Background
Aim
Methods
Design
Search strategy
Study selection procedure
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Non-conveyance rates;
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Characteristics of non-conveyed patients;
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Follow-up care after non-conveyance;
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Non-conveyance guidelines, protocols, or on-scene triage criteria;
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Professional competencies needed to initiate non-conveyance;
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Factors influencing the non-conveyance decision-making process.
Quality assessment
Data extraction
Data synthesis and presentation
Results
Review statistics
Study Characteristics
1st author (Year) Country [ref] | Design | Methods/Data sources | Patients (n) | Professionals (n) |
---|---|---|---|---|
Alicandro (1995) USA [29] | Pre-test post-test | Data card, Online database | Patients (n = 361) who refused conveyance | Not described |
Alrazeeni (2016) Saudi Arabia [31] | Retrospective, observational | Patient care reports | Patients (n = 1791) who were not conveyed | EMTs |
Anderson (2002) Denmark [32] | Retrospective, observational | Prehospital database, National Patient Register, Central Personal registry, Registry of Causes of Death | Patients (n = 1187) with hypoglycaemia | MICU physicians |
Burstein (1996) USA [56] | Prospective, cohort | Identifying card, Telephone follow-up | Patients (n = 361) who refused medical assistance | Emergency physicians (n = 22), ALS and BLS providers |
Burstein (1998) USA [57] | Prospective, observational | 10-point assertiveness scale, ED disposition instrument | Patients (n = 130) who refused medical assistance | Paramedic medical-control console operators, EMS-crews, Emergency physicians |
Burrell (2013) UK [82] | Qualitative | Topic guided in-depth interviews | No patient population included | EMT level 2 (n = 1), EMT level (n = 4), Paramedics (n = 5), Paramedic team leaders (n = 4), Emergency care practitioner (n = 1) |
Cain (2003) USA [58] | Prospective, observational | Patient care report, Refusal form | Ambulance calls (n = 17,416) | Basic & advanced paramedics |
Carter (2002) Canada [59] | Prospective, observational | Telephone calls, Ambulance call reports | Patients (n = 100) with hypoglycaemia receiving IV dextrose | Paramedics, Emergency medicine senior residents |
Chen (1996) Taiwan [60] | Prospective, observational | Dispatch record, Ambulance run record, ED disposition form | Patients (n = 1035) who called an ambulance | EMTs |
Cone (1995) USA [8] | Retrospective, observational | Emergency department records, Telephone follow-up, Ambulance call reports, Medical command control forms | Patients (n = 85) who refused conveyance | Paramedics, Volunteer municipal basic life support units |
Deasy (2008) Ireland [61] | Prospective observational | Data sheets | Ambulance calls (n = 263) | Emergency Medicine Specialists, Paramedics |
Ebrahimian (2014) Iran [83] | Qualitative | Semi-structured interviews | No patient population included | EMS staffs (n = 18) |
Gerlacher (2001) USA [79] | Cross-sectional | Patient records | Patients (n = 15,409) ≤ 12 years | First responder firefighters, EMTs, Paramedics |
Goldstein (2015) Canada [33] | Retrospective, observational | Electronic patient care records | Patients (n = 63,067) ≥ 65 years | Primary care paramedics, Intermediate care paramedics, Advanced care paramedics |
Haines (2006) USA [62] | Prospective, observational | Telephone follow-up questionnaire, Ambulance records | Patients (n = 5336) <21 years | ALS-paramedics, Physicians |
Halter (2011) UK [84] | Qualitative | Semi-structured interviews | No patient population included | EMTs, Paramedics (n = 12) |
Hipskind (1997) USA [63] | Prospective, observational | Ambulance run reports | Patients (n = 683) who refused conveyance | Paramedics (n ≈ 350) |
Højfeld (2014) Denmark [34] | Retrospective, observational | MECU database, Medical records | Mobile emergency care unit runs (n = 15,392) | Anaesthesiologists |
Jensen (2013) Canada [64] | Prospective, observational | Data from emergency health services, Patient care records, Databases | Ambulance calls (n = 265) for long term care facility patient | Extended care paramedics (n = 7), Paramedics |
Kahalé (2006) Canada [65] | Prospective, observational | Ambulance call reports, Hospital charts, Telephone interviews | Patients (n = 345) <16 years | EMTs, Paramedics |
Kamper (2001) USA [35] | Retrospective, observational | Ambulance run records, ED records, Hospital records | Ambulance calls (n = 53,627) | Paramedics |
Kannikeswaran (2007) USA [36] | Retrospective, observational | Standardized data extraction sheets | Ambulance runs (n = 5976) for children <18 years | EMT-Ps, EMT-Bs |
Keene (2015) Australia [85] | Mixed-methods | Structured interviews, Patient care records | Patients (n = 33,333) where an ambulance was dispatched | Ambulance paramedics, Intensive care paramedics |
Key (2003) USA [30] | Pre-test post-test | Patient/ambulance records | Ambulance calls (n = 11,488) | Paramedics, EMTs |
Knight (2003) USA [37] | Retrospective, descriptive | State-wide EMS data, State-wide ED data, Death certificate data | EMS dispatches (n = 277,221) | Not described |
Lerner (2003) USA [66] | Prospective, observational | Telephone interviews | Patients (n = 36) with hypoglycaemia | EMT-Ps (n = 23) |
Magnusson (2016) Sweden [38] | Retrospective, observational | Patient notes | Patients (n = 529) with low priority, uncertain need for ambulance and vague symptoms | Ambulance nurses |
Marks (2002) UK [9] | Retrospective, observational | Patient report forms | Patients (n = 500) not conveyed | EMTs, Paramedics |
Mechem (1998) USA [67] | Prospective, observational | Telephone interviews | Ambulance calls (n = 115,135) | Nurses, Paramedics |
Minhas (2015) Canada [39] | Retrospective, cohort | EMS patient records, ED patient records | Patients (n = 286) 18–65 years with supraventricular tachycardia | ALS paramedics |
Moss (1998) USA [40] | Retrospective, observational | Prehospital records | EMS responses (n = 6512) | Paramedics |
Murphy-Jones (2016) UK [86] | qualitative, phenomenological | Semi-structured interviews | No patient population included | Paramedics (n = 6) |
Newton (2015) South-Africa [68] | Prospective, observational | Computerized dispatch logs, Patient report forms | Ambulance calls (n = 1689) | BLS emergency care providers, ILS emergency care providers, ALS emergency care providers |
O’Hara (2015) UK [87] | Qualitative | Reviewing relevant national and local documents (Reports, policies, protocols), Semi-structured interviews, Observations, Digital diaries, Informal interviews, Focus groups, Written notes | No patient population included | Directors, Managers, Specialist paramedics, Paramedics, Emergency care assistants/technicians/support workers |
Persse (2002) USA [69] | Prospective, observational | Patient care records, Structured telephone interviews | Patients (n = 2207) ≥ 65 years | Paramedics, EMTs |
Peyravi (2013) Iran [41] | Retrospective, observational | National data registry, Ambulance station data registry | Ambulance runs (n = 84,084) | Nurses, Paramedics, GPs |
Peyravi (2015) Iran [42] | Retrospective observational | Patient care records, Telephone interviews | Ambulance runs (n = 81,999) | Not described |
Porter (2007) UK [88] | Qualitative | Focus groups (n = 3) | No patient population included | Paramedics (n = 25) |
Pringle (2005) USA [43] | Retrospective, observational | EMS reports, Telephone interviews | EMS patient encounters (n = 1894) | EMT-Bs, Paramedics |
Rudolph (2011) Denmark [44] | retrospective, observational | Medical emergency care unit database, Autopsy reports | Patients (n = 4762) with acute opioid overdose | Anaesthesiology specialists, ALS providers |
Schmidt (2001) USA [70] | Prospective, observational | Patient records | Patients (n = 1433) were an ambulance was dispatched | EMT-Ps, EMT-ILSs, EMT-Bs |
Schmidt (1998) USA [71] | Prospective, observational | Structured telephone interview | Patients (n = 324) who refused conveyance | Paramedics |
Schmidt (2000) USA [72] | Prospective observational | Data sheets | Patients (n = 1433) where an ambulance was dispatched | EMT-Ps, EMT-ILSs, EMT-Bs |
Schmidt (2006) USA [45] | retrospective, observational | EMS database | Ambulance runs (n = 1501) | Paramedics |
Selden (1990) USA [46] | Retrospective, observational | Run records | Ambulance runs (n = 11,780) | Paramedics |
Seltzer (2001) USA [47] | Retrospective, observational | Run records, Structured telephone interviews | Patients (n = 89) <18 years who refused conveyance against medical advice | EMT-Ds, EMT-Ps |
Shaw (2006) UK [81] | Mixed methods | Patient records | Ambulance runs (n = 76,635) | Paramedics, EMTs |
Simpson (2014a) Australia [74] | Prospective, cohort | Data sheets, Administrative databases | Patients (n = 1610) ≥65 years who have fallen | Paramedics |
Simpson (2014b) Australia [73] | Prospective, cohort | Data collection tool, Dispatch system | Patients (n = 1610) ≥65 years who have fallen | Paramedics (n = 384) |
Snooks (2005) UK [89] | Qualitative | Focus groups | No patient population included | Paramedics (n = 26) |
Snooks (2014) UK [27] | CRCT | Paramedic records, ED records | Patients (n = 779) ≥65 years who have fallen | Paramedics (n = 42) |
Snooks (2004a) UK [28] | Quasi-experimental | Patient report forms, ED records, GP records, Questionnaire | Patients (n = 797) were an ambulance was dispatched | Paramedics (n = 5), EMTs (n = 5) |
Socransky (1998) USA [48] | Retrospective, observational | Patient records, Hospital records | Ambulance runs (n = 10,888) | Paramedics |
Stark (1990) USA [49] | Retrospective, observational | EMS database | Ambulance calls (n = 1715) | Paramedics, Physicians |
Staudenmayer (2012) USA [50] | Retrospective, cohort | Population-based injury database | Patients (n = 69,413) with a primary diagnosis of ‘injury’ or ‘trauma’ | Not described |
Strote (2008) USA [75] | Prospective, cohort | Medical incident report forms, Telephone interviews | Patients (n = 2359) with hypoglycaemia | EMTs, Paramedics |
Stuhlmiller (2005) USA [51] | Retrospective, observational | On-line medical command audio tapes, Patient run sheets, Non-conveyance sheets | On-line medical control calls (n = 137) for patient-initiated refusals | Paramedics |
Tiedemann (2013) Australia [76] | Prospective, cohort | Patient records, Questionnaires (e-mail) | Patients (n = 2842) ≥70 years who have fallen | Paramedics |
Tohira (2016a) Australia [53] | Retrospective cohort | Patient care records, ED information system, Death registry | Patients (n = 1238) post-ictal or with hypoglycaemia | Paramedics |
Tohira (2016b) Australia [52] | Retrospective, cohort | Patient care records, ED information system, Death registry | Patients (n = 127,574) were an ambulance was dispatched | Paramedics |
Van der Pols (2011) Netherlands [77] | Prospective, cohort | Patient record, Hospital databases, Dispatch centre database | Patients (n = 1842) were an ambulance was dispatched | Ambulance nurses |
Vilke (1999) USA [54] | Retrospective, observational | Prehospital database, Death registry | Patients (n = 94,466) were an ambulance was dispatched | Paramedics |
Vilke (2002) USA [78] | Prospective, observational | Telephone interviews | Patients (n = 636) ≥ 65 years and who signed out against medical advise | EMTs, EMT-Ps, EMT-Ds |
Zachariah (1992) USA [55] | Retrospective, observational | Patient records, Structured telephone interviews | Patients (n = 158) not conveyed | Paramedics |
Zorab (2015) UK [80] | Cross-sectional | Questionnaires | No patient population included | Emergency Care Assistants, Ambulance Technicians, Student Paramedics, Paramedics, Emergency Care Practitioners, Critical Care Paramedics |
1st author (year) country | Aim | Databases | Selection criteria | Included articles |
---|---|---|---|---|
Mikolaizak (2013) Australia [26] | To summarize the evidence in relation to (1) non-conveyance rates, (2) outcomes following non-conveyance, and (3) outcomes from alternative care pathways for non-conveyed older people who have fallen | 1. Medline 2. Embase 3. CINAHL 4.PsycINFO 5.Cochrane Library 6. Web of Science | 1. Peer-reviewed articles 2. Original data relating to non-transport rates for older people who have fallen 3. Outcomes on falls or outcomes for alternate care pathways for non-transported people who have fallen | 12 articles: 2 randomized controlled trials, 5 prospective cohort studies, 4 retrospective cohort studies and 1 historical cohort trial. |
Snooks (2004b) UK [10] | 1. To describe outcomes of non-conveyed patients 2. To describe triage ability of crews 3. To assess effectiveness and safety of protocols that allow crews to convey patients to alternative receiving units or to self-care | 1. Medline 2. BIDS 3.Healthplan 4. Helmis | Articles on paramedics trained with extra skills to perform tasks beyond their baseline competencies | 31 articles: 13 retrospective observational studies, 8 prospective observational studies, 6 cross-sectional studies, 3 case studies and 1 quasi-experimental study |
Quality assessment (Additional file 4: Appendix 3, Additional file-5: Appendix 4, Additional file 6: Appendix 5, Additional file 7: Appendix 6)
Outcomes
Non-conveyance rates (Additional file 8: Appendix 7)
Characteristics of non-conveyed patients (Additional file 8 Appendix 7)
Follow-up of patients after non-conveyance (Table 3)
1st author (year) Country [ref] | Follow-up outcomes | Results |
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Anderson (2002) Denmark [32] | • Patient outcome – hospitalization • Patient outcome – recurrent symptoms | • 76/968 (7.9%) patients have secondary blood glucose regulatory problems <72 h ◦ 46/76 (60.5%) have a recurrent hypoglycaemia, 33/46 (71.7%) of these cases occur <24-72 h • 49/968 (5.1%) are hospitalized <72 h ◦ 21/49 (42.9%) have a recurrent hypoglycaemia of which 12/21 (57.1%) are hospitalized <24-72 h |
Burstein (1996) USA [56] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – EMS (call or EMS run) • Repeat access emergency healthcare – ED | • 199/321 (62.0%) patients who had follow-up. ◦ 95/199 (47.7%) patients sought additional medical care <1 week. ▪ 51/95 (53.7%) went to the ED: 7 through EMS, 41 referred themselves to the ED and 3 were referred by their physician. ▪ 44/95 (46.3%) were seen by their physician. |
Burstein (1998) USA [57] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Patient outcome – mortality • Patient outcome – hospitalization | • 66/69 (95.7%) patients could be contacted through follow-up <2–3 days ◦ 33/66 (50.0%) patients saw their own physicians ◦ 17/66 (25.8%) went to an ED on their own ◦ 8/66 (12.1%) were admitted to the hospital ◦ 4/66 (6.1%) died |
Cain (2003 USA [58] | • Repeat access emergency healthcare – EMS (call or EMS run) | 40/145 (27.6%) patients had signs and symptoms compatible with low blood sugar occurring <10 months after initial event and requiring a repeat EMS call: • 2/24 (8.3%) patients >65 years • 38/121 (31.4%) patients <65 years 3/145 (2.1%) patients had signs and symptoms compatible with low blood sugar occurring <48 h after initial event and requiring a repeat EMS call: • 0/24 (0.0%) patients >65 years • 3/121 (2.5%) patients <65 years • No significant differences in repeat (p = .43) any time during the ten-month study period, recurrences (p = .33) <48 h and interval for repeat episodes (p = .60) between conveyed and non-conveyed patient calls. |
Carter (2002) Canada [59] | • Patient outcome – recurrent symptoms | Repeated access to healthcare <21 days: • 6/41 (14.6%) patients for all complaints • 2/41 (4.9%) patients for the same complaint |
Cone (1995) USA [8] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Patient outcome – hospitalization | 54/81 (67%) had follow-up: • 37/54 (68.5%) sought no medical care • 10/54 (18.5%) were evaluated in the ED: 3 were discharged, 7 were admitted: 3 were admitted to monitored beds and 4 were admitted to unmonitored beds • 7/54 (13.0%) saw their own physician <48 h after refusal |
Haines (2006) USA [62] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Patient outcome – hospitalization | 527/704 (74.8%) completed phone follow-up: • 13/527 (2.5%) non-transport group hospitalized • 279/527 (52.9%) patients had follow-up-care <72 h (median 2.5 h, inter-quartile range 1.5–13 h) ◦ 203/279 (72.6%) patients had follow-up-care <12 h ◦ 148/279 (65.9%) patients came to ED ◦ 95/279 (34.1%) patients came via primary care physician ◦ 19/279 (6.8%) patients were evaluated by a medical provider more than once in 72 h |
Højfeld (2014) Denmark [34] | • Repeat access emergency healthcare – ED • Patient outcome – mortality • Patient outcome – hospitalization | 113/1609 (7.0%) patients had renewed treatment in hospital or ED <24 h ◦ 58/113 (51.3%) had to be admitted ◦ 51/113 (45.1%) visited the ED ◦ 4/113 (3.5%) died |
Jensen (2013) Canada [64] | • Repeat access emergency healthcare – EMS (call or EMS run) | 6/238 (2.5%) patients who received extended paramedic care but who were not transported subsequently triggered a EMS call <48 h |
Kahalé (2006) Canada [65] | • Repeat access general healthcare – GP • Repeat access general healthcare – walk-in clinic • Repeat access emergency healthcare – ED | 51/345 (14.8%) non-transported children were seen at the ED <48 h Telephone follow-up with patients (n = 106) about additional care <48 h: • 51/106 (48.1%) patients did not seek medical follow-up • 28/106 (26.4%) patients went to the ED • 22/106 (20.8%) patients visited the family physician/paediatrician office • 4/106 (3.8%) patients visited a walk-in clinic • 1/106 (0.9%) patients went to a hospital/outpatient clinic |
Knight (2003) USA [37] | • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) • Patient outcome – mortality • Patient outcome – hospitalization | 3454/26574 (13.0%) follow-up was obtained <1 week: • 174/3454 (5.0%) patients were admitted to the hospital • 25/3454 (0.7%) patients died • 465/3454 (13.5%) patient had an EMS dispatch ◦ < 3 years: 8/465 (1.7%) ◦ 3–12 years: 14/465 (3.0%) ◦ 13–17 years: 24/465 (5.2%) ◦ 18–64 years: 301/465 (64.7%) ◦ ≥ 65 years: 118/465 (25.4%) • 2790/3454 (80.1%) of the patients had an ED visit ◦ < 3 years: 133/3454 (3.9%) ◦ 3–12 years: 175/3454 (5.1%) ◦ 13–17 years: 223/3454 (6.5%) ◦ 18–64 years: 2041/3454 (59.1%) ◦ ≥ 65 years: 218/3454 (6.3%) • 174/3454 (5.0%) of the patients were admitted ◦ < 3 years: 12/174 (6.9%) ◦ 3–12 years: 13/174 (7.5%) ◦ 13–17 years: 7/174 (4.0%) ◦ 18–64 years: 97/174 (55.7%) ◦ ≥ 65 years: 45/174 (25.9%) |
Lerner (2003) USA [66] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED | 20/36 (55.6%) sought further medical assistance <48 h: • 11/20 (55.0%) called their personal physician • 8/20 (40.0%) visited their personal physician • 1/20 (5.0%) went to the ED |
Magnusson (2016) Sweden [38] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Patient outcome – hospitalization | 38/200 (19.0%) patients visited the ED <72 h: • 24/38 (63.2%) self to ED ◦ 12/24 (50.0%) admitted • 14/38 (36.8%) referred by GP ◦ 8/14 (57.1%) admitted |
Mechem (1998) USA [67] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) • Patient outcome – hospitalization | 94/103 (91.3%) patients had no recurrence of symptoms in <72 h: • 7/94 (7.4%) contacted private physician 9/103 (8.7%) recontacted the EMS < 72 h:
• 5/9 (55.6%) transported and released from ED • 3/9 (33.3%) transported and admitted • 1/9 (11.1%) refused transport |
Mikolaizak (2013) Australia [26] | • Repeat access general healthcare – GP • Repeat access general healthcare – walk-in clinic • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) • Patient outcome – mortality • Patient outcome – hospitalization | Follow-up periods varied from 1 to 12 months. Outcomes: 12%–49% readmission in ambulance or other health service facility, non-transported patients have significantly higher risk of death compared to age matched peers |
Minhas (2015) Canada [39] | • Repeat access emergency healthcare – EMS (call or EMS run) | 1/76 (1.3%) of the patients treated and released had 14 representations <72 h |
Moss (1998) USA [40] | • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) • Patient outcome – mortality • Patient outcome – hospitalization | 431/443 (97.3%) patients a follow-up was obtained: • 10/431 (2.3%) called EMS again <48 h ◦ 4/10 (40.0%) were admitted to a hospital ◦ 4/10 (40.0%) were discharged from the ED ◦ 1/10 (10.0%) died ◦ 1/10 (10.0%) was transferred to another facility |
Persse (2002) USA [69] | • Patient outcome – hospitalization | Phase 1: 151/254 (59.5%) patients were contacted by telephone: • 56/151 (37.1%) sought further medical help <24 h • 19/151 (12.6%) were hospitalized Phase 2: 109/198 (55.1%) patients were contacted by telephone: • 37/109 (33.9%) sought further medical help <24 h • 7/109 (6.4%) were hospitalized |
Pringle (2005) USA [43] | • Patient outcome – mortality • Patient outcome – hospitalization | 310/906 (34.2%) follow-up was obtained (1 week): • 172/310 (55.5%) patients sought medical care: ◦ 106/172 (61.6%) medical care was changed • 25/310 (8.1%) were admitted to a hospital • 1/310 (0.3%) patients died |
Rudolph (2011) Denmark [44] | • Patient outcome – mortality | 18/2241 (0.8%) patients released on scene died <48 h |
Schmidt (2006) USA [45] | • Patient outcome – mortality | 2/128 (1.6%) patients not-transported died <30 days |
Snooks (2004a) UK [28] | • Patient outcome – hospitalization | Intervention group: 5/93 (5.4%) patients were admitted to a hospital <14 days Control group: 12/195 (6.2%) patients were admitted to a hospital <14 days |
Socransky (1998) USA [48] | • Repeat access emergency healthcare – ED • Patient outcome – hospitalization • Patient outcome – recurrent symptoms | 25/412 (6.1%) of the patients who refused transport had a relapse <48 h: • 14/25 (56.0%) refused transport again • 6/25 (24.0%) admitted to the ED • 5/25 (20.0%) were admitted to a hospital |
Staudenmayer (2011) USA [50] | • Repeat access emergency healthcare – ED • Patient outcome – hospitalization • Patient outcome – mortality | 1715/5865 (29.2%) follow-up obtained: • 1616/1715 (94.2%) patients were seen in the ED and discharged • 92/1715 (5.4%) were admitted to the hospital • 7/1715 (0.4%) died |
Strote (2008) USA [75] | • Repeat access general healthcare – GP • Repeat access emergency healthcare – ED • Patient outcome – hospitalization | 203/402 (49.5%) follow-up obtained: • 111/203 (54.7%) patients contacted their primary care physician <24 h • 8/203 (3.9%) patients called the EMS again <48 h • 16/203 (7.9%) patients went to the hospital <48 h |
Tiedemann (2013) UK [76] | • Patient outcome – recurrent symptoms | 62/251 (24.7%) of the non-transported patients required ≥1 fall related repeat ambulance attendance <6 months |
Tohira (2016b) Australia [52] | • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) • Patient outcome – mortality • Patient outcome – hospitalization | Subsequent events after discharge at the scene, Unadj OR (95% CI) ∗ Adj OR (95% CI)∗ Ambulance request • Within 1 day 672/11096 (6.1%) 3.5 (3.1–4.0) 3.4 (3.0–3.9) • Within 3 days 995/11096 (9.0%) 2.3 (2.1–2.5) 2.1 (1.9–2.4) • Within 7 days 1305/11096 (11.8%) 1.9 (1.7–2.0) 1.7 (1.6–1.9) ED attendance • Within 1 day 514/11096 (4.6%) 3.4 (3.0–3.9) 3.3 (2.8–3.8) • Within 3 days 710/11096 (6.4%) 2.0 (1.8–2.2) 1.9 (1.7–2.2) • Within 7 days 898/11096 (8.1%) 1.5 (1.4–1.6) 1.4 (1.2–1.5) Hospitalisation • Within 1 day 361/11096 (3.3%) 4.1 (3.5–4.9) 4.2 (3.4–5.1) • Within 3 days 500/11096 (4.5%) 2.5 (2.2–2.9) 2.3 (2.0–2.7) • Within 7 days 634/11096 (5.7%) 2.0 (1.8–2.2) 1.8 (1.6–2.0) Death • Within 1 day 19/11096 (0.2%) 1.6 (0.9–2.8) 1.8 (0.99–3.2) • Within 3 days 32/11096 (0.3%) 1.7 (1.1–2.6) 1.9 (1.2–3.0) • Within 7 days 56/11096 (0.5%) 1.6 (1.2–2.3) 1.8 (1.3–2.5) ∗ vs. ED-discharge |
Van der Pols (2011) The Netherlands [77] | • Repeat access general healthcare – GP | Motorcycle response vehicles with one ambulance nurse with additional training (n = 468) compared to regular ambulance (n = 1196): • referral to GP 138/468 (29.5%) vs 167/1196 (14.0%) RR 2.11 (95%CI 1.73–2.58) |
Vilke (2002) USA [78] | • Repeat access general healthcare – GP • Repeat access general healthcare – walk-in clinic • Repeat access emergency healthcare – ED • Repeat access emergency healthcare – EMS (call or EMS run) | 71/121 (58.7%) follow-up was obtained: • 27/71 (38.0%) visited family physician • 25/71 (35.2) visited urgent care facility • 9/71 (12.7%) second EMS call and transported to ED • 9/71 (12.7%) transport to ED by private vehicle • 1/71 (1.4%) second EMS call and treated at scene |
Zachariah (1992) USA [55] | • Repeat access general healthcare – GP • Patient outcome – hospitalization | 93/158 (58.9%) follow-up was obtained: • 60/93 (64.5%) sought care from a physician: ◦ 15/60 (25.0%) were admitted to hospital. |
Existing guidelines, protocols and triage criteria for non-conveyance (Additional file 9: Appendix 8)
Professionals competencies and other factors influencing the non-conveyance decision-making process (Table 4)
Authors (publication year) country [ref] | Competences/influencing factors | Type of factor |
---|---|---|
Alicandro (1995) USA [29] | The implementation of a (1) high risk card (T1) and (2) online medical control (T2) for patients with high-risk criteria improved the transport rate: T0 2/60 (3.3%)- T1 7/70 (10.0%) - T2 12/34 (35.3%) p = .00003 | 1. Supportive tools 2. Healthcare process/system |
Burstein (1998) USA [57] | The implementation of medical control by telephone to convince patients who attempt refusal of medical care to be transported to the ED: 61/130 (47%) of the patients was convinced | 1. Healthcare process/system |
Ebrahimian (2014) Iran [83] | Affecting factors of EMS staffs’ decision about transporting: 1. patient’s condition: a. Physical health status b. Socioeconomic status: i. Patient support system ii. Patient and his family’s educational status iii. Patient and his family’s financial status c. Cultural background: i. Confidence ii. Believes and attitudes 2. The context of the EMS mission: a. Characteristics of the mission b. EMS staffs’ characteristics | 1. Patient/relative 2. Healthcare process/system |
Halter (2011) UK [84] | Influencing factors: 1. Pre-arrival: forming an early opinion from information from the emergency call 2. Initial contact: assessing the need for any immediate action and establishing a report 3. Continuing assessment: gathering and assimilating medical and social information 4. Making a conveyance decision: negotiation, referral and professional defense using professional experience, instinct | 1. Healthcare process/system |
Jensen (2013) Canada [64] | Extended care paramedics received additional specialized training in the following “extended care” roles: 1. Geriatric assessments and management 2. End-of-life care 3. Primary wound closure techniques (suturing, tissue adhesive) 4. Point-of-care testing. LTC patients treated by ECPs remained at the LTC facility in 98 of 140 (70%) cases, compared to 21 of 98(21.4%) of emergency paramedic calls. | 1. Professional |
Kahalé (2006) Canada [65] | Reasons for non-transport as cited in parent/patient interviews (n = 106): 1. 31/106 (29.2%) EMS-personnel stated that transport was unnecessary 2. 25/106 (23.6%) parents thought that going to the hospital was unnecessary 3. 22/106 (20.8%) parents wanted to use another method of transportation to seek medical care 4. 5/106 (4.7%) parents were concerned about costs related to ambulance transports 5. 23/106 (21.7%) other | 1. Professional 2. Patient/relative |
Keene (2015) Australia [85] | Reasons for not accepting transport (from fieldnotes): 1. Just wanted reassurance, assistance, advice or support/ referral 2. Symptoms had resolved prior to arrival or during assessment 3. Concern over ED waiting time/ED workload 4. Prior negative experience with a hospital 5. Personal reasons: (e.g. ‘I just didn’t want to go’. ‘I was embarrassed by all the fuss’ | 1. Patient/relative |
Mikolaizak (2013) Australia [26] | Factors influencing transport decision: 1. refusal to travel 2. patient did not sustain an injury/only minor injuries 3. sufficient on-scene treatment 4.referral to GP | 1. Patient/relative |
Murphy-Jones (2016) UK [86] | 3 main themes: 1. Patient wishes (insufficient care plans, nursing care staff insufficient knowledge of patients’ wishes, patients’ inability to express their wishes) 2. patients’ best interest (when patients were not considered to have the capacity for decision making, paramedics want to act in their best interest, factors used: diagnosis, comorbidities, quality of life, wishes and current condition, risks and benefits of hospitalization, concerns about care provision in some nursing homes 3. influence of others (nursing home staff, patients’ relatives and other paramedics) | 1. Patient/relative 2. Healthcare process/system |
O’Hara (2015) UK [87] | 7 overarching system influences on decision making: 1. Increasing demand (of non-emergent cases) 2. Performance regime and priorities 3. Access to appropriate care options in case of non-conveyance to an ED 4. Disproportionate risk aversion: non-conveyance was perceived as a risk for both patient and paramedic 5. Beneficial impact of additional training on decision making competences 6. Communication and feedback to crews 7. Ambulance service resources | 1. Healthcare process/system |
Porter (2007) UK [88] | Influencing factors: 1. Patient autonomy 2. Opinion family/carers 3. Clinical need as assessed by crew members 4. Protection of themselves for the risk of litigation by crew members 5. Mental capacity of the patient to make a transport decision 6. Lacking skills or status of the crew member to be judging the mental capacity of the patient 7. Back-up of other professionals 8. Fear of a possible comeback if the non-conveyance decision turned out to be wrong | 1. Patient/relative 2. Professional |
Simpson (2014a) Australia [74] | 6-item predictive model for non-conveyance odds (goodness-of-fit test indicated good model fit (8 DF, χ2 = 7.43, p = 0.49), factors associated with increased odds of a non-conveyance outcome. 1. 65–74 year 2. Lower response priority (90 min response time) 3. The presence of personal alarm 4. The absence of new injury/pain 5. Normal physiology 6. Change in usual level of function post fall | 1. Patient/relative 2. Healthcare process/system |
Snooks (2005) UK [89] | Influencing factors on ED conveyance: 1. Experience and intuition of the paramedic 2. Pragmatism: conveyance – the easy option 3. Patient/carer factors | 1. Professional 2. Patient/relative |
Stark (1990) USA [49] | Predictors for left at Scene Against Medical Advice: 1. Family present (β = −1.87, p = .001) 2. Disorientation (β = −1.04, p = .04) 3. Abnormal speech (β = −1.92, p = .05) 4. Police hold (β = −2.04, p = .03) 5. Alcohol use (β = 1.48, p = .006) 6. Treated hypoglycemia (β = 1.63, p = .05) | 1. Patient/relative 2. Healthcare process/system |
Stuhlmiller (2005) USA [51] | 28/137 (20.4%) patients with whom the online medical control (OLMC) physician spoke during the encounter: 9/28 (32.1%) agreed to be transported, compared with nine (8.3%) of the 109 patients who did not speak to the OLMC physician (p = .001) | 1. Supportive tools |
Van der Pols (2011) Netherlands [77] | Motorcycle response vehicles with one ambulance nurse with additional training (n = 468) compared to regular ambulance (n = 1196): (1) treat and release 129/468 (27.6%) vs 149/1196 (12.5%) RR 2.21 (95%CI 1.80–2.73) | 1. Professional |
Vilke (2002) USA [78] | Patient reasons (n = 100) for patients to refuse transport: 1. 37/100 (37.0%) did not want transport and ED care 2. 23/100 (23.0%) concerned about the cost/coverage of ED 3. 19/100 (19.0%) paramedics implied no transport was needed 4. 17/100 (17.0%) concerned about the cost of the ambulance 5. 4/100 (4.0%) language barrier | 1. Patient/relative |
Zorab (1999) UK [80] | 274/302 (90.7%) paramedics felt that a lack of health information of the patient had led to a less appropriate carepathway being selected, information that could have helped according to paramedics: 1. Resuscitation status (n = 233, 77.2%) 2. Current medication (n = 184, 60.9%) 3. Allergy information (n = 103, 34.1%) 4. Previous medical history (n = 262, 86.8%) 5. Patient’s normal parameters (n = 235, 77.8%) 6. End of life care choices (n = 221, 73.2%) 7. Information about implanted devices, e.g. pacemakers (n = 106, 35.1%) 8.Other, e.g. ECG, mental health records, blood and other test results (n = 38, 1.3%) | 1. Professional |