1. Introduction

Hypertension is among the most frequently diagnosed conditions by Emergency Medical Teams (EMT), highlighting the significant burden it places on emergency medical services (EMS) [1]. This high incidence underscores the critical role EMTs play in managing hypertensive crises, which, if left untreated, can lead to severe complications such as stroke, myocardial infarction, and organ damage [2]. The prompt and effective management of hypertensive emergencies by EMT members is crucial for delivering efficient and timely care to patients, ensuring favorable outcomes, and minimizing long-term health risks.

However, not all cases of hypertension require immediate intervention by EMS. Often, these conditions can be managed more appropriately by primary care physicians [3, 4]. Misallocation of EMS resources to non-emergency hypertensive cases can delay critical care for other patients in need of urgent medical attention, exacerbating the strain on already limited EMS resources [5]. This issue is particularly pressing in rural and underserved areas, where the availability of EMTs is constrained. Inappropriate use of EMS for non-emergency hypertensive cases not only impacts patient care but also affects the overall efficiency of the healthcare system.

Previous studies have emphasized the importance of prehospital management of hypertensive emergencies and the role of EMTs in ensuring optimal patient outcomes. For instance, research by Patrick et al. [6] demonstrated that effective prehospital care could significantly reduce the incidence of adverse cardiovascular events in patients with hypertensive emergencies. Furthermore, a study by Świeżewski et al. [7] highlighted the challenges faced by EMTs in rural areas, where resource constraints often lead to delays in providing necessary medical interventions.

The ongoing COVID-19 pandemic has added complexity to the healthcare landscape, affecting how medical services are delivered and utilized [8]. EMTs are now faced with additional challenges in managing hypertensive emergencies while adhering to pandemic-related protocols, such as personal protective equipment (PPE) usage, social distancing and infection control measures [9]. These protocols can extend the duration of interventions and affect decision-making processes. The pandemic has also altered patient behavior, with many individuals avoiding healthcare facilities due to fear of infection, potentially leading to delays in seeking care and more severe presentations of hypertension when EMS is finally called [10]. Studies such as those by Hadian et al. [11] and Hick et al. [12] have documented the increased burden on EMS during the pandemic, with longer response times and more complex decision-making processes due to these additional challenges.

Recent literature also points to the effectiveness of specific pharmacological interventions in prehospital care. A study by Raina et al. [13] found that the use of combination therapies, including captopril, furosemide and hydroxyzine, could stabilize patients sufficiently to reduce the need for hospital transport. This approach aligns with findings from earlier research, such as that by Kim et al. [14], which recommended comprehensive medication protocols for EMTs to manage hypertensive crises effectively.

Moreover, the pandemic has spurred the need to reassess the protocols and guidelines governing EMT responses to hypertensive emergencies. The increased strain on EMS systems during the pandemic has led to discussions about the sustainability of current practices and the potential for integrating new technologies and telemedicine into prehospital care [15]. Studies have suggested that telemedicine could play a crucial role in guiding EMTs through complex decision-making processes in real time, potentially reducing the need for hospital transport and optimizing resource allocation [16]. Additionally, the integration of artificial intelligence in prehospital settings is being explored as a means to enhance the accuracy of EMT assessments and treatment decisions [17].

Understanding the therapeutic actions and decisions made by EMTs during this period can offer valuable insights into improving emergency medical responses and resource allocation. Analyzing the patterns and outcomes of EMT interventions for hypertension during the pandemic can help identify gaps in care, inform training programs, and develop guidelines that optimize the use of EMS resources. This knowledge is essential for preparing EMTs to handle not only the current pandemic but also future public health emergencies that may disrupt healthcare delivery.

The aim of this study is to analyze the decision-making processes of EMTs in managing prehospital primary hypertension and to determine the factors influencing these decisions. By examining the treatment patterns and outcomes, we seek to identify strategies that can enhance the efficiency and effectiveness of EMS in handling hypertensive emergencies, particularly in the context of the ongoing COVID-19 pandemic. Through this analysis, we hope to contribute to the development of best practices for managing hypertensive patients in emergency settings, ultimately improving patient care and optimizing the use of EMS resources.

2. Materials and methods

3. Results

4. Discussion

Our study highlights significant findings regarding the prehospital management of primary hypertension by EMTs during the COVID-19 pandemic. The analysis demonstrated that patients transported to the ED had significantly higher systolic and diastolic blood pressure compared to those left at the scene. This suggests that EMTs made transport decisions based on the severity of the patient’s hypertension, with those who remained on-site responding better to initial pharmacological interventions. Moreover, patients who were stabilized and left at the scene exhibited a greater reduction in mean arterial pressure, indicating that effective pharmacological intervention can reduce the need for hospital transport in many cases.

In addition to optimizing EMT response times and medication administration, it is crucial to consider the training and education of EMT personnel. Continuous education programs that focus on the latest guidelines for managing hypertensive emergencies, especially in the context of pandemics, can significantly enhance the effectiveness of prehospital care. Research by Naylor et al. [18] supports the idea that regular training and simulations can improve EMTs’ clinical skills and decision-making abilities. Implementing these educational initiatives can ensure that EMTs are well-prepared to handle complex situations efficiently, thereby improving patient outcomes and resource utilization.

Our analysis of response times demonstrated that EMTs spent significantly more time on interventions when patients were transported to the emergency department compared to those left at the scene or who declined hospitalization. This prolonged intervention time can be attributed to the additional protocols and safety measures necessitated by the pandemic, such as the use of personal protective equipment (PPE) and thorough disinfection procedures.

These differences in response times can be attributed to several factors. When a patient is transported to the ED, EMTs are required to undertake additional steps that prolong the intervention time, including securing the patient for transport, continuous monitoring during the transport, and completing the necessary documentation for the handover to hospital staff. The enhanced COVID-19 protocols, such as PPE use and thorough disinfection procedures, likely contributed to the longer intervention times for transported patients.

Specifically, when transporting patients to medical facilities, EMTs were required to follow rigorous infection prevention procedures to minimize the risk of COVID-19 transmission. These procedures included not only wearing PPE but also thoroughly disinfecting the ambulance and medical equipment both before and after patient transport. Additionally, EMTs had to ensure that patients were properly isolated during transport, which sometimes involved using specialized barriers or equipment, further adding to the complexity and duration of the intervention.

There is evidence from other studies that these enhanced safety measures increased EMS response times, particularly in cases requiring transport to a hospital. For example, studies have shown that the time taken to don and doff PPE, combined with the need for comprehensive disinfection protocols, contributed to longer overall EMS intervention times during the pandemic. These findings align with our results, suggesting that while these procedures were essential for infection control, they also led to significant delays in EMS operations [19].

Streamlining these processes without compromising safety is crucial to improving response efficiency, especially in the context of ongoing or future public health emergencies. Future studies could focus on identifying ways to optimize these procedures to reduce their impact on response times while maintaining the necessary protective measures.

Moreover, our blood pressure analysis revealed that patients transported to the ED had significantly higher SBP and DBP readings compared to those left at the scene. This finding likely reflects the decision-making process of EMTs, where the choice to transport a patient is based on several factors, including the severity of hypertension and the patient’s response to initial treatment attempts [20, 21]. Patients requiring transport often presented in more critical condition, necessitating more extensive care, such as the administration of multiple medications, detailed monitoring, and reassessment, all of which contribute to the longer time spent with these patients.

In many cases, EMTs attempt to control the patient’s blood pressure with medication on the scene. If these attempts are unsuccessful or if the patient’s condition is deemed too severe to be managed safely outside of a hospital setting, the EMTs may decide to transport the patient to the emergency department. This decision is often guided by established protocols and the clinical judgment of the EMTs, who assess the risk of complications based on the patient’s current condition. Additionally, patient preference can play a role, particularly if the patient expresses a desire to be evaluated in a hospital despite some stabilization.

Given this context, it is reasonable to observe that patients who are transported typically have higher blood pressure readings, as these cases likely represent those where initial on-scene management was insufficient to achieve adequate control, or where the risk of severe outcomes was too high to leave the patient at the scene. This reinforces the importance of effective triage by EMTs, which is critical in ensuring that resources are appropriately allocated, and that patients at the greatest risk receive the necessary hospital care.

The significance of this triage process within the EMS system cannot be overstated. EMTs serve as the first line of medical intervention, and their ability to accurately assess and triage patients directly impacts patient outcomes and the overall efficiency of emergency medical services. Effective triage helps prevent unnecessary hospital transports, reducing the burden on emergency departments, while also ensuring that patients with more severe conditions receive timely and appropriate care. Future research could further explore the specific criteria used by EMTs in these decisions and how they might be optimized to improve outcomes.

The study examined the use of medication combinations by EMTs and their influence on transport decisions. Patients who received combinations of captopril, furosemide and hydroxyzine were more frequently left at the scene, indicating that EMTs often relied on these pharmacological interventions to stabilize hypertensive patients on-site. While hydroxyzine is not typically a first-line treatment for hypertension, it was frequently used in combination with other medications in this study. Hydroxyzine, an antihistamine with sedative and anxiolytic effects, may have been administered to reduce anxiety in patients, which can indirectly contribute to elevated blood pressure. Its role in the treatment may reflect regional EMS practices or established protocols for prehospital hypertension management. The frequent use of hydroxyzine alongside captopril and furosemide suggests its value in managing the overall condition of hypertensive patients in emergency situations.

The use of specific medication combinations was typically guided by established protocols and, in some cases, direct medical direction provided by supervising physicians. These protocols likely influenced the choice of medication combinations, and further exploration of these protocols could provide insight into their efficacy. Further analysis of these protocols could help assess their efficacy in prehospital hypertension management.

Additionally, the number of medications administered was significantly higher for patients left at the scene compared to those transported. EMTs primarily used medications such as captopril, furosemide and hydroxyzine to manage hypertension in the field. These medications were selected based on their complementary effects in rapidly controlling blood pressure and stabilizing the patient. The use of specific medication combinations was typically guided by established protocols and, in some cases, direct medical direction provided by supervising physicians.

EMTs generally observed patients for a designated period after administering hypertensive medications to ensure the drugs took effect and to monitor the patient’s response. This observation period allowed EMTs to assess whether the patient’s condition was stable enough to remain at the scene or if hospital transport was necessary. The confidence in leaving patients at the scene after administering multiple medications suggests that EMTs relied on both the effectiveness of the medication and the patient’s response during this observation period. This strategy not only alleviates the burden on EDs but also conserves EMS resources for more critical cases, aligning with studies that emphasize the importance of comprehensive prehospital care in improving patient outcomes and optimizing resource allocation.

Furthermore, our analysis of the mean arterial pressure differences revealed that patients left at the scene exhibited a higher MAP reduction compared to those transported to the ED. This significant reduction underscores the efficacy of prehospital interventions in managing hypertensive emergencies, enabling EMTs to stabilize patients adequately before making transport decisions. Other research has similarly highlighted the importance of achieving substantial MAP reductions in prehospital settings to prevent complications and ensure patient safety. The significant reduction in MAP among non-transported patients suggests that EMTs were able to achieve effective blood pressure control on-site, reducing the need for hospital transport. This emphasizes the efficacy of prehospital interventions in managing hypertensive emergencies.

Comparative studies have also highlighted regional differences in EMS protocols and the availability of resources, which can impact the generalizability of findings. For example, a study by Newton et al. [22] in urban settings found that EMTs had access to more advanced medical equipment and support, leading to different intervention outcomes compared to rural settings. Our study’s focus on the Bieszczady EMS operational area, which has its own unique challenges and resource limitations, adds valuable context to the broader understanding of prehospital hypertension management.

Comparative studies have shown that regional differences in EMS protocols can affect the generalizability of findings. In some areas, EMTs are legally restricted from administering medications before hospital admission, which limits the applicability of our results [23]. In such cases, EMTs must rely on non-pharmacological interventions, such as patient positioning and monitoring, and make transport decisions based on the severity of the patient’s condition. While our study focuses on a region where EMTs can administer medications, the findings may not apply to areas with such restrictions. Further research is needed to explore effective EMS strategies in these contexts.

Our findings align with several studies, such as Kawa et al. [24] and Bashar et al. [25], which highlight the importance of effective prehospital care in reducing adverse cardiovascular events and managing resource constraints in rural areas. The prolonged intervention times observed during the pandemic are consistent with Varughese et al. [26] and Penney et al. [27], who reported increased EMS workload and complexity due to COVID-19 protocols. Furthermore, the efficacy of medication combinations found in our study is supported by Lindbeck [28] and Strandås et al. [21] emphasizing the role of tailored pharmacological strategies in prehospital care.

These findings have several practical implications for emergency medical practice. First, there is a need to enhance training for EMTs on efficient intervention techniques that adhere to safety protocols without causing significant delays. Studies have shown that targeted training programs can significantly improve the performance and decision-making skills of EMTs in managing hypertensive emergencies. Second, our results suggest that prehospital management protocols should include guidelines for the use of specific medication combinations to stabilize patients effectively on-site. This approach could reduce unnecessary hospital transports, freeing up ED resources for more critical cases. Previous studies have highlighted the benefits of tailored pharmacological strategies in prehospital care, suggesting that they can lead to better patient outcomes and more efficient use of medical resources. Third, the data underscores the importance of continuous monitoring and assessment of prehospital care practices. Implementing real-time feedback mechanisms and regular audits can help identify areas for improvement and ensure that EMTs are adhering to best practices. Research has demonstrated that continuous quality improvement initiatives in EMS can lead to significant enhancements in patient care and operational efficiency.

Overall our study provides valuable insights into the prehospital management of hypertension by EMTs during the COVID-19 pandemic. The findings highlight the importance of efficient intervention techniques, effective use of medications, and robust triage strategies. By addressing these areas, EMS systems can enhance the quality of care for hypertensive patients, optimize resource allocation, and improve overall patient outcomes during public health emergencies. Further research and continuous evaluation are essential to refine these practices and ensure the readiness of EMS systems for future challenges.

5. Limitations

While our study provides valuable insights into the prehospital management of hypertension by Emergency Medical Teams during the COVID-19 pandemic, several limitations may affect the generalizability and interpretation of our findings.

First, the retrospective nature of the study limits our ability to control for potential confounding variables. Data were extracted from existing medical records, which may not have captured all relevant clinical details. This introduces potential biases related to documentation practices, and our findings are constrained by the quality and completeness of the available records. Incomplete or inconsistent documentation may have led to misclassification or missing data, affecting the reliability of the study outcomes.

Second, the accuracy of our data is dependent on EMT documentation practices, which may vary between individual EMTs and across shifts. Such variations could introduce inconsistencies, potentially affecting the overall validity of the study. Furthermore, the study was conducted within the operational area of the Bieszczady Emergency Medical Service, limiting the generalizability of our findings to other regions or EMS systems. Differences in EMS protocols, resources and patient demographics across regions may influence the applicability of our results in other settings.

Third, the unique conditions imposed by the COVID-19 pandemic significantly impacted EMS operations, patient behavior and hypertension management. Factors such as increased stress, reduced access to routine healthcare, and changes in patient behavior (e.g., delaying care) likely influenced the prevalence and severity of hypertension. Additionally, infection control measures, including personal protective equipment use and disinfection protocols, affected EMT response times and decision-making. These pandemic-specific factors limit the comparability of our findings to non-pandemic contexts.

Although the study was conducted during the COVID-19 pandemic, our analysis does not differentiate between the pandemic and non-pandemic periods. Without this comparison, we cannot conclusively attribute our findings to COVID-19-specific effects, which may limit the broader applicability of the results. Future studies should aim to compare pandemic and non-pandemic periods to better understand these impacts.

Finally, our analysis did not account for several variables that could influence EMT decision-making and patient outcomes, such as the severity of comorbid conditions, patient preferences, or variations in EMT training and experience. Future research should aim to include these factors to provide a more comprehensive understanding of prehospital hypertension management in both pandemic and non-pandemic conditions.

6. Conclusions

Our study demonstrates that EMT interventions for prehospital hypertension are significantly longer when patients are transported to the ED compared to those left at the scene. Patients left at the scene had lower systolic and diastolic blood pressure readings and experienced a greater reduction in MAP, suggesting effective on-site management. Additionally, the higher number of medications administered to patients left at the scene highlights the role of pharmacological intervention in reducing hospital transport, potentially easing the burden on EDs.

These findings underscore the importance of efficient, targeted prehospital management strategies in hypertensive emergencies. By optimizing medication protocols and refining triage decisions, EMTs can improve patient outcomes and better allocate EMS resources.

Future research should focus on comparing data from COVID and non-COVID periods to understand the pandemic’s impact on EMS operations. Additionally, further studies are needed to explore strategies for improving EMT training, medication administration, and long-term patient outcomes.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Author contributions

AM and SK—conceptualization, methodology. KG and KZK—formal analysis. SK—investigation. MG and KG—supervision. KZK—validation. MG and AMAW—visualization. MG, AM, SK, KZK, AMAW and KG—writing–original draft. MG, AMAW and KG—writing–review. All authors have read and agreed to the published version of the manuscript.

Ethics approval and consent to participate

Ethical approval for the current research was obtained from the Bioethics Committee at the Medical University of Lublin (decision number: KE-0254/150/06/2022). All participants provided informed consent to participate in this study, in accordance with the guidelines approved by the Bioethics Committee at the Medical University of Lublin.

Acknowledgment

The authors would like to extend their appreciation to King Saud University for funding this work through the Researchers Supporting Project number (RSPD2024R649), King Saud University, Riyadh, Saudi Arabia.

Funding

This research was funded by the King Saud University Research (Project number: RSPD2024R649).

Conflict of interest

The authors declare no conflict of interest. Krzysztof Goniewicz and Ahmed M. Al-Wathinani are serving as the Guest editors of this journal. We declare that Krzysztof Goniewicz and Ahmed M. Al-Wathinani had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to TK.