Understanding variation in ambulance service non-conveyance rates: a mixed methods study

Abstract

Background In England in 2015/16, ambulance services responded to nearly 11 million calls. Ambulance Quality Indicators show that half of the patients receiving a response by telephone or face to face were not conveyed to an emergency department. A total of 11% of patients received telephone advice only. A total of 38% of patients were sent an ambulance but were not conveyed to an emergency department. For the 10 large ambulance services in England, rates of calls ending in telephone advice varied between 5% and 17%. Rates of patients who were sent an ambulance but not conveyed to an emergency department varied between 23% and 51%. Overall non-conveyance rates varied between 40% and 68%. Objective To explain variation in non-conveyance rates between ambulance services. Design A sequential mixed methods study with five work packages. Setting Ten of the 11 ambulance services serving > 99% of the population of England. Methods (1) A qualitative interview study of managers and paramedics from each ambulance service, as well as ambulance commissioners (totalling 49 interviews undertaken in 2015). (2) An analysis of 1 month of routine data from each ambulance service (November 2014). (3) A qualitative study in three ambulance services with different published rates of calls ending in telephone advice (120 hours of observation and 20 interviews undertaken in 2016). (4) An analysis of routine data from one ambulance service linked to emergency department attendance, hospital admission and mortality data (6 months of 2013). (5) A substudy of non-conveyance for people calling 999 with breathing problems. Results Interviewees in the qualitative study identified factors that they perceived to affect non-conveyance rates. Where possible, these perceptions were tested using routine data. Some variation in non-conveyance rates between ambulance services was likely to be due to differences in the way rates were calculated by individual services, particularly in relation to telephone advice. Rates for the number of patients sent an ambulance but not conveyed to an emergency department were associated with patient-level factors: age, sex, deprivation, time of call, reason for call, urgency level and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors after adjustment for patient-level factors: the percentage of calls attended by advanced paramedics [odds ratio 1.05, 95% confidence interval (CI) 1.04 to 1.07], the perception of ambulance service staff and commissioners that advanced paramedics were established and valued within the workforce of an ambulance service (odds ratio 1.84, 95% CI 1.45 to 2.33), and the perception of ambulance service staff and commissioners that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78, 95% CI 0.63 to 0.98). Limitations Routine data from ambulance services are complex and not consistently collected or analysed by ambulance services, thus limiting the utility of comparative analyses. Conclusions Variation in non-conveyance rates between ambulance services in England could be reduced by addressing variation in the types of paramedics attending calls, variation in how advanced paramedics are used and variation in perceptions of the risk associated with non-conveyance within ambulance service management. Linking routine ambulance data with emergency department attendance, hospital admission and mortality data for all ambulance services in the UK would allow comparison of the safety and appropriateness of their different non-conveyance rates. Funding The National Institute for Health Research Health Services and Delivery Research programme.

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

“…This population-based retrospective cohort study was conducted in Region Stockholm, Sweden, with the approval of the Regional Ethical Review Board of Stockholm (2017Stockholm ( /2187 and complied with the guidelines speci ed by the Strengthening The Reporting of Observational Studies in Epidemiology (STROBE) statement [16]. The de nition of non-conveyance within the ambulance service which is used by the National Health Service in England, that is, "a term used to describe a 999 call to the ambulance service which results in a decision not to transport the patient to a health-care facility", was applied in this study [2].…”

“…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].…”

Electronic health records in ambulances: the ERA multiple-methods study

“…Rates of non-conveyance in the UK are around 30%, but vary considerably between ambulance services. 10 To enable non-conveyance to happen safely, ambulance clinicians need to be able to decide which patients will benefit from being left at home, to be able to access appropriate referral pathways to alternative care providers and to ensure that appropriate and accurate patient information is passed on to community-based providers.…”

“…We had 2 days in one of the suites. There was about 10 of us in a room, we'd all got one and we were literally going through page by page by page, stage by stage to log onto it and then to do this and then went through, and you've got like, lists of likethere would be about 10 Despite this, the focus group participants did not generally feel that they required more training as the system was not very different from the one that they had been using and was thought to be fairly straightforward to use.…”

Decision making for patients categorised as ‘amber’ in a rural setting

“…This is fuelled by increasing demand and an ageing population that requires more complex care. Minimising the number of unnecessary conveyances to hospital is a strategy to reduce delays and overcrowding (O'Cathain et al, 2018). The potential for paramedics delivering patient care away from the ED has been recognised (Auditor General for Wales, 2013).…”