Document Type : Original Article


1 Professor in Workplace Health Promotion Research Center (WHPRC), Department of Health in Emergencies and Disasters, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

2 Department of Health in Disasters and Emergencies, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran

3 Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran

4 Department of Nursing, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran

5 Department of Neurobiology, Care Sciences and Society (NVS), H1, Division of Family Medicine and Primary Care, Huddinge, Sweden


BACKGROUND: To avoid making decisions based on the unproven opinions of emergency medical
technicians (EMTs), many emergency medical service (EMS) systems rely on emergency medical
protocols. As protocol‑based on‑scene decision‑making is influenced by many challenges, identifying
these challenges can result in providing appropriate conditions for EMTs’ decision‑making. Therefore,
this study aimed to identify the barriers and requirements in the off‑line emergency medical protocols
implementation m in the prehospital emergency medical system.
MATERIALS AND METHODS: To conduct this study, qualitative content analysis using 10 field
observations, 22 interviews, and 2 rounds of focus group discussions was applied. The duration of
interviews lasted from October 2019 to January 2020. The Graneheim and Lundman approach was
used to analyze the data.
RESULTS: Seven categories (15 subcategories) including education and awareness (professional
training and education and community‑based education); attitudes (professional attitude and
community attitude); interactions and coordination (interpersonal interactions, organizational
interferences, and community’s interactions); rules and instructions (instructions and supportive
rules); control system (monitoring and evaluation and motivational system); accessibility (recourses
and communication); and organization (structure and process) were obtained as the obstacles and
challenges in the offline emergency medical protocol implementation in the prehospital system.
CONCLUSIONS: There are many challenges in implementing offline emergency medical protocols in
the prehospital emergency system. To achieve the effectiveness and efficiency of offline prehospital
emergency protocols, it is necessary to facilitate these challenges and improve the EMTs’ knowledge,
attitude, and performance through cooperative and skill‑based education. The findings of this study
can be useful for EMS systems from national to local levels.


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