Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence

Abstract

Background The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known. Methods This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages. Results Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood. Conclusions This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.

EMS non-conveyance: A safe practice to decrease ED crowding or a threat to patient safety?

“…Data are given as n (%) unless otherwise noted in which the sample size is small the follow-up is by telephone, which may lead to bias because the follow-up of a large number of patients may fail [5,17]. Thus, comparisons with our findings are challenging.…”

“…Decisions not to convey patients may represent a risk to patient safety. These safety factors are unclear in the prehospital setting [4,16] and relevant studies are lacking [5,17]. However, some studies indicate that EMSs are able to make accurate preliminary diagnoses [18].…”

“…Older age and abnormal vital signs are common predictors of adverse outcomes after non-conveyance and, therefore, pose a threat to patient safety [21]. Finally, from the patient safety perspective, little is known about nonconveyance decisions and related adverse outcomes [5,17,22].…”

Outcomes in patients not conveyed by emergency medical services (EMS): a one-year prospective study

“…Even if non-conveyance has become an everyday practice for EMS worldwide, the decision to non-convey a patient is described as complex and involve a significant amount of responsibility [ 6 , 8 – 10 ]. Patient-safety issues have also been raised [ 11 , 12 ]. Previous research shows contradictory results regarding the EMS capability to safely non-convey patients [ 4 , 11 – 13 ].…”

Using machine learning to predict subsequent events after EMS non-conveyance decisions

“…Finally, the safety factors of EMS non-conveyance and the following subsequent events are unclear [2,17,18]. To the best of our knowledge, there are no existing studies that report on the use of machine learning to analyze narrative texts of EMS ePCRs.…”