Non-conveyance of patients: Challenges to decision-making in emergency care

Abstract

Background: It has been suggested that emergency care providers' decision-making competence should be strengthened regarding whether or not to transport the patient. This qualitative study describes challenges related to non-conveyance situations from emergency care providers' perspective. Methods: Data were collected by a questionnaire from emergency care providers of a hospital district in Finland in 2014. Responses to open questions were analyzed using inductive content analysis to examine the difficulty of non-conveyance decisions, reasons for non-conveyance and challenges related to the non-conveyance decision after immediate care. Results: The majority (70%) of care providers did not experienced difficulty in making non-conveyance decisions, although those working in basic emergence care found decision-making slightly more challenging than workers in advanced emergency care. Care providers' reasons for not transporting patients were most commonly connected with their assessment of care needs and the conclusion that no hospital care was required. Other reasons involved treating the patient on site, psychosocial reasons and not seeing the patient as an emergency care client. Difficulty of reaching mutual understanding with patients was considered the greatest challenge. Other challenges included worrying about the patient's coping at home and problems in inter-professional co-operation, related to hurry and the concern that doctors did not always document requests for care instructions. Conclusions: The results suggest that care providers' skills in assessing care needs and making decisions based on assessments are a decisive factor in non-conveyance situations. Reaching a mutual understanding with the patient is the greatest challenge.

Clinical reasoning in the emergency medical services: an integrative review

“…In this context, a patient’s surrounding environment is an important aspect of this information, as it may provide clues about everyday life and ability to cope. This is especially important when the patient is not deemed to need hospital care [29, 34, 42, 43]. However, there are also descriptions of occasions on which medical history was not obtained and medical examinations not conducted [37].…”

“…This can be exemplified by a clinician who attended a course on assessing myocardial infarction and was more proficient in conducting assessments as a result of taking this course. Another example concerns EMS clinicians who were physically influenced by fatigue, which resulted in poor decision-making regarding assessment and treatment [30, 35, 43, 44, 46–51]. The socioeconomic status of the patient was described as not directly influencing the treatment provided.…”

“…Clinicians need to be able to understand patients’ and relatives’ perspectives, cultural beliefs, and any perceived or expressed wishes regarding medical treatment or the withholding of it. However, it was noted that the more critical a patient’s health condition was, the less the patient’s own views were considered [9, 34, 43, 44, 48, 49]. While EMS clinicians actively seek to involve patients and/or their relatives in decision-making [31, 52], it is also important that they pay attention to their relationship with the patient and any conflict or tension arising [9].…”

Out-of-hospital emergency care providers’ work and clinical skills in Finland: A follow-up study

“…[24] Earlier, patients were more commonly transported to hospital for further care, while nowadays they are often treated on scene. [23,25] Among other things, emergency care providers are expected to be able to assess and prioritize patients, provide emergency treatment, determine the patient's health status and assume an expert role in the management of emergency incidents. [26] The care providers participating in this research rated their competence and individual clinical skills as good.…”

Out‐of‐hospital emergency care providers' work and challenges in a changing care environment

“…A change in out‐of‐hospital emergency care providers' job description has been reported in a few countries, for example in the UK and the USA . Nowadays, an assessment of the situation is conducted on the basis of the patient's condition in order to identify the possibility of treating the patient on site instead of hospital . It has been reported that out‐of‐hospital emergency care providers have treated patients without transportation to hospital in cases where the patient had a minor trauma, blunt injury to the head or face or no illness or injury .…”