Research Project

Development of a taxi-based dispatcher-controlled EMS for low and middle income countries

Geetam Tiwari, Dinesh Mohan and Nezamuddin

Project Details

Feasibility of a Taxi-based, Dispatcher-Coordinated, Layperson Emergency Medical System

Background
In India, and most of the world, victims of traffic crashes are transported from a crash scene to a hospital by passing vehicles and bystanders. The availability of an organized emergency medical system (EMS) with ambulances and trained providers is likely to remain low in most low- and middle-income countries (LMICs) for the foreseeable future. However, an ongoing revolution in urban transport due to developments in mobile technology may present an opportunity for EMS improvements in LMICs. Residents of cities in many LMICs already use their smartphones to request a taxi, track its arrival in real time, estimate the quickest route in traffic, and pay without using cash. This raises the question: Can a taxi-based, dispatcher-coordinated EMS improve trauma outcomes in LMICs? This is the central question addressed by this project.

In principle, EMS aims to improve trauma outcomes by providing:(1) medical interventions in the field, and (2) rapid transport to a definitive care facility. However, evidence suggests that many pre-hospital interventions are ineffective and that the main benefits of EMS likely accrue from rapid transfer. Increasingly, studies have questioned the benefits of emergency endotracheal intubation, intravenous drug therapy, fluid resuscitation, and spine immobilization. In fact, studies show that trauma victims transported by advanced life support ambulances have similar or worse outcomes than basic life support, likely due to interventions that are poorly performed and which delay transfer to definitive care. Recognizing the weak evidence for advanced training of first responders, the World Health Organization (WHO) recommends that LMICs should train lay responders, such as commercial drivers, to provide basic first-aid and rapid transfer to hospitals. Several studies have reported training of commercial drivers, police, community leaders and others in LMICs  (Ghana, Madagascar, Iraq, and Uganda, among many others).   

The second key aspect of an EMS – coordination of lay responders to reduce transfer time – has received very little attention in advocacy efforts. Although advanced communication networks has been previously viewed as expensive components of the most advanced systems, recent developments in smartphone technology have made coordinated taxi fleets common in LMICs. In fact, there have been several unsuccessful attempts to develop a “layperson-EMS” by using peer-to-peer or dispatcher-coordinated networks of lay responders. For instance, in recent years, ridesharing companies in India (Uber in Hyderabad]; Wagon Cab in Delhi) have launched emergency ride options. Similarly, some services have attempted to build dispatcher-coordinated networks of existing private ambulances (AMBER Health and LifeHover in Delhi, Dial242 in Mumbai, StanPlus, eSahai and Call Ambulance in Hyderabad). Such services have typically not sustained after the initial launch and there is no existing example of a citywide, coordinated, layperson-EMS. This indicates that layperson-EMS may face legal, medical and social barriers that need to be systematically studied and addressed. 

The coordinated layperson-EMS we envisioned in this project would consist of a fleet of smartphone-equipped taxis with drivers trained in first-aid. The layperson-EMS would be coordinated by a dispatcher and a smartphone app. When an emergency call is received at the control room and no ambulance is available, the dispatcher uses the smartphone app to contact the taxi closest to the crash site. The app provides the taxi-driver with navigation to the crash site and then onward to the closest hospital participating in the system. At the hospital, the driver is paid for their effort using mobile-to-mobile cash transfer. 

Before such a taxi-based EMS can be field-trialed, many social, legal, and technical questions need to be assessed and analyzed. Therefore, this project had the following components.

Project Components
1. Assess the legal, medical, and social barriers to a taxi-EMS in Delhi
APPROACH: We conducted a qualitative study through key informant interviews with a wide range of frontline stakeholders (taxi drivers, police personnel, medical practitioners, legal scholars, and policy makers) in New Delhi, India. These interviews sought to understand how trauma victims currently access medical care, and the barriers to such a system being formalized into a coordinated layperson-EMS. In particular, we sought to understand the following aspects from the perspective of frontline stakeholders, policymakers and experts: (i) who helps victims, (ii) how are they transported to hospitals, (iii) what deters help from good Samaritans, (iv) how can these barriers be addressed, and (v) whether a layperson-EMS could improve outcomes. In this paper, we report our findings and share recommendations for EMS policy in Delhi and similar settings. 

FINDINGS:  Respondents noted that most trauma victims in Delhi are rapidly brought to hospital by bystanders, taxis, and police. While ambulances are common, they are primarily used for inter-facility transfers. Entrenched medico-legal practices result in substantial police presence at the hospital, which is a major source of harassment of good Samaritans and interferes with patient care. Trauma victims are often turned away by for-profit hospitals due to their inability to pay, leading to delays in treatment. Recent policy efforts to circumscribe role of police and force for-profit hospitals to stabilize patients appear to have been unsuccessful. 

IMPLICATIONS: Existing healthcare and medico-legal practices in India create large systemic impediments to improving trauma outcomes. Until India’s ongoing health and transport sector reforms succeed in ensuring that for-profit hospitals reliably provide care, good Samaritans and layperson-EMS providers should take victims with uncertain financial means to public facilities. To avoid difficulties with police, providers of a layperson-EMS would likely need official police sanction and carry visible symbols of their authority to provide emergency transport. Delhi already has several key components of an EMS (including dispatcher coordinated police response, large ambulance fleet) that could be integrated and expanded into a complete system of emergency care.

PUBLICATIONS: The main findings of this qualitative study are described in the following publication:
Bhalla K, Sriram V, Arora R, Ahuja R, Varghese M, Agrawal G, et al. The care and transport of trauma victims by layperson emergency medical systems: a qualitative study in Delhi, India. BMJ Global Health. 2019;4: e001963. doi:10.1136/bmjgh-2019-001963. CLICK HERE TO ACCESS PAPER

2. Develop technical specifications for a taxi-based EMS in New Delhi, India
APPROACH: The appropriate configuration of a taxi-based EMS for a city depends on the geospatial and temporal distribution of crashes, hospitals, taxis, and traffic congestion. We use empirical data for these variables and computer simulations to study how the city’s urban transport network and typical congestion patterns would affect the performance of the taxi-based EMS. Specifically, we answered the question: Given the distribution of taxis in the city, what level of taxi participation is needed to provide quicker transfer to a hospital than a realistic implementation of ambulance-based EMS?

PUBLICATIONS: The main findings of this simulation study are described in the following publications:
Ahuja R, Tiwari G, and Bhalla K., 2019, Going to the nearest hospital vs. designated trauma centre for road traffic crashes: estimating the time difference in Delhi, India. International Journal of Injury Control and Safety Promotion. 2019; 1–12. doi:10.1080/17457300.2019.1626443. CLICK HERE TO ACCESS PAPER
Mishra, V., Ahuja, R., Nezamuddin, and, Tiwari, G., 2019, Capacity building of Emergency Medical Services (EMS) in Low and Middle Income Countries (LMIC) using Taxi-EMS systems: Case study Delhi, India, Transportation Research Board Annual Meeting.

3. Develop a smartphone application to coordinate a layperson EMS
Working with DIMTS, we developed a smartphone application for use by taxi-drivers participating in a taxi-based EMS and the coordinating interface for use by the dispatcher at the control room. For more information about the smartphone app, please contact Kavi Bhalla (kavibhalla@gmail.com).

Project Collaborators
The project was conducted through a collaboration between the Department of Public Sciences at the University of Chicago and the Transportation Research and Injury Prevention Programme (TRIPP) at the Indian Institute of Technology (IIT) - Delhi. The software app was developed by Delhi Integrated Multi-Modal Transit System (DIMTS) Limited. 

Project Investigators


University of Chicago
Kavi Bhalla, Assistant Professor 
Veena Sriram, Post-doctoral scholar


Indian Institute of Technology - Delhi, India
Geetam Tiwari, Professor
Dinesh Mohan, Honorary Professor
Richa Ahuja, PhD student

Delhi Integrated Multi-Modal Transit System (DIMTS) Limited
Vaibhav Singh, Deputy Manager - Information Technology 


Other Institutions and Researchers
Radhika Arora, Independent Researcher
Mathew Varghese, Orthopaedics, St Stephen’s Hospital, Delhi
Girish Agrawal, O.P. Jindal Global University, Sonipat, India
Sauleh Siddiqui, Johns Hopkins University

Acknowledgments
This project received core support from the US National Institutes of Health (NIH, Fogarty, grant number 5R21TW010168). The mid-project stakeholder consultation was partly supported by funding from the University of Chicago Center in Delhi. We are grateful to the many researchers and practitioners who helped us identify relevant documents and connect with stakeholders. 

More Information
For more information about this project, please contact:
In the US:
Kavi Bhalla, PhD
Assistant Professor of Epidemiology and Global Health
Department of Public Health Sciences
University of Chicago 
Phone:  +1-773-795-2203
Email: kavibhalla@gmail.com

In India:
Geetam Tiwari, PhD
MoUD Chair Professor,  Civil Engineering Department &
Transportation Research and Injury Prevention Programme
Indian Institute of Technology, Delhi, 110016, India
Phone: +91-11-2659-1047
Email: geetamt@civil.iitd.ac.in

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