Trauma systems improve the survival rates of trauma patients. Trauma registries represent an integral and essential part of the system to document the epidemiology, management and outcome of trauma patients.^1,2 Emergency medical services (EMS) provide a spectrum of urgent medical care that includes initial prehospital critical interventions and transportation, ending with handover to continued care in emergency departments, especially in low- and middle-income countries (LMICs).³ The systems have been shown to reduce mortality.⁴ Timely prehospital care is key to improving outcomes in time-sensitive injuries in sub-Saharan Africa (SSA).⁵ In general, trauma patients in LMICs requiring interhospital transfer took longer to reach the referral hospital than direct transfers (0.56–37.91 h).⁶

Many LMICs lack components of formal trauma systems, including prehospital EMS, provider education and patient triage, transfer and management protocols.⁴ In Tanzania, major barriers identified in the implementation of community-based or hospital EMS included the financial status of patients and limitations in healthcare insurance and the level of technical credibility of layperson first responders.⁷ In Uganda, there is an unstructured EMS impaired by a lack of national policy, guidelines and standards, funding for medical products and coordination. The police, as well as private for-profit and non-profit agents, provided prehospital care services.⁸

South Africa (SA) currently falls within the World Health Organization trauma system classification of maturity at level 2 (prehospital resources available, identifiable health personnel and with roles of various health facilities clear, but no formal trauma system); however, different situations prevail across the various provinces. There are seven specialised trauma centres spread across the country, with immediately available surgical facilities, and yet there is no formal national trauma system.^4,9 In Cape Town, a barrier to EMS access included a lack of telephone access and no universal emergency number, which is now corrected. Also, equipment was thought to be a barrier, including ventilators, IV pumps, pulse oximetry and cardiac monitors.¹⁰ A study in the KwaZulu-Natal (KZN) province by Govender found that the response to obstetric patients was delayed by a lack of ambulances and obstetric equipment.¹¹ Also in KZN, Aschokcoomar, et al. found problems such as lack of essential equipment, dysfunctional equipment and unsterile procedures and concluded that EMS providers in the province lacked preparedness to manage interfacility neonatal transfers.¹² The Limpopo province is an under-researched and under-resourced province where no previous EMS research studies were conducted. The objectives of this study were: (1) to determine response times of primary and secondary calls in the Limpopo province, (2) to compare primary and secondary calls with international and SA standards and then (3) to make recommendations on improving policies governing transportation of emergency patients, specifically addressing the transfer of major and polytrauma patients to tertiary facilities.¹³

This was a retrospective cross-sectional study of all patients, including trauma, from 01 January 2020 to 31 December 2020.

A total of 1040 patients were analysed with a similar distribution for male (49.8%) and female (50.1%) patients. Most of the patients (62.9%) were between 16 and 54 years. This is detailed in Table 1. While trauma was only 20.7% of the workload, it was dominated by head and orthopaedic injuries, in keeping with a blunt trauma dominance.

Primary calls constituted 79.9%, while secondary calls encompassed 20.1%. With primary calls, 83.0% were non-trauma, while with secondary calls, 69.4% were non-trauma. Most of the patients fell into the medical category (30.5%), followed by maternity (25.6%) and then the trauma (20.7%) group. Trauma cases were mostly caused by assault (49.2%), followed by motor vehicle crash (22.4%). Further assessment of the trauma cohort was undertaken.

The average response time for all patients was 28 min. The average patient treatment time (rounded to the nearest minute) was 54 min, while the mission time was 2 h 37 min. This is illustrated in Table 2 with the detailed times listed. The mean response time for primary calls was 25 min, while the mean response time for secondary calls was 37 min. Student’s t-test produced a t-value of −1.740 with 1035 degrees of freedom and a p-value of < 0.001, indicating a statistically significant difference in response times for the two call types. The mean mission time for secondary calls was 7 h. This is shown in Table 2 and Table 4. Table 3 reveals that the response time for trauma patients was longer at 39 min when compared with non-trauma patients (24 min), while the mission time for trauma patients was 3 h 07 min as compared with 2 h 30 min for non-trauma patients. In Table 5, the Student’s t-test shows a statistically significant difference in response times between trauma and non-trauma cases, and trauma cases had a mean delay of 15 min.

In Table 5, the Student’s t-test shows a statistically significant difference in response times between trauma and non-trauma cases, and trauma cases had a mean delay of 15 min.

Using linear regression analysis, as illustrated in Table 6, only the type of call (whether primary or secondary) was known to be statistically significant in predicting response time (p-value of 0.022).

Providing timely access to EMS in SA remains elusive in both urban and rural environments.¹⁴ Emergency medical service in most provinces is still developing and not without challenges.⁸ The SA healthcare system is built on three tiers (primary, secondary and tertiary or quaternary) characterised by multiple health facilities sited more for political and historical reasons rather than modern population density and demand.¹⁵ The majority of patients transported with EMS were medical patients, followed by maternity and then trauma. This concurs with the general South African quadruple burden of disease, the human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) epidemic, with a high burden of tuberculosis (TB), high maternal mortality and high levels of trauma and violence, in addition to non-communicable diseases.¹⁶

The response times and mission times are generally longer than recommended standards. The mean response time for primary calls was 25 min, while the mean response time for secondary calls was 37 min. Compared with international standards of 8 min and acceptable SA standards of 12 min, they are higher. The mean response time for severe trauma patients was 39 min, which is far longer than any acceptable standards. The SA EMS system is now experiencing multiple challenges that can be addressed by increased staff numbers and vehicles with optimal centralised control with effective communication systems and call prioritisation, which have been shown to reduce mortality. The EMS system in Limpopo is currently not adequately fulfilling its role, which is to ensure timely response and transfer to hospital of emergency cases, and this requires urgent intervention by the National Department of Health. Future research should include how implementation barriers of EMS services impact the outcome of trauma patients.