Study characteristics.

The 73 quantitative studies (including the quantitative arms of two mixed-methods studies) (Tables 2–8) were published between 2004 and 2022 and were from the USA (n = 24; 32.9%) or Canada (n = 2; 2.7%), Europe (n = 21; 28.8%), Asia (n = 22; 30.1%), and Australia (n = 3; 4.1%), while one Delphi study [17] included an international panel of experts (1.4%).

A large proportion of studies (n = 15; 20.5%) were cross-sectional, questionnaire studies. Sample sizes (excluding those analysing EMS call volumes, dispatches and/or response times) ranged from 10 to 15,339 participants ([18] did not specify their final sample size). One study [19] only included male participants and many studies had either data missing or did not report gender data. Ages ranged from 19 to over 80 years, with many studies not reporting any relevant data. Only 8 studies (11%) included details on their participants’ ethnicity, with the majority identifying as White.

Most studies included combinations of paramedics and Emergency Medical Technicians (EMTs) or other types of EMS personnel (such as nurses or physicians), while some studies defined their participants as emergency prehospital medical care workforce [20, 21], EMS personnel [22, 23] or first responders [24, 25]. One study [17], using a systematic Delphi procedure, included a multidisciplinary group of experts on outbreak preparedness. Various studies included only patients, while two studies included patients and paramedics [26, 27]. Two studies recruited healthy volunteers [28, 29].

Quantitative narrative synthesis.

After considering each included study’s aims, outcomes, and major findings, we developed seven overarching themes, describing EMS pandemic preparedness plans and interventions implemented in response to pandemics.

Willingness to work, treat patients and get vaccinated. Seven studies (9.6%) [2, 10, 20, 30–33] asked EMS staff members about their views on working during disease outbreaks/pandemics and factors influencing their decisions. Most respondents would be willing to report for duty in case of a disease outbreak or pandemic, with corresponding percentages ranging from 56.3% [20] to 93% [2]. One further study [24], conducted since the COVID-19 pandemic begun, found that willingness to respond to alarms was lower during the pandemic (with or without PPE). Despite that, most participants were willing to perform chest compressions, defibrillate using an automated external defibrillator, ventilate a patient using a bag and mask and an appropriate airway filter, and ventilate a patient using a face mask.

Most papers identified predictors of reporting for duty, such as operating in a state that had emergency preparedness laws [34]; first responders knowing and being prepared to perform their responsibilities in a pandemic [2, 32]; knowing that one of their colleagues had been exposed to suspected or a known case of pandemic human influenza [20]; confidence about safety at work [2, 10, 20, 32] or that the employer would provide appropriate training, an effective treatment and vaccine when available [10] or adequate PPE [30, 31]; receiving prophylaxis for themselves and their family members [31, 32]; having adequate knowledge and training for disease outbreaks [2, 20, 30]; being concerned about self or family safety [10, 20, 30, 33]; having family prepared to function in their absence [10]; lack of confidence in emergency health preparedness and lack of PPE availability [33]; and, believing their co-workers were likely to work [32]. Other predictors of a greater likelihood of reporting for duty were younger age, male gender, single status, and having no young children [31].

Finally, one study [35], exploring the COVID-19 vaccination acceptance of EMS personnel, found that 57% of participants were willing to be vaccinated and 27.6% were undecided. Participants who showed higher willingness to be vaccinated tended to be male, of higher education level, older age, and felt more strongly that they were personally burdened by the pandemic.

Preparedness to face pandemics/recommendations. Three cross-sectional, questionnaire studies (4.1%) [3, 18, 33] found that EMS workers exhibited low levels of knowledge and training about infectious diseases, as well as compliance with practices (such as selecting and removing PPE) [3, 33]. Often, they had limited access to PPE equipment and regular decontamination of EMS equipment after each patient contact was not a regular practice [3]. On the contrary, a study by Jadidi and colleagues [18] revealed that Iranian EMS’ efficacy and preparedness levels to face Ebola were higher than standards, as represented by factors such as triage, diagnosis, isolation processes, using PPE, as well as transporting and providing care during transfers.

One study [36] used discrete event simulation models to evaluate the resource requirements during the peak of the pandemic, by estimating number of beds needed in the ED, number of ambulances required to maintain pre-pandemic response times for emergency patients, as well as to study the effects of ED boarding time for COVID-19 patients. They found that a strict testing policy increased the bed requirements in the ED, while it led to decreased ambulance response times. They also showed that when boarding is considered, the effects were most prominent during night and weekends.

One further study [37] developed and evaluated a dedicated paramedic surveillance and quarantine program, during a Severe acute respiratory syndrome (SARS) outbreak. They determined the number of paramedics on quarantine each day, the type of quarantine, and the development of SARS-like symptoms, and concluded that their program could provide a useful means to managing the paramedic resource during that and any future SARS outbreaks.

Finally, Belfroid and colleagues [17] employed a systematic Delphi procedure and presented 18 recommendations for future pandemic preparedness.

Knowledge & education. Thirteen studies (17.8%) [20–22, 32, 33, 38–45] explored issues around EMS staff members’ pandemic knowledge and training.

Most studies [21, 32, 33, 40, 45] found low levels of pandemic-related training and knowledge including that of infection transmission. Most studies [33, 40, 45, 46] found that PPE use was inconsistent and knowledge about PPE requirements low, e.g., how N95 masks worked or the correct PPE removal sequence. Practices employed to alter the environment within the ambulance, such as ensuring the desired airflow when transporting a patient with an airborne illness or disinfection of the ambulance at any time were inconsistent, despite respondents reporting that ambulances were routinely cleaned [40].

Only two studies (2.7%) [38, 42] reported adequate levels of training on patient and practitioner safety related to infectious and communicable diseases (including routes of exposure) [42]; how to screen and provide emergency medical treatment for such patients [42]; and respirator use during the COVID-19 pandemic [38]. The main barriers to adequate awareness/training included part-time employment, providing 9-1-1 response service, working at a non-fire-based EMS agency, and working in a rural setting [38]. Some participants did express an interest in having more quality training and not feeling confident enough to respond to diseases with the magnitude or severity of Ebola virus disease [42].

In addition, four studies (5.5%) [22, 41, 43, 44] investigated the effectiveness of various educational interventions. These interventions were effective in increasing knowledge and behavioural intentions to use respirators, get vaccinated and willingness to report for duty during a potential pandemic [41]; increasing adequate choice of PPE [43, 44], especially for those student paramedics who were also actively working in an ambulance company [44]; and increasing comfort levels in managing respiratory failure in suspected/known COVID-19 patients, as well as non-COVID-19 patients [22].

Finally, one study [39] showed that a simulation software environment (SPECTRa) provided a feasible alternative approach to live prehospital simulation and showed potential for remote healthcare research and training during the COVID-19 pandemic.

Infection risks & control. Three studies (4.1%) focused on the safety of ambulances and their role in EMS crew COVID-19 infections [47–49]. Their results showed that negative pressure ambulances can help decrease the number of new, confirmed COVID-19 cases [47]; that the most frequently contaminated areas in ambulances were the left front door’s outer handle, driver’s handle, gear lever, and mat, the rear door, rear door lining, and handle over the roof [48]; as far as personnel is concerned, the most frequently contaminated areas before the removal of PPE are the lower chest to the belly area, bilateral hands, lower rim of the gown, and shoes, and after PPE removal, traces of fluorescence were observed over the neck, hands, and legs [49]; and that when both crew and patient wore respirators or a cloth mask during a simulated ambulance transfer, these practices reduced predicted mean infection risks by 85% (which was a higher reduction than when only one of them wore a respirator or a cloth mask) [49].

Two further studies (2.7%) [19, 27] examined various factors associated with COVID-19 infection risks in EMS staff members. Results showed that EMS providers’ positive tests for COVID-19 (after having been exposed to patients with COVID-19) were not attributed to occupational exposure from inadequate PPE and that programmatic strategies were associated with a temporal increase in adequate PPE use and a decrease in EMS provider exposures [27]. Results also showed that the factors mostly correlated with the increasing risk of COVID-19 in EMTs were having two EMTs taking care of patients, working with a confirmed case teammate, using personal items (e.g., mobile phone or jewellery) despite protective clothing, contact with the outer surface of clothing while removing PPE, not taking precautions such as seal check after wearing the mask, and not covering the hair with a medical hat [19].

Making improvements regarding resources & PPE. Six studies (8.2%) evaluated the use of improved resources or PPE during COVID-19 [28, 29, 50–53]. Three of these studies [28, 29, 53] found that negative pressure devices (a powered air purifying respirator helmet called AerosolVE; a procedural tent called AerosolVE BioDome; and a portable, reusable, transparent vinyl chloride shield together with suction to generate negative pressure, respectively) can filtrate or reduce aerosol dispersion and exposure to airborne particles, thus, making ambulances potentially safer for EMS personnel. Another study [51] showed that a compact atmospheric plasma device could be used successfully to disinfect ambulances.

In addition, Małysz and colleagues [52] showed that chest compressions with LUCAS 3 can increase the chest compression quality (when compared with manual chest compressions and the TrueCPR), as evidenced by the depth and rate of the compressions, as well as chest recoil. Finally, one study [50] evaluating the influence of PPE with different types of filtering face piece (FFP) masks on attention and dexterity of EMS personnel during basic life support procedures found that neither of these two neuropsychological components were affected by FFP mask use.

Call volumes, ambulance response times and triage (logistics of service delivery). Twenty five studies (34.2%) [11, 24, 54–76] looked at the impact of the COVID-19 pandemic on EMS utilisation and how implementing a variety of COVID-19-related interventions (such as changing coding calls and protocols for assessment or care; developing coronavirus EMS support tracks or web-based self-triage systems, etc.) affected EMS utilisation.

Data analysis of most studies revealed that despite an initial increased demand on EMS resources (especially in relation to call volume), EMS response remained, on the average, relatively controlled, as demonstrated by overall call volume [67, 75], response times [24, 66], daily ambulance diversion rates [68], and the number of out-of-hospital cardiac arrests [67].

Other studies, however, found less positive results related to a sustained increase of EMS calls [58, 69, 70, 73], queue times (though the significant increase in the total EMS call volume was mitigated by the implementation of a coronavirus EMS support track) [60], EMS dispatches [69, 73], EMS processing times [62], prehospital times (except for the scene time of cardiac arrest patients) [68], and response times/interval [70, 72]. Mulyono and colleagues [11], employing an agent-based simulation model, found that the main factors contributing to increased response times were the process of preparing crew and ambulance during the pandemic (relating to the safety procedure in handling patients), service coverage area, traffic density and crew responsiveness. The recommended coverage area for maintaining a low response time was 5 km.

Twelve studies (16.4%) [54–57, 59, 61, 63–65, 71, 74, 76] explored ways of managing the response to emergency calls (during the COVID-19 pandemic) by implementing a range of technology and protocol/systems interventions. These were: applying Business Intelligence to the management of EMS [74]; using the Internet of Things to design a relief supply chain network to address multiple suspected cases during the pandemic [76]; applying a novel Deep Self-Learning Approach to Artificial Orca Algorithm and based on mutation operators to address ambulance dispatching and emergency calls covering problems [55]; applying two Swarm Intelligence Algorithms (Artificial Orca Algorithm and Elephant Herding Optimization) to organize and manage the dispatching of emergency vehicles while respecting the cover of calls during a crisis [56]; running a first-stage optimization model to designate ambulances to serve only infected patients and suspected cases [71]; and, using information and communication technology for emergency medical services (ICT-EMS) systems to improve the transportation of emergency patients [64]. A few interventions [6.8%] also focused on phone or video triage [54, 59, 61, 63, 65], with positive results. A study [57] evaluating the safety of a new EMS protocol directing non-transport of low-acuity patients during the COVID-19 pandemic reported large deviations from the novel non-transport protocol and that several patients had to be admitted to hospital, both when the protocol was used correctly and when it was used incorrectly.

Identifying patients, testing & vaccinations. Ten studies (13.7%) investigated the diagnostic accuracy of EMS in identifying COVID-19 patients [23, 46, 65, 77– 82] or predicting death from pre-hospital vital signs [83].

According to their findings, initial vital signs (with the exception of body temperature) [82], prehospital triage tools [81], and telephone screening processes/surveillance tools used by emergency medical dispatchers [46, 65, 77, 80] had little to moderate predictive value for the identification of COVID-19 patients and/or death.

Other studies (n = 4; 5.5%) have found more encouraging results, such as the lowest recorded pre-hospital oxygen saturation being an independent predictor of mortality in COVID-19 patients [83]; rapid antibody testing helping to diagnose COVID-19 in both asymptomatic and symptomatic EMS personnel [23]; newly developed clinical criteria for identifying COVID-19 patients showing a strong degree of correlation between such emergency transports and new hospitalizations [79]; and, a prehospital sit-stand test identifying stable, suspected COVID-19 patients in risk for later deterioration [78].

Two studies (2.7%) [26, 84] explored how EMS can help facilitate testing for COVID-19 by evaluating the implementation of drive-through COVID-19 testing facilities operated by EMS. Results from both studies showed that COVID-19 testing performed by EMS staff can be efficient and safe to operate for both the staff and the patients [26, 84], as well as cost-effective [84].

Finally, two studies (2.7%) looked at the role of EMS in mass vaccinations and concluded that EMS providers were “uniquely equipped to participate in mass immunization efforts” [85] and played an important role in planning and logistics, patient screening and observation, vaccine preparation and administration, and home vaccination efforts [86].

Study characteristics.

The 18 qualitative studies (including the qualitative arms of 3 mixed-methods studies, the surveys that analysed their findings qualitatively, and the text and opinion paper) (Table 9) were published between 2018 and 2022 and were predominantly from the USA (33.3%). Sample sizes ranged from 3 to 424 participants and included both male and female participants (27.8% did not report any data on gender). Participants were EMS staff members or community members. One study included EMS providers [16] but did not report any more information about their participants. Two studies [13, 87] also reported the perceptions and experiences of hospital healthcare workers and essential workers (e.g., gas station and grocery store employees), respectively, whose views, however, will not be included in this review, as they did not meet the study’s criteria for inclusion.

Only 12 studies (66.7%) presented information about the participants’ age, with ages ranging from 22 to 78 years old for emergency services personnel; community members’ ages ranged between 35 and 64 years old [88]. Only two studies (11.1%) [13, 89] specified the ethnicity of their participants, with the majority identifying as White.

Most studies were based on individual semi-structured interviews (61.1%) and two studies were PhD theses (11.1%) [10, 90]. One study [16] was a reflection/text and opinion paper that included excerpts of participants but gave no additional information about their data collection methods and did not include any formal analysis. Various methods of analysis were employed, with seven studies using thematic analysis (38.9%).

Qualitative data synthesis.

We used narrative synthesis to summarise and explain the findings of this scoping review.

Motivation, confidence, and feelings about working during pandemics. Working during a pandemic was a traumatic experience for many staff members [16, 91], who felt that they were often faced with significant challenges [13, 16, 91, 92], such as not knowing how to properly treat patients, not feeling safe due to poor PPE or the constant changes in protocols and procedures [16]; being unable to socialise and take comfort in colleagues and friends [12, 16]; as well as having less contact with their families [12, 13, 16, 90].

When asked about their feelings about working during pandemics, EMS personnel reported feeling a myriad of different emotions, such as stress [12, 13, 16, 25, 87, 89–91, 93, 94], anxiety and fear [10, 12, 13, 15, 16, 25, 87–96], as well as feelings of frustration [13, 91, 94] or failure, when they couldn’t save a patient [16]. They also felt they were faced with difficult clinical and ethical decisions in their practice, such as having to decide between prioritising their own safety and the safety/care of the patient [92].

Despite these negative emotions, many participants also felt positive about the experience of caring for patients and reported feeling proud [87], excited [87, 89], or even safe and protected [87]. They also mentioned what they felt were the positive outcomes of pandemics, such as giving them a chance to test their protocols and increasing their team spirit [87], as well as encouraging the use of technology across the healthcare system [91] and using what they’ve learned to help expand prehospital care [16].

As a result, the majority of EMS personnel were willing to report for duty during a pandemic [10, 13, 16, 89] and often felt they had a high professional and ethical obligation to work under any and all situations [10, 13, 16, 88, 89, 91].

There were others who were unwilling to report for work or provide care for patients [10, 88, 89]. Some of the main reasons behind their unwillingness to report for duty were not understanding the cause and modes of transfer of a disease [10], not having been provided with appropriate PPE [10], not feeling confident in their skill set [10], role ambiguity [90], lack of trust in their employer [90], and being concerned about their own or their family’s safety [10, 89, 90]. On the contrary, some of the factors that would positively affect someone’s willingness to report for duty were receiving adequate education and training, having appropriate PPE and equipment, and transparent protocols [10, 89].

Balancing safety and risks. Overall, participants felt that being an EMS staff member was inherently risky work [10, 89, 90, 92, 94] but understood and accepted the risks and felt a duty to perform their jobs despite this [10, 16, 88, 89, 91, 94].

Various participants expressed concerns about their own safety [10, 12, 15, 16, 25, 90–92, 94–96], not having adequate training or PPE [10, 93–95], and the risk of transmitting the disease to their family [10, 12, 13, 15, 16, 25, 87, 89–92, 94–96]. As a result, they often took extra care and precautions to limit their risk of exposure [10, 15, 90]. Similarly, families of EMS personnel were also anxious about their safety and that of their working relative [87]. Finally, one study [97] found that fear of exposure and infection delayed EMS utilisation among patients with chronic health conditions and was also a concern for patients with acute health conditions (although they did continue to access services as required).

Despite participants’ need for and greater feeling of safety with PPE, they also discussed the negative side of wearing PPE while providing care for patients (especially during hot weather), such as experiencing stress and anxiety, profuse sweating, shortness of breath, local pain, restricted movement, or discomfort due to fogging goggles and/or prolonged use of masks [90, 95, 96]. Similarly, patients and their carers also discussed how communicating with EMS staff wearing PPE was challenging, especially for those who were deaf or hard-of-hearing [97].

The limits to personal moral duty. Even though most participants felt that EMS personnel had a duty to report for work, many also felt that there were potential limitations on duty to treat [88, 91]. Some of these acceptable limitations were their own physical health (such as pregnancy or pre-existing chronic conditions) or that of a family member [88, 91]; having mental health problems [88]; being a single caregiver with dependents or when both parents were healthcare workers [88]; as well as work-related factors, such as lack of appropriate PPE, anti-viral medication or appropriate vaccines during infectious disease outbreaks/pandemics, lack of appropriate quarantine facilities away from the home, and lack of relevant training [88].

One paper [88] also discussed community views on risk-taking by EMS personnel. Community members had differing views; some felt that EMS personnel shouldn’t be expected to put themselves at risk to treat patients during a disaster, pandemic, or even on a normal day, whereas others felt that there was a certain level of duty or obligation that comes with being an EMS worker [88].

Need for information, communication, and support. First responders expressed a desire for infectious disease information (such as routes of transmission, incubation period, infection rates, policies and protocols) [10, 90, 93, 95], as well as follow-up information regarding a transported patient’s health status and detailed, localised data that could help them understand the geographic spread of cases throughout their area [13]. However, many also felt that receiving too much and constantly changing information was overwhelming and challenging [13, 14, 91] and that there was a lot of misinformation and lack of reliable data (in regard to COVID-19), which often made them sceptical about the information they were receiving [13, 16, 25, 90–92].

Participants also highlighted the importance of proper communication during disease outbreaks [10, 12–14, 16, 87, 89–91, 94] and how they felt that it was their employer’s responsibility to keep them (and their families) informed with the most up-to-date information about the disease and what they were expected to do [10, 12, 87]. Despite many participants reporting feeling adequately informed by their employers [10, 91], but some felt that there was lack of communication by leadership, management, and politicians [12, 16, 94]. Participants said they would have liked to receive more consistent and transparent information about the disease [12–14, 87, 89–90, 92], the provision of support in case of illness [94], and any protocols for triaging and transporting patients [12, 13, 87, 89, 90, 93, 94]. Others felt that there was lack of communication and collaboration between departments and organisations, such as the emergency department and EMS or the hospital and coordinating centres such as the Centre for Disease Control in the United States [13, 14, 16, 89, 92, 94].

Another topic discussed in various papers was the importance of support from employers, colleagues and managers. Participants felt that building a relationship of trust between colleagues was an important element in the EMS [10, 90] and reported often turning to their colleagues and team managers for emotional support and for stress relief [10, 13, 16, 87]. In contrast, participants found it particularly tough when they could not socialise or take comfort from their teammates, for example during COVID-19 [16].

EMS personnel also recognised that their organisations put effort into their comfort and safety, and knowing that their organisation was continuously reviewing and improving procedures made them feel safe and protected [87]. They also expected organisations to provide them with resources, necessary materials and PPE, training and communication during disease outbreaks [10, 87, 92], as well as prioritising testing to keep them safe and to enable them to return to their duties [13]. In addition, some felt that it was the employer’s responsibility to provide a “safe haven” to their families as well, including offering them vaccines and/or treatment, if available [10]. Some EMS workers, however, felt unsupported and “left alone to fend” for themselves [12–14, 16, 94].

Regarding mental health support, opinions were also divided. Some would have liked to have received such support [12, 87, 93], while others felt either that they did not need it or that they could get it from other sources (e.g., family, friends, colleagues, private counsellors, the service Chaplain, etc.) [91]. Finally, EMS personnel found lack of financial support in the case of illness a major challenge, especially for those who were new in their role or couldn’t take any sick days, and often led to people hesitating to get tested, as they wouldn’t be able to take any time off work [13].

Requirement for resources, training, guidance, evaluation & solutions. Participants felt that adequate and up-to-date training and education were important [10, 12, 87, 89, 95] and could influence their willingness to report for work [10, 89]. Most participants were satisfied with the training they received, as they felt it prepared them well for their tasks [87, 89], while others were not satisfied [10, 12, 89, 90, 91], especially when it was lecture-based and not hands-on training [10].

Participants also felt that having clear, transparent, and simple protocols was equally important [87, 89, 90, 93] and that it helped them remain calm by following the instructions [87]. In addition, lack of transparency about how the protocols were designed [89] and the constant protocol changes (e.g., about PPE) as the pandemic evolved, only added to their anxiety, frustration, and confusion [12–14, 16, 90, 91, 93–95] and made them concerned about whether the new protocols were sufficient [87]. Some also thought that these changes in clinical practice and guidance were rushed [91], that the quality of care was being compromised [91] and they felt ethically challenged, as the new protocols were asking them to deviate from what they were taught [16]. Participants also felt that their organisations and the governments were overall ill prepared to face a pandemic, such as COVID-19 [12, 95].

Regarding the provision of resources and equipment to keep them safe and to ensure that they are able to carry out their job properly, various participants reported not having access to appropriate or up-to-date PPE during the COVID-19 pandemic and that this was a major concern for them [12, 13, 90–92, 94–96]. Participants also mentioned that in some cases EMS workers did not comply to wearing PPE, mainly due to force of habit, not being used to having PPE on, not recognizing when it is the appropriate time to use the PPE, and/or thinking they won’t need them since they may not directly contact the patient [10]; this study, however, was conducted prior to the COVID-19 pandemic. Concern about and frustration with lack of compliance with hand hygiene routines (during the COVID-19 pandemic) was also discussed [15]. The main factors affecting hygiene compliance were the unpredictable work environment, situations where time is critical, worries about the risk of using new protective equipment (e.g., gas masks, which were introduced in the ambulance service during the pandemic), and having initiatives supported by their managers/organisations [15]. Having access to testing was also considered important for workers to be able to return to their duties, but many reported challenges in scheduling testing [13].

Finally, participants made a series of recommendations for future outbreak response. Participants felt that it would be best to have specialised teams dealing with outbreaks, such as a permanent infectious disease response team that would be responsible for maintaining and updating protocols, the training of personnel, and the “institutional readiness of disease outbreaks and epidemics” [89]. Participants also highlighted the importance of continuous training and education for pandemic preparedness [12, 89] and suggested using a tiered training model (or even a peer training approach), where a few selected staff members would be trained comprehensively, who would, in turn, train others based on what their roles would be [89]. They also thought it would be a good idea to have regular “drills for the triage and transport of infectious patients, similar to that of mass casualty and disaster drills”, as well as to have training on how to use different types of PPE, to ensure that everyone is always prepared for a future pandemic [89]. Other suggestions were to have a dedicated app, through which accurate, up-to-date information (including localized infection rates and spread) could be delivered directly to EMS personnel, holding local question and answer sessions, or using social media to keep them informed [13].