Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

Abstract

BackgroundThe decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital’s emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest.ObjectiveTo provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions.Data sourcesA mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included.Study eligibility criteriaOnly studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included.SettingPrehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance.Study appraisal and synthesis methodsThe Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a ‘best fit’ framework synthesis approach.ResultsED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male–female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision’s outcomes.ConclusionMany non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.

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

“…Our model also indicates that the non-conveyance decision was more likely made by ALS units, which is consistent with a previous study [13]. ALS units' higher education and competence partly explain these differences in non-conveyance decision making.…”

“…The non-conveyance decision-making process seems to be complex [5] and is influenced by several factors from both the EMS staff and patient perspectives [13]. Non-conveyance is part of the EMS process in all types of EMS systems all over the world with patients of all ages, both men and women [5].…”

“…Non-conveyance is part of the EMS process in all types of EMS systems all over the world with patients of all ages, both men and women [5]. The likelihood of nonconveyance is increased as a result of urgency of mission, the time of day, a longer distance to a healthcare facility [7], the EMS' higher educational level [13], the patients' younger age and a rural area. In contrast, the likelihood of conveyance is increased due to urban areas and patients' older age [11].…”

Patient characteristics, triage utilisation, level of care, and outcomes in an unselected adult patient population seen by the emergency medical services: a prospective observational study

“…However, it is not clear which type of additional training that is needed [23]. Non-transport decisions by EMS nurses are based on several factors, including experience, education, confidence, and guidelines [33]. If non-transported patients with a time-critical diagnosis within 72 h in our study are extrapolated to the whole EMS organisation in the study, then there are 150 non-transported patients with a time-critical condition every year.…”

“…A separate triage system has been proposed for the elderly due to the significantly lower sensitivity for this already vulnerable patient group [49]. Access to past medical records at the scene may aid the EMS nurse in patient assessment, and it has been reported as essential to include a physician consultation for non-transport decisions [33]. An increased set of instruments for the EMS nurse is proposed, containing point of care testing, video access for medical consultation, and a digitalised decision support system targeted at the EMS setting, including medical history with machine learning capabilities for assessments of people of all ages with specific cut-offs for VS.…”