This review assessed the development of Taiwan's emergency medical services (EMS) and focused on the optimizing initiatives of the EMS systems, the current state of Taiwan's EMS system, EMS benchmarks in different regions of Taiwan, EMS response during the coronavirus disease 2019 (COVID-19) pandemic, and future design. In the past decade, there has been a noticeable increase in prehospital services, numerous optimizing initiatives to improve patient prognosis, and the medical oversight model. Taiwan's current EMS system, including the dispatch system, out-of-hospital cardiac arrest (OHCA) patient management, time-sensitive critical illness in prehospital settings, and disaster response, has undergone significant improvements. These improvements have been demonstrated to have a measurable impact on patient outcomes, as supported by medical literature. Each region in Taiwan has developed a unique EMS system with local characteristics, such as the implementation of the Global Resuscitation Alliance 10 steps for OHCA-related quality control, hearing automated external defibrillator program, a five-level prehospital triage system, an island-hopping strategy for patients with major trauma, dispatcher-assisted teamwork for OHCA resuscitation, and optimized prehospital care for acute coronary syndrome patients. In response to the COVID-19 pandemic from 2019 to 2023, Taiwan's EMS implemented measures to combat the outbreak such as interagency collaboration to obtain patient's personal information, to optimize prehospital management initiatives, and to provide financial compensation and personal insurance for emergency medical technicians. The areas that need focus include integrating prehospital and in-hospital information to build a national-level database (One-Stop Emergency Management), increasing public awareness of first responders and emergency casualty care, and evolving the EMS system by incorporating private EMS system, initiating school-based education of paramedicine, and legally recognizing paramedics as medical and health care personnel. By improving these areas, we can better prepare for the future and ensure that Taiwan's EMS system continues to provide high-quality care to those in need.