Changing role of EMS –analyses of non-conveyed and conveyed patients in Finland

Abstract

Background: Emergency Medical Services (EMS) and Emergency Departments (ED) have seen increasing attendance rates in the last decades. Currently, EMS are increasingly assessing and treating patients without the need to convey patients to health care facility. The aim of this study was to describe and compare the patient casemix between conveyed and non-conveyed patients and to analyze factors related to non-conveyance decision making. Methods: This was a prospective study design of EMS patients in Finland, and data was collected between 1st June and 30th November 2018. Adjusted ICPC2-classification was used as the reason for care. NEWS2-points were collected and analyzed both statistically and with a semi-supervised information extraction method. EMS patients' geographic location and distance to health care facilities were analyzed by urban-rural classification. Results: Of the EMS patients (40,263), 59.8% were over 65 years of age and 46.0% of the patients had zero NEWS2 points. The most common ICPC2 code was weakness/tiredness, general (A04), as seen in 13.5% of all patients. When comparing patients between the non-conveyance and conveyance group, a total of 35,454 EMS patients met the inclusion criteria and 14,874 patients (42.0%) were not conveyed to health care facilities. According the multivariable logistic regression model, the non-conveyance decision was more likely made by ALS units, when the EMS arrival time was in the evening or night and when the distance to the health care facility was 21-40 km. Furthermore, younger patients, female gender, whether the patient had used alcohol and a rural area were also related to the non-conveyance decision. If the patient's NEWS2 score increased by one or two points, the likelihood of conveyance increased. When there was less than 1 h to complete a shift, this did not associate with either nonconveyance or conveyance decisions. Conclusions: The role of EMS might be changing. This warrants to redesign the chain-of-survival in EMS to include not only high-risk patient groups but also non-critical and general acute patients with non-specific reasons for care. Assessment and on-scene treatment without conveyance can be called the "stretched arm of the emergency department", but should be planned carefully to ensure patient safety.

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

“…Emergency Medical Services (EMSs) and emergency departments (EDs) have reported increased workload [1,2], mainly due to an aging population and difficulties accessing primary care [2]. The role of the EMS has changed to include more non-critical emergency patients [3], and patients are increasingly assessed and treated at the scene by EMSs, avoiding unnecessary conveyance to EDs [4]. Reported non-conveyance rates substantially vary internationally, between 3.7 and 93.7% in the general population [5]; in Finland, the rate is approximately 40% [3,6,7].…”

“…The role of the EMS has changed to include more non-critical emergency patients [3], and patients are increasingly assessed and treated at the scene by EMSs, avoiding unnecessary conveyance to EDs [4]. Reported non-conveyance rates substantially vary internationally, between 3.7 and 93.7% in the general population [5]; in Finland, the rate is approximately 40% [3,6,7].…”

“…The decision-making process for non-conveyance appears to be complex and multifactorial [5]. EMS care providers' higher education level [3,8], EMS arrival time in the evening or at night [3,7,9,10], longer distance to a healthcare facility [7], rural area, younger patient age [3,10,11], low National Early Warning Score (NEWS2), and alcohol use increase the likelihood of nonconveyance [3]. A recent review showed that, after a non-conveyance decision, re-contact with the EMS or the ED, hospitalization and mortality rates varied a lot [5].…”

The Safety of Non-Transport Decisions Made by Ambulance Personnel: A Retrospective Study of Subsequent Hospital Admission and 30-Day Mortality

“…A recent systematic review that included studies from North America, Europe, Australia, Asia, and Africa reported that non-transport rates varied from 4% to 94% [7]. Other studies have found non-transport rates of 40% in Finland [14], 38% in the UK [15], 26.2% in Netherlands [16], 15.5% in Australia [8], 13.8% in Sweden [17], and 12.9% in Denmark [18]. Comparatively, the non-transport rate in our study is low.…”

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: A cohort analysis

“…By its very nature, the ambulance service constitutes a high-risk patient safety environment which provides round-the-clock, year-round care services to a large volume of patients with a wide range of medical complaints [1]. Patients who are not transported to the hospital after an initial assessment by ambulance clinicians, that is, non-conveyed patients in the ambulance service [2], represent a signi cant and increasing proportion of those who seek ambulance services [3][4][5]. The research on patient outcome following non-conveyance is relatively sparse and, to some extent, has contrasting results [6][7][8].…”