Delays in Initiating Ambulance Transport Following Emergency Patient Referral to Mulago National Referral Hospital

Introduction Timely ambulance transport is critical for emergency care, yet delays in initiating transport for transfers are common in low- and middle-income countries. In Uganda, given the limited ambulance fleet, we conducted a secondary analysis of data from a cross-sectional study that was conducted to assess compliance with national ambulance operational standards across key emergency medical services domains. The objective of this secondary analysis was to determine the factors associated with delays of more than 60 minutes in initiating ambulance transport from the decision to refer to Mulago National Referral Hospital. Methods This was a non-pre-specified secondary analysis of data from a cross-sectional study assessing ambulance operational performance in Uganda between May and August 2024. Variables in the primary dataset were reviewed for relevance to the specific outcome of delayed initiation of ambulance transport and were included in the analysis. The primary outcome was time to transport initiation following referral decision, categorized by a 60-minute threshold (≤60 vs >60 minutes), as per Uganda's national EMS strategic plan for ambulance operations. Multivariable binary logistic regression analysis identified factors associated with delayed initiation. Results Among 118 emergency interfacility referrals, 71 (60.2%) were initiated after 60 minutes. Delayed initiation was observed more frequently when ambulances were occupied at the time of interfacility referral (AOR 5.5; p <0.008), fuel was inadequate (AOR 3.1; p 0.008), staffing was hospital-based rather than by dedicated emergency medical technicians (EMTs) (AOR 2.5; p 0.015), and when the availability of essential medical products was below 75% (AOR 2.4; p 0.032). Conclusions Most emergency interfacility referrals experienced delays in initiating ambulance transport. Delays were commonly observed in settings where ambulances were occupied, fuel was inadequate, staffing relied on hospital-based personnel, or medical products were limited. These findings identify operational factors associated with delayed ambulance transport initiation, highlight potential benchmarks for improving timeliness, and warrant further evaluation to refine time benchmarks for interfacility emergency transport.