Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians

Abstract

ObjectivesTo combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients’ need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs’ experiences of assessing non-conveyed patients.DesignA phenomenological interview study based on a reflective lifeworld research approach.SettingThe target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200 000 ambulance assignments annually, and approximately 25 000 patients are non-conveyed each year.Informants11 ACs.MethodsIn-depth open-ended interviews.ResultsACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations.ConclusionsThis study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.

Non-conveyance in the ambulance service: a population-based cohort study in Stockholm, Sweden

“…Ambulance clinicians have previously expressed a need for support from the wider healthcare system, such as primary care, to achieve a satisfying level of patient safety and their own sense of security when conducting non-conveyance assessments. 7 Our finding encourages future studies investigating patient outcome following non-conveyance.…”

“… 21 Perceived limited support from ambulance management regarding non-conveyance has earlier been described by clinically active ambulance clinicians in this paper’s study setting area. 7 This could possibly explain the lower non-conveyance rates seen in this paper compared with other non-conveyance rates in western ambulance services.…”

“… 6 Research has shown that conducting a non-conveyance assessment carries several challenging clinical paradoxes and is perceived to be a difficult task by ambulance clinicians. 7 However, comparisons between different ambulance services are problematic due to an absence of definitions related to the non-conveyance cohort, the use of different research approaches, the lack of explicit national non-conveyance guidelines, differences in ambulance clinicians’ competencies and the use of different triage tools. 6 8 Regardless of which triage tool is used, assessment of vital signs is a fundamental part of all triage tools.…”

Dyadic teams and nursing care: A critical incident study of nurses in the emergency medical service

“…This diversity of goals may be the result not only of differing professional views on nursing care, but also of a paradigm shift in the EMS role. The care has changed from providing out-of-hospital urgent and emergency medical treatment, to a care based on assessing the patients multiple needs (Edwards, Bassett, Sinden, & Fothergill, 2014) and less acute conditions (Durant & Fahimi, 2012), in order to define an appropriate level of care (Lederman, Löfvenmark, Djärv, Lindström, & Elmqvist, 2019;Norberg, Wireklint Sundstrom, Christensson, Nystrom, & Herlitz, 2015). Hence, the assessment of the patient may generate several possible solutions, for example nonconveyance with self-care advice or conveyance to primary care services.…”

Quality Evaluation of Clinical Practice Guidelines for Comprehensive Patient Assessment in Emergency Care: A National Cross-sectional Survey

“…Patients without need of life-saving interventions are often assessed with low medical priority, which means that these patients could spend several hours at the ED (2). In prehospital contexts, low-priority patients may be referred to a different level of care than the ED or left at home or on site with self-care advice (3,4). Whatever the emergency care context may be, it can be a challenge to encounter patients' urgent care needs, as these needs may prove to be based on nonphysical problems.…”