Table 3. Summary of findings related to the six different quality domains.

Quality Domain	Finding	Sources
Safety: Avoiding harm to clients from the care that is intended to help them.[5]	1. In Riyadh, SA, a face-to-face cross-sectional interview with EMS provider has shown that around 98% of participants dispatched their clients to the nearest hospitals without considering the availability of stroke treatment facilities.[19]	[19]
Time-centeredness Reducing waits and sometimes harmful delays for both those who receive and those who give care.[5]	1. A study in Gulf States (excluding SA, but including the non-gulf state of Yemen) compared the usage of private transportation and EMS for ACS clients. The study found that among EMS users, reperfusion therapy for STEMI/LBBB clients was significantly less likely (20% vs. 31%: P < 0.001). [27] 2. A study in multiple Gulf States (excluding SA, but including Yemen, which is not a gulf state member) compared the demographic and clinical characteristics of STEMI clients who received timely primary percutaneous intervention (pPCI). They reported door to balloon time (D2B) ≤ 90 minutes versus delayed pPCI (D2B > 90 minutes). Compared to being transported by private means, an ambulance ride was associated with shorter D2B, but this was not statistically significant (30 of 45 [66.7%] patients transported by ambulance had a D2B ≤ 90 minutes, 78 of 153 [51.0%] transported privately, P = .063).[33] 3. Study conducted in 5 out of 6 Gulf States (except Kuwait) found that clients with STEMI, who arrived by EMS, had a significantly longer interval from symptom onset to hospital arrival (median 184, range 111–370 vs 173, 90–358 minutes; P = .018), but a similar percentage of clients presented to the ED within 12 hours of symptom onset. They also had similar rates of receiving thrombolytic therapy and shorter door-to-needle time (DNT; median 35, range 23–60 vs 40, 25–65 minutes, P = .01) but were less likely to receive primary PCI (26.7 vs 35.5%, P = .04. Furthermore, he found that There was no significant difference in median length of stay for those who transport by EMS compare with Private Transport P = 0.284. [15] 4. Another Study conducted in 5 of 6 Gulf States (except Kuwait) found that the median (IQR) from symptom to ED time was significantly shorter for Out-of-Hospital EMS 144 (IQR 191) when compared to inter-hospitals ambulance transportation 230 (IQR 277), and private transportation 185(IQR 241), P< 0.001.[16] 5. In SA, a study evaluating the EMS rescue times found that the mean response time was 10.23 min (S.D = 5.66 min). The average EMS time was 61.19 min (SD = 16.86 min) and the average scene time was 15.2 min. In addition, 85% of the incidents took up to 66 min or less to be completed. [11] 6. Another study in SA found that the response time was within 25 minutes in 80.9% of calls; 65% of calls were responded to within the first 15 minutes. The response time was limited to half an hour in 82.9% of calls. The average response time was lower at locations near the dispatching EMS centers: sometimes as low as 5 minutes. [18] 7. In Jeddah, in SA, study found that according to people perception. The majority estimated that the estimated time arrival ETA of an ambulance response to their home to be about 30 minutes or more. [28] 8. In UAE, EMS transportation was associated with a shorter time to treatment in the Hospitals when compared with other modes of transportation in Abu Dhabi.[24] 9. In UAE, the median EMS response time was 9 minutes (IQR: 6 to 14). In 75% of cardiac arrests, the EMS response time was 14 minutes or less.[20] 10. Another study performed in UAE found a median EMS response time of 9 minutes (IQR 6 to10), and a median scene time of 9 minutes, (IQR 4–13).[34] 11. Study described EMS performance toward OHCA in UAE, Dubai, found the EMS response time was 10 minutes (IQR 7 to 12).[32] 12. A study in Qatar found a median EMS time for trauma clients who died (6.8% of all) of 60.5 Minutes (range: 3–160).[10] 13. Another study in Qatar described the presentation, and outcome of traumatic brain injury (TBI) for two groups of clients who survived and those who died. It showed the scene time is significantly higher for non-survival in compare with survival [17] minutes (IQR 1 to 90), Vs 23 minutes (IQR 1 to 110), P value = 0.009]. The median of total EMS time for both of group was 60 Minutes (IQR 3 to 234) without any significant difference for both groups. [26] 14. The EMS response time was less than eight minutes for 25% of transported case in Qatar, while 75% took more than 8 minutes. On average, scène time 26.5 minutes (SD 12.1) was higher than response time 14.6 Minutes (SD 8.7), and transportation time 22.7 Minutes (SD 12.7). [13] 15. In Qatar, the median response time was 8.72 min (IQR 6.8 to11.8). The median scene time was 37.9 min (IQR 28.0 to 50.6), and the median transport time was 21.4 min (IQR 13.7 to 31.5).[29]	[27] [33] [15] [16] [11] [18] [28] [24] [20] [34] [32] [10] [26] [13] [29]
Effectiveness: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively).[5]	1. Study in Gulf states include Yemen, non-gulf state, and exclude SA measured the utilization of ACS clients for EMS compare with Private transportation. The study found 17% of ACS clients used EMS. Regarding the Crude rates of in-hospital outcomes by mode of presentation to the ED, it was found Clients transported by EMS had higher rates of in-hospital mortality, cardio- genic shock, and stroke (p < 0.01 but when confounding factor adjusted for age, gender, and presentation characteristics, the associations between EMS utilization and in-hospital outcomes were no longer statistically significant. [27] 2. A study in multiple Gulf States compared two groups of clients. The first group of clients received timely pPCI (D2B ≤ 90 minutes) and were compared to delayed pPCI (D2B > 90 minutes). The study showed that the use of ambulance services was substantially low (<30%) in both groups[33] 3. Study conducted in 5 of 6 Gulf States, except Kuwait, found that 25% of ACS clients use EMS for the transportation to high facility hospital. They observed a higher CVS complication, and mortality rate in the EMS group, but this could be explained by confounders such as age, risk factors (OR 1.54, 1.12–2.13) and at 30 days (OR 1.37, 1.04–1.8) and 1 year (OR 1.41, 1.12–1.78) after hospital discharge, but that difference became non-significant after multiple adjustments. [15] 4. Other study in gulf state without Kuwait found 3.7% of STEMI clients were transported by Out-of-Hospital EMS while 22% were transported from non- PCI hospital to PCI hospital. Worthwhile, three fourth of STEMI clients were transported to PCI and non- PCI hospitals by private.[16] 5. A study in SA in a small sample of clients: (n = 96) showed that two third of OHCA after trauma were transported by EMS while the rest were transported by private transport. Of all non-traumatic OHCA clients, only one third were transported by EMS, the rest by other means. Meanwhile, none of the cases who were transported by EMS had Resuming Of Spontaneous Circulation ROSC before arrival to ED. [21] 6. Another multicenter study in SA described the total admission of acute myocardial infarction. The study showed that 5.2% (n = 96) transported by Saudi EMS to Emergency department in 50 hospitals of 13 provinces in SA. [17] 7. An interview with SA EMS providers showed that 78% had no knowledge of stroke subtypes, and most of them had previous more than or equal to five years experiences. Meanwhile, only 10% of those EMS providers with five or more year of experiences were aware of tPA. 94% of all participants were unaware of Tissue Plasminogen Activator t-PA. [19] 8. In Makkah, during the seasonal Muslim gathering in one month, one study in SA observed that 2.5% of ER attendee were transported by ambulance and the vast majority of clients transported by EMS whom require airway management (80%), and breathing support (92.4%) did not received it [25] 9. In Riyadh, the capital city of SA, a retrospective study to identify factors contribute to EMS non-conveyance of clients reported that the non-conveyance rate was 25% while only 3.9% of non-conveyance’s cases treated at the scene [18] 10. In UAE, study found that 60% of Clients with STEMI transported by private and 12% by EMS while 28% was inter-hospital clients’ transportation. Those STEMI clients that were transported by EMS did not receive ECG during transportation. The study also observed a higher mortality rate in the EMS group, but this could be explained by confounders such as age, risk factors, and socioeconomically status.[24] 11. In Abu Dhabi, UAE, study measures the STEMI clients perception, utilization, and knowledge toward EMS which found 15% of clients had transported by EMS while 85% transported by non-EMS vehicle. [23] 12. Prospective study to describe EMS performance toward OHCA in the Northern Province of UAE, found that 99.5% of all OHCA cases were transported by EMS to hospitals and EMS provide shock rhythm analysis for 17% of transported clients. In addition, 71% of cases received mechanical chest compression devices, 84% of clients received laryngeal mask airway management, and ROSC was resumed for 3.1% of OHCA by EMS. [20] 13. Study to describe EMS performance toward pediatrics OHCA of UAE, found that all clients were transported by EMS. However, EMS providers used the automated external defibrillator for 11% of child with OHCA; inotropic medications were given for 6% of clients by EMS. In addition, EMS gave Intravenous Dextrose for 75% of clients. ROSC was resumed in 6% of clients by EMS, and 6% of clients were received laryngeal mask airway management by EMS. [34] 14. Study to describe the UAE-Dubai EMS performance toward all transported OHCA clients, found that (n = 46) 11.4% of transported clients have been witness by EMS providers. 13% (n = 6) of them has ROSC.[32] 15. Study to describe the Qatar EMS performance toward all transported OHCA clients due to cardiac reasons, found that 80% of clients are non-shockable and EMS provide shock rhythm for the other 20% shockable clients. 95% of EMS clients received ACLS and mechanical chest compression devices for 70% of EMS Clients. ROSC was resumed for 13% of OHCA by EMS. [29] 16. In Qatar, study to describe the outcomes of OHCA after trauma found that 98% of cases transported by EMS. EMS defibrillated 10.2% and three fourth of clients received ACLS and control bleeding was done for 10%. [30] 17. In Qatar, EMS transported 94% of acute severe traumatic clients who required intubation, while 6% were transported by private vehicle. Of those transported by EMS, 45% were intubated during transportation. PHI was associated with high mortality when compared with ERI. However, selection bias could not be ruled out and therefore, PHI needs further critical assessment. [13] 18. In Qatar, 91.3% of trauma-related death cases had been transported by ambulance, and 4.8% were transported by private car. [10] 19. In Oman, private vehicles transported 33% of all trauma clients while 67% were transported by EMS. Those traumatized patents who transported by EMS had a statistically non-significant 36% reduction in mortality compared with privately transported clients. Analysis showed no significant difference in short- and long-term outcomes for both group of clients. The EMS-transported group had a lower mortality rate compared to the non-EMS group (5.3% vs 8.1%; p = 0.67). [12] 20. Another study in Oman measuring epidemiology and outcome of OHCA clients who admitted to single tertiary hospital found that EMS transported 1.4% (n = 3) of total clients arrived to hospital whereas 98.6% (n = 213) arrived by private.[31]	[27] [33] [15] [16] [21] [17] [19] [25] [18] [24] [23] [20] [34] [32] [29] [30] [13] [10] [12] [31]
Patient-centered: Providing care that is respectful of and responsive to individual clients preferences, needs, and values and ensuring that clients values guide all clinical decisions.[5]	1. In Jeddah, in SA, study found that 33% of people did not know the call number; 94% said that MEDEVAC is needed. Furthermore, 17.7% of people still found it unacceptable for male paramedics to respond to a female emergency unescorted by a male family member. The client’s preference rate to request EMS for their relatives with cardiac arrest was 57%. It also shows that (70%) of client were satisfied about the services had been given to them. [28] 2. In a survey among EMS providers in three major cites of SA, it was found that 60% of EMT stated that the presence of family and bystanders, and the impression of people and family, were the most two agreed upon barriers for the participant. The third barrier was traffic congestion with 54.8%. Although, over half reported that clients did not resist their treatment, 60% of them reported they think clients have an unfavorable impression of EMS providers. [14] 3. In Riyadh, the capital city of SA, a retrospective study to identify factors contribute to EMS non-conveyance of clients, the study shows that 54% of the client refused to be transported via themselves and their relatives. [18] 4. In Abu Dhabi, UAE, study shows that Less than half of the physicians were "Somewhat Satisfied" (35%) or "Very Satisfied" (7%) with current EMS level of care for S-T Elevation Myocardial Infarction STEMI clients. Most participants were "Very Likely" (67%) to advise a clients with a cardiac emergency to use EMS, but only (39%) felt the same for themselves or their family in Acute Coronary Syndrome ACS in Abu Dhabi, UAE. [22] 5. In Abu Dhabi, UAE, study found around 55% of participants stated that the EMS telephone number is unknown to them. It is worthwhile to note, around half of clients prefer private because it is quicker than EMS; 13.4% stated that private transport is easier to access; 8% of clients stated that they select private because they thought that their symptoms were not cardiac related. [23]	[28] [14] [18] [22] [23]
Efficiency: Avoiding waste, including waste of equipment, supplies, ideas, and energy.[5]	No study found measuring this domain.
Equity: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.[5]	1. Study conducted in 5 of 6 Gulf States, except Kuwait, found that 81% of ACS clients who were transported by EMS were male and more than half were Gulf State citizens. [15] 2. Study conducted in 5 of 6 Gulf States, except Kuwait, found that 17.5% of Gulf citizens used EMS during STEMI attacks. Furthermore, clients earning up to 5000 per month were more likely to take the EMS in case of STEMI compared to clients earning over $5000 per month (odds ratio [OR]: 1.6). [15] 3. In Riyadh, SA, a study to identify factors contributing to EMS non-conveyance of clients reported that the male to female ratio for non-transported cases was 2:1 where males account for 51.9%, and female’s clients account for 23.4%. Meanwhile, in a significant number of cases (24.7%) the gender was not listed in the clients care reports (PCR). [18] 4. In Makkah the rate of male to female percentage transported by EMS: 67.8%. Vs 32.2%. [25] 5. Study in SA described the total admission of STAMI clients to 50 Saudi’s hospitals. The study showed that 5.2% (n = 61) of STAMI clients who admitted to emergency department were transported by Saudi EMS. Male were 86.9% (n = 53) and female 13.1% (n = 8). [17] 6. Study in UAE; found that individuals from the Indian subcontinent represented the largest group of OHCA, accounting for 38.8% of all cases, while clients from other Arab countries represented 23.7% of all cases. The UAE nationals accounted for 16.7% of cases. Male percentage were 76% while females were 24% for all transported OHCA clients. [20] 7. Study to describe EMS performance toward pediatric OHCA in UAE, found that 76.5% of pediatric out of hospital cardiac arrests who transported by EMS were male. [34] 8. Study described the EMS performance toward OHCA in UAE-Dubai found that 82.7% (n = 335) of transported client were male sex. [32] 9. Study in Qatar analyzing the time-based mortality trauma clients shows the male: 95% (n = 316) female: 5% (n = 17).[10] 10. Study in Qatar comparing the successful intubation rate in field, and in ER, it shows the male (95%) female (5%).[13] 11. Study in Qatar found 92% of Out of Hospital Cardiac Arrest clients after trauma who were transported by EMS were male while 7% were Female. 25% were Middle Eastern, 37.6% South Asian, 4% African, and in 28%, ethnicity was not mentioned.[29] 12. Study in Qatar showed that the majority of cases were male (80.5%) with a median age of 51 years (IQR = 39–66). Frequently observed ethnicities of OHCA clients were Qatari (19.9%) and South Asians (45%); Indian (16.6%), Nepalese (11.6%), and Pakistani (6%). [30] 13. In Oman, study of show that both ethnicities Omani and non-Omani were transported. It is worthwhile to note, the significance of more male clients was represented in the EMS compared with the non-EMS group (72.8 vs 63.4, p value 0.006). [12]	[15] [16] [18] [25] [17] [20] [34] [32] [10] [13] [29] [30] [12]

ACLS, Advanced Cardiac Life Supports; CPR, Cardio Pulmonary Resuscitation; CVS, Cardiovascular System; D2B, Door to Balloon time; DNT, Door to Needle Time, EMS, Emergency Medical Services; ED, Emergency Room; ERI, Emergency Room Intubation; IV, Intra Venous; MEDEVAC, Medical Evacuations; OHCA, Out-of-Hospital-Cardiac-Arrest; pPCI, primary percutaneous intervention; PCR, Clients Care Report; PHI, Pre-Hospital Intubation.; ROSC, Resuming of Spontaneous Circulation; STEMI, S-T Elevated Myocardial Infarction; SA, Saudi Arabia; t-PA, Tissue Plasminogen Activator; UAE, United Arab of Emirates.