• Kristin Kuzma, Andrew George Lim, Bernard Kepha, Neema Evelyne Nalitolela, and Teri A Reynolds.
• Emergency Medicine, University of California San Francisco, San Francisco, California, USA.
• BMJ Open. 2015 Jan 1;5(4):e006921.

ObjectivesWe sought to characterise the prehospital experience of Tanzanian trauma patients, and identify barriers and facilitators to implement community-based emergency medical systems (EMS).SettingsOur study was conducted in the emergency department of an urban national referral hospital in Tanzania.ParticipantsA convenience sample of 34 adult trauma patients, or surrogate family members, presenting or referred to an urban referral emergency department in Tanzania for treatment of injury, participated in the study.InterventionsParticipation in semistructured, iteratively developed interviews until saturation of responses was reached.OutcomesA grounded theory-based approach to qualitative analysis was used to identify recurrent themes.ResultsWe characterised numerous deficiencies within the existing clinic-to-hospital referral network, including missed/delayed diagnoses, limited management capabilities at pre-referral facilities and interfacility transfer delays. Potential barriers to EMS implementation include patient financial limitations and lack of insurance, limited public infrastructure and resources, and the credibility of potential first aid responders. Potential facilitators of EMS include communities' tendency to pool resources, individuals' trust of other community members to be first aid responders, and faith in community leaders to organise EMS response. Participants expressed a strong desire to learn first aid.ConclusionsThe composite themes generated by the data suggest that there are myriad structural, financial, institutional and cultural barriers to the implementation of a formal prehospital system. However, our analysis also revealed potential facilitators to a first-responder system that takes advantage of close-knit local communities and the trust of recognised leaders in society. The results suggest favourable acceptability for community-based response by trained lay people. There is significant opportunity for care improvements with short trainings and low-cost supply planning. Further research looking at the effects of delay on outcomes in this population is needed.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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