some countries, correlates with improved patient survival outcomes.[32]

Motivating personnel is vital for achieving superior results, as is the protection of technicians from violence during specialized missions. The development of protective legislation is suggested to safeguard those involved in specialized treatment procedures.[33] Performance monitoring of the specialized team, encompassing both individual and group metrics, is another critical aspect of EMS management. Regular assessments of the team’s capabilities through various management strategies are recommended to maintain high standards of performance in EMS.[34] The study identifies interdepartmental cooperation as a significant managerial opportunity for emergency managers. Experienced participants recommended the use of Red Crescent facilities to augment EMS teams, a practice already in use in Saudi Arabia.[35] However, some concerns were raised about potential role conflicts arising from collaboration with the welfare organization’s social emergency services. Although the opinions of the experts have been very challenging, their consensus has all been on the importance of specializing the EMS.

Limitations and Recommendations

Dispersion of participants’ opinions and difficulty in coordination in interviewing them were the limitations of this study. In future studies, it is recommended to conduct interviews with experts and managers of different levels of responsibility with the snowball sampling method.

Conclusion

The research underscores the emergent public demand for specialized EMS, necessitating the development of appropriate infrastructure. Therefore, policymakers are advised to have a specialized team consisting of physicians, trained nurses, and experienced technicians with the support of logistical facilities, equipment, and communication systems. Post-implementation, a robust management system is recommended by nursing managers to oversee the project, with regular activity monitoring to ensure performance accuracy. Despite the financial burden on the medical system, the anticipated benefits, reduced disease complications, and heightened patient satisfaction are likely to justify the investment.

Ethics approval

Ethical approval was obtained from the ethic committee of Isfahan University of Medical Sciences. (Code: IR.MUI.NUREMA.REC.1400.143).

Consent for publication

All authors have consented to the publication of this work.

Authors’ contributions

• M.F. and H.A.B. were responsible for the study design, writing, and review.

• H.A.B. managed data acquisition and initial drafting.

• G.M. and M.F. handled the methodology, data analysis, and interpretation.

• F.R. contributed to manuscript drafting, editing, and final approval for publication.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Funding was provided by Isfahan University of Medical Sciences (Grant No. 3400571).