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

An analysis of characteristics and associated factors for re-contacts after EMS non-conveyance: a retrospective cohort study in the Netherlands

BACKGROUND

Non-conveyed patients are a significant population within ambulance care. To gain insight in patient safety for this population, ambulance re-contacts within 72 h are monitored. However, little is known about the background of these non-conveyance cases with a re-contact. This study aims to investigate the incidence of re-contacts, analyse characteristics, and identify factors associated with re-contacts following non-conveyance.

METHODS

This was a retrospective cohort study of all non-conveyance cases and all associated re-contacts in two EMS regions in the Netherlands, Gelderland-Zuid and Gelderland-Midden. Data was collected from 1 January 2022 till 31 December 2022. Characteristics of non-conveyance cases with and without a re-contact within 72 h were compared and differences were analysed univariately. Logistic regression analyses were used to quantify bivariate and multivariable associations between characteristics of non-conveyance cases and EMS re-contact within 72 h. Associations are expressed in odds ratios with 95% confidence interval.

RESULTS

In the analysis of 19.563 cases, the overall incidence for an EMS re-contact within 72 h was 5.0% (N = 984/19.563), with 3.4% (669/19.563) within 24 h, 1.0% (195/19.563) within 24-48 h and 0.6% (120/19.563) within 48-72 h. In a subset of 13.010 complete cases, significant multivariable associations were observed between re-contacts and age > 65 (OR 2.15, CI 1.82-2.53), male gender (OR 1.39, CI 1.18-1.63), and medical complaints related to specialism 'Pulmonology' (OR 2.45, CI 1.67-3.64), 'Neurology' (OR 1.81, CI 1.28-2.59) and 'Traumatology/surgery' (OR 0.51, CI 0.34-0.76). Other significant associations were noted with night-time cases (OR 1.49, CI 1.21-1.82) and cases in which consultation or handover to a general practitioner occurred (OR 1.25, CI 1.06-1.47).

CONCLUSIONS

A low overall incidence of EMS re-contacts indicates that non-conveyance within the EMS system is relatively safe. The likelihood of re-contact is higher for age above 65, male gender, and medical complaints within the specialisms of 'Pulmonology' and 'Neurology'. Non-conveyance cases that involve consultation or handover to a GP and cases occurring at night are also more likely to have a re-contact. The findings inform non-conveyance decision-making, and could serve as a starting point to adapt EMS curricula, and develop guidelines and protocols. This may fuel the enhancement of non-conveyance decision-making, thereby improving the quality of healthcare within the EMS system.

Exploring care pathways of patients conveyed by emergency medical services (EMS) through electronic health records

BACKGROUND

Emergency Medical Services (EMS) and Emergency Departments (ED) have reported increased patient volumes in the last decades. Despite high rates of non-conveyance decisions, unnecessary conveyances by EMS still occur. The aim of this study was to explore care pathways of conveyed patients by EMS through registry data.

METHODS

This was a retrospective cohort study of EMS patients in Finland. The primary outcomes were EMS recontacts and visits to a primary health care facility or ED within seven days. The secondary outcome was mortality within one week. Univariate and multivariable associations between the outcome variables and categorical variables were analysed with logistic regression. Results are presented with odds ratios (ORs) together with 95% confidence intervals (CIs) and p-values.

RESULTS

The conveyed patients' visits to health care facilities were mainly brief. EMS arrival during night-time (20:00-08:00) (OR 1.69; 95% CI 1.59 to 1.80), in urban area (OR 1.21; 95% CI 1.13 to 1.29) and alcohol use (OR 2.55; 95% CI 2.26 to 2.86) predicted short ED visits (< 24 h). 77% of the patients were discharged from primary health care within one hour (median 22 min, IQR 18-60). After EMS conveyance and visit to the ED or primary health care facility, 10.5% of the patients were readmitted within one week. Non-urgent patients (OR 1.26; 95% CI 1.14 to 1.39), an EMS mission at night (OR 1.36; 95% CI 1.24 to 1.50), and based on univariate analyses, the usage of alcohol (OR 1.26; 95% CI 1.09 to 1.45) increased the likelihood of a readmission. 449 patients of all conveyed EMS patients (n = 20376) died within one week (2.2%).

CONCLUSIONS

EMS non-conveyance reduces patient flow in EDs, but there is a possibility that more could be done related to unnecessary conveyances to health care facilities, especially in urban areas and at night. The pathway analyses of post conveyance re-contacts show that a small number of patients burden the system. Further in-depth studies are needed to understand of unnecessary conveyances, find solutions, and provide repeated users the appropriate care.

Is non-conveyance solo-ambulances a useful mean to meet the increasing demand for emergency medical services in Denmark?

BACKGROUND

The growing demand for acute medical assistance creates an increasing pressure on emergency medical services (EMS) and emergency departments. This calls for initiatives to prevent avoidable admissions. A novel non-conveyance solo-ambulance was introduced in the Central Denmark Region; the Prehospital Visitation Unit (PVU). We investigated patient characteristics and prehospital management by the PVU, while exploring employee perspectives on the implementation process and how they perceived their expanded role and responsibilities working with the PVU.

METHODS

This mixed-methods study had a convergent parallel design. Patient data was collected on all patients assessed by the PVU between April 1st 2022 and April 1st 2023. Furthermore, 19 semi-structured interviews with paramedics, EMS dispatchers and technical dispatchers partaking in the operation of the PVU were conducted. Interviews were analyzed using thematic analysis with an inductive approach, drawing on principles from grounded theory.

RESULTS

Throughout the study period, the PVU served 1510 patients (median age: 60, IQR: 33-77). Among these, 83.6% were assigned an urgency level B, indicating acute, but not life-threatening, situations. Patients presented with a broad range of complaints, including a high number of patients with non-specific complaints. Paramedics completed treatment on-scene for 29.1% of all patients, spending a median time of 49 min (IQR: 33-64) on-scene. In the interviews, four themes were identified: (1) The implementation strategy had gaps, but was supported by ongoing adjustments, (2) Facilitating a patient-centered approach for the benefit of the patient and the system, (3) Community partnership and internal collaboration enabled paramedics as healthcare facilitators, and (4) Flexible workflows were needed to maintain professional agency.

CONCLUSIONS

The PVU seems to offer a valuable alternative within the EMS, particularly for patients with non-specific complaints and conditions manageable at a lower level of care. Strong collaboration allowed paramedics to take on a facilitating role, creating appropriate pathways and providing patient-centered care. However, for successful implementation, ongoing adjustments were required, particularly in maintaining the professional autonomy of the healthcare professionals. As prehospital EMS increasingly respond to non-acute medical needs, initiatives like the PVU can play an important role in meeting growing demands.

Factors influencing paramedic conveyance decisions when attending children with minor head injury: a qualitative study

INTRODUCTION

Children with head injury are commonly transported to the ED by ambulance. However, most of those conveyed are deemed non-serious and are discharged at triage. Research is needed to explore the factors that influence paramedics when deciding to convey children with minor head injury to the ED, and to establish whether a clinical decision tool designed to support them would be beneficial.

METHODS

A generic qualitative approach, comprising semistructured interviews with front-line ambulance paramedics working in the UK. Interviews were audio-recorded and transcribed. Data were analysed using reflexive thematic analysis. Interviews aimed to explore the factors that influence paramedics when deciding to convey children with minor head injury to the ED.

RESULTS

A total of 20 paramedics from several ambulance services participated in interviews. Three overarching themes were identified: 'we just take them in'; 'there are too many hurdles'; 'creating the right tool'. These were further categorised into subthemes. Paramedics do not feel confident when assessing and managing children with head injury, and convey children to hospital due to fear of consequences, despite knowing there will be no intervention in the ED. Further education, a prehospital paediatric clinical decision tool and greater support from Ambulance Trusts would be welcomed by paramedics. Criteria such as: parental anxiety; time; wound closure; policy and non-accidental injury need to be considered in a clinical decision tool designed to support paramedics' management of children with head injury.

CONCLUSION

Paramedics generally feel a lack of confidence in assessing and managing children with head injury. A decision tool, coupled with training and useful feedback from EDs following conveyance, would be useful to help improve decision-making.

Patient complaints are not common in emergency medical services: A mixed methods study

INTRODUCTION

Patient safety has become a central research theme in emergency medical services (EMS). The population age structure is changing in high-income countries, potentially causing increases in the need for EMS. As the number of EMS missions is growing, the safety of non-conveyance has become the topic of wide discussion. Managing adverse events is part of quality management and safety improvement. This study aimed to examine the incidence, reasons, and process of complaints related to EMS.

METHODS

A retrospective mixed methods study was conducted on EMS-related complaints that were evaluated by Regional State Administrative Agency during 2013-2019. The data was classified according to conveyance and authority's decision, and finally analysed thematically.

RESULTS

The data included 73 complaints, 39 of which were included in the study. There were more complaints related to non-conveyance than conveyance. The authority provided administrative guidance in approximately half of the cases in both groups. One of the most common event types in both groups was related to ethical competence and conduct.

CONCLUSIONS

The number of complaints was very low. A considerable portion of the complaints related to paramedics' behavior and patient treatment. Respecting and actively listening to patients may further decrease these complaints. No administrative caveats to paramedics were observed in our data.

The experiences of patients not conveyed after evaluation by emergency medical services in Southwest Finland - A qualitative survey study

BACKGROUND

The amount of non-critical Emergency Medical Services missions has been increasing. After examination and treatment, paramedics can decide, based on guidelines, not to convey the patient to a healthcare facility. This study aimed to investigate patients' experiences in non-conveyance situations in Southwest Finland. Our research questions were: 1) Which patient concerns were not addressed? 2) What key actions improved patient comfort? and 3) What possible enhancements could make the patient experience more positive?

METHODS

This was a qualitative survey study. In March 2023, all the patients who met the inclusion criteria (N = 1017) received a survey via mail. The data from three open-ended questions were analyzed using inductive content analysis.

RESULTS

The response rate was 22.2 % (n = 226). The unaddressed patient concerns were related to inadequate immediate care and guidance and non-clinical factors causing concern. Key actions for improved patient comfort were related to immediate treatment and guidance, as well as non-clinical factors that impact the patient experience. More thorough treatment processes and more attentive encounters would have enhanced the patient experience.

CONCLUSIONS

Predominantly, patients reported having received excellent services. Utilizing paramedics' soft skills and keeping the patient as the central focus is key to improving the non-conveyance process and experience.

'Blue-lighting' seizure-related needs in care homes: a retrospective analysis of ambulance call-outs for seizures in North West England (2014-2021), their management and costs, with community comparisons

OBJECTIVES

With a projected rise in care home residency and the disproportionate impact of epilepsy and seizures on older adults, understanding seizure-related needs in this population is crucial. Data silos and inconsistent recording of residence status make this challenging. We thus leveraged ambulance data to investigate seizure call-out incidence, characteristics, management and costs in care homes compared with the wider community.

DESIGN

Retrospective analysis of dispatch data from a regional English ambulance service over four 9-month periods between 2014/2015 and 2021/2022. Suspected seizures in adults (≥16 years) were identified, with data on location, patient age, severity and management extracted. Incidence rates, trends over time and case characteristics were compared. Costs of ambulance response were estimated, and factors influencing emergency department (ED) conveyance were analysed using logistic regression.

SETTING

North West Ambulance Service National Health Service Trust, serving an adult population of ~5.5 million.

PARTICIPANTS

Dispatch data for 98 752 suspected seizure cases.

RESULTS

Care homes, accommodating ~0.8% of the regional population, accounted for 7.2% of seizure call-outs. Incidence was higher in care homes than the wider community (55.71 vs 5.97 per 1000 person/year in 2021/2022) and increased over time. Care home cases peaked around 8:00-9:00. Despite similar or lower severity, they had a higher ED conveyance rate (78.3% vs 70.6%). Conveyance likelihood was influenced by factors beyond severity: reduced in homes specialising in learning disabilities (adjusted OR=0.649) and increased in homes with nursing provision (adjusted OR=1.226). Care homes accounted for 7.26% of the £24 million cost.

CONCLUSIONS

This study highlights the growing seizure-related needs in care homes. Despite similar severity, most cases result in ED conveyance. Future research should examine the appropriateness and implications of these transfers, ensuring specialist services support the care home population effectively.

Treat and release: an observational study of non-conveyed high-acuity dispatches in a Danish emergency medical system

Non-conveyance refers to the practice of treating a patient on-site without transporting them to a medical facility. It may decrease unnecessary hospital transfers and improve patient satisfaction. Nonetheless, ensuring patient safety remains paramount. The objective of the study was to assess admission to hospital and mortality in non-conveyed patients. This population-based cohort study included all high-acuity dispatches in Region Zealand, Denmark between 2019 and 2022. The primary outcome was admission within 48 h, and the secondary outcome was 30-day mortality. Descriptive statistical analyses were conducted, and logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals. A non-conveyance rate of 14% was identified in 95,238 transports. Admission within 48 h was seen in 22% of non-conveyed patients vs. 95% in conveyed patients, p < 0.001. The adjusted analysis showed a decreased likelihood of admission within 48 h within non-conveyed patients, with an aOR of 0.01 95% CI (0.01-0.01). Non-conveyed patients had a crude 30-day mortality rate of 2 vs. 6% among conveyed patients, p < 0.001. The adjusted analysis showed an increased likelihood of 30-day mortality in non-conveyed patients with an odds ratio of 1.21, 95% CI (1.05-1.40). Non-conveyed patients constitute a substantial proportion of patients assessed by ambulances following high-acuity dispatch. Less than one in four non-conveyed patients were admitted within 48 h. Despite the low crude mortality in this study, an increased likelihood of mortality was found within the non-conveyed population. However, additional investigation is warranted in future research.

Ambulance quality and outcome measures for general non-conveyed populations (AQUA): A scoping review

BACKGROUND

An increasing number of patients receive ambulance care without being conveyed to a definitive care provider. This process has been described as complex, challenging, and lacking in guideline support by EMS clinicians. The use of quality- and outcome measures among non-conveyed patients is an understudied phenomenon.

AIM

To identify current quality- and outcome measures for the general population of non-conveyed patients in order to describe major trends and knowledge gaps.

METHODS

A scoping review of peer-reviewed original articles was conducted to identify quality- and outcome measures for non-conveyance within emergency medical services. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement (PRISMA-ScR) was followed. The PROSPERO and OSF database were checked for pending reviews or protocols. PubMed, CINAHL, Scopus, Web of Science and the Cochrane Library database were searched for relevant articles. Searches were performed in November 2023.

RESULTS

Thirty-six studies fulfilled the inclusion criteria and were included in the review. Mortality was the most used outcome measure, reported in 24 (67%) of the articles. Emergency department attendance and hospital admission were the following most used outcome measures. Follow-up durations varied substantially between both measures and studies. Mortality rates were found to have the longest follow-up times, with a median follow-up duration a little bit over one week.

CONCLUSIONS

This scoping review shows that studies report a wide range of quality and outcome measures in the ambulance setting to measure non-conveyance. Reported quality and outcome measures were also heterogeneous with regard to their follow-up timeframe. The variety of approaches to evaluate non-conveyance poses challenges for future research and quality improvement. A more uniform approach to reporting and measuring non-conveyance is needed to enable comparisons between contexts and formal meta-analysis.

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Emergency Call versus General Practitioner Requested Ambulances - Patient Mortality, Disease Severity and Pattern

Introduction

Ambulance requests by general practitioners for primary care patients (GP-requested) are often omitted in studies on increased demand within emergency care but may comprise a substantial patient group. We aimed to assess acute severity, intensive care unit (ICU) admission, and diagnostic pattern, including comorbidity, and mortality among GP-requested ambulance patients, compared to emergency call ambulance patients. Our hypothesis was that emergency call patients had more severe health issues than GP-requested ambulance patients.

Methods

Historic population-based cohort study of ambulance patients in the North Denmark Region, 2016-2020. Hospital contact data including diagnoses, ambulance data, vital signs and vital status was linked using each patient's unique identification number. Primary outcome measure was mortality within 1, 7, and 30 days. Secondary outcomes were disease severity expressed as modified National Early Warning Score (NEWS2), and ICU admission. Admission status and hospital diagnostic pattern, including comorbidity were described and compared.

Results

We included 255,487 patients. GP-requested patients (N = 119,361, 46.7%) were older (median years [IQR] 73 [58-83] versus 61 [37-76]) and more had moderate/severe comorbidity (11.9%, N = 13,806 versus 4.9%, N = 6145) than the emergency call patients. Prehospital mNEWS2 median scores were lower for GP-requested patients. For both groups, mNEWS2 was highest among patients aged 66+. GP-requested patients had higher 30-day mortality (9.0% (95% CI: 8.8-9.2), N = 8996) than emergency call patients (5.2% (95% CI: 5.1-5.4), N = 6727). Circulatory (12.0%, 11,695/97,112) and respiratory diseases (11.6%, 11,219/97,112) were more frequent among GP-requested patients than emergency call patients ((10.7%, 12,640/118,102) and (5.8%, 6858/118,102)). The highest number of deaths was found for health issues 'circulatory diseases' in the emergency call group and 'other factors' followed by "respiratory diseases" in the GP-requested group.

Conclusion

GP-requested patients constituted nearly half of the EMS volume, they were older, with more comorbidity, had serious conditions with substantial acute severity, and a higher 30-day mortality than emergency call patients.

Service users' preferences and feasibility - which alternative care pathway for adult ambulance users achieves the optimal balance? Workshops for the COLLABORATE project

INTRODUCTION

Adults presenting to the ambulance service for diagnosed epilepsy are often transported to emergency departments (EDs) despite no clinical need. An alternative care pathway (CP) could allow paramedics to divert them from ED and instigate ambulatory care improvements. To identify the most promising CP configuration for subsequent testing, the COLLABORATE project surveyed people with epilepsy and family/friends who had recently used the English ambulance service to elicit preferences for 288 CP configurations for different seizures. This allowed CPs to be ranked according to alignment with service users' preferences. However, as well as being acceptable to users, a CP must be feasible. We thus engaged with paramedics, epilepsy specialists and commissioners to identify the optimal configuration.

METHODS

Three Knowledge Exchange workshops completed. Participants considered COLLABORATE's evidence on service users' preferences for the different configurations. Nominal group techniques elicited views on the feasibility of users' preferences according to APEASE criteria. Workshop groups specified the configuration/s considered optimum. Qualitative data was analysed thematically. Utility to users of the specified CP configurations estimated using the COLLABORATE preference survey data.

RESULTS

Twenty-seven participants found service users' preferences broadly feasible and outlined delivery recommendations. They identified enough commonality in preferences for different seizures to propose a single CP. Its configuration comprised: 1) patients staying where they were; 2) paramedics having access to medical records; 3) care episodes lasting <6 h; 4) paramedics receiving specialist advice on the day; 5) patient's GP being notified; and 6) a follow-up appointment being arranged with an epilepsy specialist. Preference data indicated higher utility for this configuration compared to current care.

DISCUSSION

Stakeholders are of the view that the CP configuration favoured by service users could be NHS feasible. It should be developed and evaluated.

Developing an alternative care pathway for emergency ambulance responses for adults with epilepsy: A Discrete Choice Experiment to understand which configuration service users prefer. Part of the COLLABORATE project

INTRODUCTION

To identify service users' preferences for an alternative care pathway for adults with epilepsy presenting to the ambulance service.

METHODS

Extensive formative work (qualitative, survey and knowledge exchange) informed the design of a stated preference discrete choice experiment (DCE). This hypothetical survey was hosted online and consisted of 12 binary choices of alternative care pathways described in terms of: the paramedic's access to medical records/ 'care plan', what happens next (described in terms of conveyance), time, availability of epilepsy specialists today, general practitioner (GP) notification and future contact with epilepsy specialists. DCE scenarios were described as: (i) typical seizure at home. (ii) typical seizure in public, (iii) atypical seizure. Respondents were recruited by a regional English ambulance service and by national public adverts. Participants were randomised to complete 2 of the 3 DCEs.

RESULTS

People with epilepsy (PWE; n = 427) and friends/family (n = 167) who completed the survey were representative of the target population. PWE preferred paramedics to have access to medical records, non-conveyance, to avoid lengthy episodes of care, availability of epilepsy specialists today, GP notification, and contact with epilepsy specialists within 2-3 weeks. Significant others (close family members or friends) preferred PWE experiencing an atypical seizure to be conveyed to an Urgent Treatment Centre and preferred shorter times. Optimal configuration of services from service users' perspective far out ranked current practice (rank 230/288 possible configurations).

DISCUSSION

Preferences differ to current practice but have minimal variation by seizure type or stakeholder. Further work on feasibility of these pathways in England, and potentially beyond, is required.

Epidemiology of prehospital emergency calls according to patient transport decision in a middle eastern emergency care environment: Retrospective cohort-based

Background and Aim

Though emergency medical services (EMS) respond to all types of emergency calls, they do not always result in the patient being transported to the hospital. This study aimed to explore the determinants influencing emergency call-response-based conveyance decisions in a Middle Eastern ambulance service.

Methods

This retrospective quantitative analysis of 93,712 emergency calls to the Hamad Medical Corporation Ambulance Service (HMCAS) between January 1 and May 31, 2023, obtained from the HMCAS electronic system, was analyzed to determine pertinent variables. Sociodemographic, emergency dispatch-related, clinical, and miscellaneous predictors were analyzed. Descriptive, bivariate, ridge logistic regression, and combination analyses were evaluated.

Results

23.95% (N = 21,194) and 76.05% (N = 67,285) resulted in patient nontransport and transportation, respectively. Sociodemographic analysis revealed that males predominantly activated EMS resources, and 60% of males (n = 12,687) were not transported, whilst 65% of females (n = 44,053) were transported. South Asians represented a significant proportion of the transported patients (36%, n = 24,007). "Home" emerged as the primary emergency location (56%, n = 37,725). Bivariate analysis revealed significant associations across several variables, though multicollinearity was identified as a challenge. Ridge regression analysis underscored the role of certain predictors, such as missing provisional diagnoses, in transportation decisions. The upset plot shows that hypertension and diabetes mellitus were the most common combinations in both groups.

Conclusions

This study highlights the nuanced complexities governing conveyance decisions. By unveiling patterns such as male predominance, which reflects Qatar's expatriate population, and specific temporal EMS activity peaks, this study accentuates the importance of holistic patient assessment that transcends medical histories.

Characteristics and Outcomes of Patients Referred to a General Practitioner by Victorian Paramedics

OBJECTIVE

Many patients who are attended by paramedics do not require conveyance to an emergency department (ED). Our study focuses on comparing the characteristics and outcomes of patients who were advised to follow up with a general practitioner (GP) by an attending paramedic with those of patients who were discharged at scene or transported to hospital.

METHODS

This was a retrospective data linkage cohort study of ambulance, ED, hospital admission, and death records for all adults attended by paramedics in Victoria, Australia between the 1st of January 2015 and 30th of June 2019. Patients were excluded if they presented in cardiac arrest, resided in a residential aged care facility, or were receiving palliative care services. Outcomes of interest included reattendance by ambulance, ED presentation; and, a high acuity outcome which we defined as a patient who (1) presented to ED and received an Australasian Triage Scale of category 1 (Resuscitation) or 2 (Emergency) AND was admitted to a ward OR (2) was admitted to an Intensive Care Unit, Coronary Care Unit or Catheter laboratory (regardless of triage category) OR (3) died. Outcomes of interest were considered within 48-h of initial EMS attendance.

RESULTS

A total of 1,777,950 cases were included in the study of which 3.1% were referred to a GP, 9.0% were discharged at scene without a follow-up recommendation, and 87.9% were transported to hospital. Patients referred to a GP were more likely than those discharged at scene to subsequently present to an ED within 48 h of their attendance (5.3% vs 3.8%). However, GP referral was not associated with any change to high acuity outcome (0.3% vs 0.2%) or ambulance reattendance (6.0% vs 6.0%) compared to discharge at scene. The only factors that were associated with ambulance reattendance, ED presentation, and a high acuity outcome were male gender and elevated temperature.

CONCLUSIONS

Despite increasing low and medium-acuity casework in this EMS system, paramedic referral to a GP is not common practice. Referring a patient to a GP did not reduce the likelihood of patients experiencing a high acuity outcome or recalling an ambulance within 48 h, suggesting opportunity exists to refine paramedic to GP referral practices.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

OBJECTIVE

Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care.

DESIGN

Systematic mapping review and narrative synthesis.

DATA SOURCES

Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED.

ELIGIBILITY CRITERIA

Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury.

DATA EXTRACTION AND SYNTHESIS

We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis.

RESULTS

Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories.

CONCLUSION

Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project

PURPOSE

Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation.

METHOD

Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis.

RESULTS

Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital.

CONCLUSION

Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.

Paramedic Education and Training for the Management of Patients Presenting with Low-Acuity Clinical Conditions: A Scoping Review

Ambulance services around the world are increasingly attending to calls for non-emergency conditions. These lower-acuity conditions do not always require patients to be transported to the emergency department. Consequently, over the past two decades, ambulance services have implemented strategies to support paramedics in diverting non-urgent patients to alternative care pathways. However, assessing and managing low-acuity conditions can be challenging for paramedics, especially when education and training has traditionally focussed on emergency care. This scoping review explores the education and training provided to paramedics on low-acuity clinical conditions and the use of alternative care pathways. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was applied. The databases searched included Scopus, CINAHL, Embase, Emcare, and MEDLINE (PubMed). The search identified one-hundred sixty-six records, with a total of nine articles reviewed after the removal of duplicates and the screening process. The articles were diverse, with education and training ranging from university degrees for extended care practitioners to short in-service-based training for a suite of protocols or assessment tools. However, the literature addressing education and training on low-acuity conditions and alternative care pathways is limited, with the type and length of education programs appearing to influence practice. There is a need for further research to establish a low acuity education model.

Raring to go? A cross-sectional survey of student paramedics on how well they perceive their UK pre-registration course to be preparing them to manage suspected seizures

BACKGROUND

Paramedics convey a high proportion of seizure patients with no clinical need to emergency departments (EDs). In a landmark study, only 27% of UK paramedics reported being "Very…"/ "Extremely confident" making seizure conveyance decisions. Improved pre-registration education on seizures for paramedics is proposed. Clarity is needed on its potential given recent changes to how UK paramedics train (namely, degree, rather than brief vocational course). This study sought to describe UK student paramedics' perceived readiness to manage seizures and educational needs; compare this to what they report for other presentations; and, explore subgroup differences.

METHODS

Six hundred thirty-eight students, in year 2 or beyond of their pre-registration programme completed a cross-sectional survey. They rated perceived confidence, knowledge, ability to care for, and educational needs for seizures, breathing problems and, headache. Primary measure was conveyance decision confidence.

RESULTS

For seizures, 45.3% (95% CI 41.4-49.2) said they were "Very…"/"Extremely confident" to make conveyance decisions. This was similar to breathing problems, but higher than for headache (25.9%, 95% CI 22.6-29.5). Two hundred and thirty-nine participants (37.9%, 95% CI 34.1-41.8) said more seizure education was required - lower than for headache, but higher than for breathing problems. Subgroup differences included students on university-based programmes reporting more confidence for conveyance decisions than those completing degree level apprenticeships.

CONCLUSIONS

Student paramedics report relatively high perceived readiness for managing seizures. Magnitude of benefit from enhancements to pre-registration education may be more limited than anticipated. Additional factors need attention if a sizeable reduction to unnecessary conveyances for seizures is to happen.

Patient factors associated with conveyance decision-making by Emergency Medical Services professionals in patients with a syncope: a cross-sectional factorial survey design

BACKGROUND

The clinical decision-making of non-conveyance is perceived as complex and difficult by emergency medical services (EMS) professionals. Patients with a transient loss of consciousness (TLOC) based on syncope constitute a significant part of the non-conveyance population. Risk stratification is the basis of the clinical decision-making process by EMS professionals. This risk stratification is based on various patient factors. This study aimed to explore patient factors significantly associated with conveyance decision-making by EMS professionals in patients with a TLOC based on syncope.

METHODS

A cross-sectional vignette study with a factorial survey design was conducted. Patient factors were derived from the "National Protocol Ambulance Care", and all possible combinations of these factors and underlying categories were combined, resulting in 256 unique vignettes (2*4*4*4*2 = 256). Patient factors presented either low-risk or high-risk factors for adverse events. Data were collected through an online questionnaire, in which participants received a random sample of 15 vignettes. For each vignette, the respondent indicated whether the patient would need to be conveyed to the emergency department or not. A multilevel logistic regression analysis with stepwise backward elimination was performed to analyse factors significantly associated with conveyance decision-making. In the logistic model, we modelled the probability of non-conveyance.

RESULTS

110 respondents were included, with 1646 vignettes being assessed. Mean age 45.5 (SD 9.3), male gender 63.6%, and years of experience 13.2 (SD 8.9). Multilevel analysis showed two patient factors contributing significantly to conveyance decision-making: 'red flags' and 'prehospital electrocardiogram (ECG)'. Of these patient factors, three underlying categories were significantly associated with non-conveyance: 'sudden cardiac death < 40 years of age in family history' (OR 0.33, 95% CI 0.22-0.50; p < 0.001), 'cardiovascular abnormalities, pulmonary embolism or pulmonary hypertension in the medical history' (OR 0.62, 95% CI 0.43-0.91; p = 0.01), and 'abnormal prehospital ECG' (OR 0.54, 95% CI 0.41-0.72; p < 0.001).

CONCLUSION

Sudden cardiac death < 40 years of age in family history, medical history, and abnormal ECG are significantly negatively associated with non-conveyance decision-making by EMS professionals in patients with a TLOC based on syncope. Low-risk factors do not play a significant role in conveyance decision-making.

Older patients' perceptions of the Swedish ambulance service: A qualitative exploratory study

BACKGROUND

As worldwide life expectancy increases, the Swedish Ambulance Service is likely to be affected by the demographic shift towards a larger proportion of older persons. An older population tends to increase the demand for ambulances, indicating a need to illuminate older patients' perspective. Thus, the aim of this study was to explore older patients' perceptions of the Swedish Ambulance Service.

METHODS

This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.

RESULTS

Three main descriptive categories emerged to describe the underlying conceptions in the interviews; A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations.

CONCLUSION

Older patients described trust in ambulance clinicians as a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. However, they also criticized the care provided because they questioned the need for certain actions.

Rethinking non-urgent EMS conveyance to ED during night-time - a pilot study in Southwest Finland

BACKGROUND

The amount of emergency medical service missions has increased internationally in recent years, and emergency departments are overcrowded globally. Previous evidence has shown that patients arriving at the emergency department during nighttime (20 - 08) have to wait longer, are more likely to leave without being seen, and often have non-urgent conditions compared to patients arriving during the day. The objective of this pilot study was to examine what kind of patient groups are conveyed as non-urgent to the hospital by emergency medical service during nighttime and what kind of diagnostic tests and medical interventions those patients receive before morning to identify patient groups that could be non-conveyed or directed to alternative points of care.

METHODS

This was a retrospective register study where the information of patients conveyed to university hospital during nighttime (20 - 08) were analyzed. Frequencies of the dispatch codes presenting complaints, medical treatments, and diagnostic tests were calculated. Age significance (under/over 70 years) was also tested.

RESULTS

73.5% of the patients received neither medical treatment nor had diagnostic tests taken before morning. Most of these were patients with mental disorder(s), hip pain/complaint, or laceration/cut. Almost half of the patients with abdominal pain or fever had laboratory tests taken. Patients over 70 years old received more medications and had more diagnostic tests taken than younger patients.

CONCLUSIONS

Some of the low-acuity patients could be non-conveyed or referred to alternative pathways of care to avoid impolitic use of emergency medical service and to reduce the workload of emergency departments. Further research is needed to ensure patient safety for patients who are not conveyed at night.

Decision-making on the fly: a qualitative study of physicians in out-of-hospital emergency medical services

BACKGROUND

Out-of-hospital Emergency Medical Services (OHEMS) require fast and accurate assessment of patients and efficient clinical judgment in the face of uncertainty and ambiguity. Guidelines and protocols can support staff in these situations, but there is significant variability in their use. Therefore, the aim of this study was to increase our understanding of physician decision-making in OHEMS, in particular, to characterize the types of decisions made and to explore potential facilitating and hindering factors.

METHODS

Qualitative interview study of 21 physicians in a large, publicly-owned and operated OHEMS in Croatia. Data was subjected to an inductive content analysis.

RESULTS

Physicians (mostly young, female, and early in their career), made three decisions (transport, treat, and if yes on either, how) after an initial patient assessment. Decisions were influenced by patient needs, but to a greater extent by factors related to themselves and patients (microsystem), their organization (mesosystem), and the larger health system (macrosystem). This generated a high variability in quality and outcomes. Participants desired support through further training, improved guidelines, formalized feedback, supportive management, and health system process redesign to better coordinate and align care across organizational boundaries.

CONCLUSIONS

The three decisions were made complex by contextual factors that largely lay outside physician control at the mesosystem level. However, physicians still took personal responsibility for concerns more suitably addressed at the organizational level. This negatively impacted care quality and staff well-being. If managers instead adopt a learning orientation, the path from novice to expert physician could be more ably supported through organizational demands and practices aligned with real-world practice. Questions remain on how managers can better support the learning needed to improve quality, safety, and physicians' journey from novice to expert.

Decision on non-conveyance of patients suspected of COVID-19 in a novel arrangement with assessment visits by paramedics at home

BACKGROUND

During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality.

METHODS

This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation.

RESULTS

During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents.

CONCLUSIONS

The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety.

Paramedic Education to Support the Use of Low-Acuity Care Pathways: A Scoping Review Protocol

Ambulance services worldwide have transformed over time into health care services that not only attend to life-threatening emergencies, but are also increasingly being utilised for patients with low-acuity or non-urgent illness and injury. As a result, there has been a need to adapt and include mechanisms to assist paramedics in the assessment and management of such patients, including alternative pathways of care. However, it has been identified that education and training for paramedics in the care of low-acuity patients is limited. This study aims to identify potential gaps in the literature and inform further research, paramedic education and training, patient care guidelines, and policy. A scoping review will be conducted utilising the Joanna Briggs Institutes methodology. A range of relevant electronic databases will be searched along with the grey literature, using search terms related to paramedic education for low-acuity patient care pathways. The search results will be screened by two authors and presented in the PRISMA-ScR format, with articles presented in tabular format and analysed thematically. The results of this scoping review will inform further research exploring paramedic education, clinical guidelines, policy and experiences in the management of low-acuity patients.

Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care

Introduction

Ambulance services play a key role in the recognition and care of patients nearing their end of life, yet are expected to recognise and manage these complex presentations often with limited education. Paramedics operate across large geographical areas, meaning education delivery is challenging. Yorkshire Ambulance Service implemented Project Extension for Community Healthcare Outcomes (ECHO), which is the creation of virtual communities of practice to address this problem and increase access to specialist supervision, education and sharing of practice. We undertook a service evaluation of the programme and interviewed paramedics about their experiences with ECHO.

Methods

Semi-structured interviews were conducted with eight ambulance clinicians who took part in the end-of-life care (EoLC) ECHO programme. Thematic analysis and coding was undertaken to identify and develop the emerging themes.

Results

This study identified three key themes: programme structure, factors influencing engagement and professional impact. The provision of a virtual community of practice through Project ECHO was a unique and highly valued experience, which was accessible and allowed for networking, peer support and sharing of practice. The concept of a ripple effect was reported in disseminating learning across the wider team.

Conclusion

The development of virtual communities of practice as a novel educational intervention has the potential to transform clinical supervision and ongoing education for ambulance clinicians who are often isolated by the nature of ambulance services that cover large regions.

Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project

INTRODUCTION

Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not.

METHODS AND ANALYSIS

Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation.

ETHICS AND DISSEMINATION

WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.

Emergency Medical Services Clinicians' Perspectives on Pediatric Non-Transport

OBJECTIVES

Emergency medical services clinicians do not transport one-third of all children assessed, even without official pediatric non-transport protocols. Little is known about how EMS clinicians and caregivers decide not to transport a child. Our objectives were to describe how EMS clinicians currently decide whether or not to transport a child and identify barriers to and enablers of successfully implementing an EMS clinician-initiated pediatric non-transport protocol.

METHODS

We conducted six virtual focus groups with EMS clinicians from the mid-Atlantic. A PhD trained facilitator moderated all groups using a semi-structured moderator guide. Multiple investigators independently coded a deidentified sample transcript. One team member then completed axial coding of the remaining transcripts. Thematic saturation was achieved. Clusters of similar codes were grouped into themes by consensus.

RESULTS

We recruited 50 participants, of whom 70% were paramedics and 28% emergency medical technicians. There was agreement that caregivers often use 9-1-1 for low acuity complaints. Participants stated that non-transport usually occurs after shared decision-making between EMS clinicians and caregivers; EMS clinicians advise whether transport is necessary, but caregivers are responsible for making the final decision and signing refusal documentation. Subthemes for how non-transport decisions were made included the presence of agency protocols, caregiver preferences, absence of a guardian on the scene, EMS clinician variability, and distance to the nearest ED. Participants identified the following features that would enable successful implementation of an EMS clinician-initiated non-transport process: a user-friendly interface, clear protocol endpoints, the inclusion of vital sign parameters, resources to leave with caregivers, and optional direct medical oversight.

CONCLUSIONS

EMS clinicians in our study agreed that non-transport is currently a caregiver decision, but noted a collaborative process of shared decision-making where EMS clinicians advise caregivers whether transport is indicated. Further research is needed to understand the safety of this practice. This study suggests there may be a need for EMS-initiated alternative disposition/non-transport protocols.

Using machine learning to predict subsequent events after EMS non-conveyance decisions

Background

Predictors of subsequent events after Emergency Medical Services (EMS) non-conveyance decisions are still unclear, though patient safety is the priority in prehospital emergency care. The aim of this study was to find out whether machine learning can be used in this context and to identify the predictors of subsequent events based on narrative texts of electronic patient care records (ePCR).

Methods

This was a prospective cohort study of EMS patients in Finland. The data was collected from three different regions between June 1 and November 30, 2018. Machine learning, in form of text classification, and manual evaluation were used to predict subsequent events from the clinical notes after a non-conveyance mission.

Results

FastText-model (AUC 0.654) performed best in prediction of subsequent events after EMS non-conveyance missions (n = 11,846). The model and manual analyses showed that many of the subsequent events were planned before, EMS guided the patients to visit primary health care facilities or ED next or following days after non-conveyance. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-, infection-related and non-specific complaints. 1 in 5 the EMS documentation was inadequate and many of these led to a subsequent event.

Conclusion

Machine learning can be used to predict subsequent events after EMS non-conveyance missions. From the patient safety perspective, it is notable that subsequent event does not necessarily mean that patient safety is compromised. There were a number of subsequent visits to primary health care or EDs, which were planned before by EMS. This demonstrates the appropriate use of limited resources to avoid unnecessary conveyance to the ED. However, further studies are needed without planned subsequent events to find out the harmful subsequent events, where EMS non-conveyance puts patient safety at risk.

Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey

Background

The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene.

Methods

The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others.

Results

A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information.

Conclusions

Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses’ interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved.

Paramedics delivering palliative and end-of-life care in community-based settings: A systematic integrative review with thematic synthesis

BACKGROUND

There is a growing demand for community palliative care and home-based deaths worldwide. However, gaps remain in this service provision, particularly after-hours. Paramedicine may help to bridge that gap and avoid unwanted hospital admissions, but a systematic overview of paramedics' potential role in palliative and end-of-life care is lacking.

AIM

To review and synthesise the empirical evidence regarding paramedics delivering palliative and end-of-life care in community-based settings.

DESIGN

A systematic integrative review with a thematic synthesis was undertaken in accordance with Whittemore and Knafl's methodology. Prospero: CRD4202119851.

DATA SOURCES

MEDLINE, CINAHL, PsycINFO and Scopus databases were searched in August 2020 for primary research articles published in English, with no date limits applied. Articles were screened and reviewed independently by two researchers, and quality appraisal was conducted following the Mixed-Methods Appraisal Tool (2018).

RESULTS

The search retrieved 5985 articles; 23 articles satisfied eligibility criteria, consisting of mixed-methods (n = 5), qualitative (n = 7), quantitative descriptive (n = 8) and quantitative non-randomised studies (n = 3). Through data analysis, three key themes were identified: (1) Broadening the traditional role, (2) Understanding patient wishes and (3) Supporting families.

CONCLUSIONS

Paramedics are a highly skilled workforce capable of helping to deliver palliative and end-of-life care to people in their homes and reducing avoidable hospital admissions, particularly for palliative emergencies. Future research should focus on investigating the efficacy of palliative care clinical practice guideline implementation for paramedics, understanding other healthcare professionals' perspectives, and undertaking health economic evaluations of targeted interventions.

The Health Humanities and Emergency Medical Services (EMS): A Call to Action

In the context of an on-going global pandemic that has demanded increasingly more of our Emergency Medical Services (EMS) clinicians, the health humanities can function to aid in educational training, promoting resilience and wellness, and allowing opportunity for self-expression to help prevent vicarious trauma.As the social, cultural, and political landscape of the United States continues to require an expanded scope of practice from our EMS clinicians, it is critical that the health humanities are implemented as not only part of EMS training, but also as part of continued practice in order to ensure the highest quality patient-centered care while protecting the longevity and resilience of EMS clinicians.

Le numéro commun santé : enjeux et impacts

Les questions relatives aux numéros d’urgence concernent en premier lieu nos concitoyens. Elles relèvent également d’enjeux de société au travers de l’impératif de maintien du fonctionnement du système dans son ensemble. Souvent réduites aux désaccords entre professionnels de l’urgence, il apparaît nécessaire de considérer les constats portés sur le territoire national et d’objectiver les impératifs opérationnels afin d’œuvrer à la mise en place d’un système lisible, simplifié et efficient. La singularité et la complexité des demandes de soins urgents, non programmés, relève d’une prise en charge spécifique. L’instauration d’un numéro commun santé, articulé et interopéré avec les services de secours et de sécurité, répond à un modèle organisationnel cible en lien avec la réalité du besoin en France, principalement constitué par la demande sanitaire. Ainsi, le service d’accès aux soins (SAS), désormais inscrit dans la loi, constitue un objectif central d’amélioration de la prise en charge des patients en situation d’urgence ou nécessitant des soins non programmés ambulatoires. Il répond à la volonté de convergence des professionnels de santé de la ville et de l’hôpital dans un objectif d’efficience grâce à l’adaptation de la réponse sanitaire au besoin de soins réels du patient. Accéder au SAS par le numéro commun santé contribue à la mise en œuvre globale d’un dispositif pertinent au regard des contraintes opérationnelles et médicoéconomiques actuelles.

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

BACKGROUND

The safety of the Emergency Medical Service's (EMS's) non-conveyance decision was evaluated by EMS re-contacts, primary health care or emergency department (ED) visits, and hospitalization within 48 h. The secondary outcome was 28-day mortality.

METHODS

This cohort study used prospectively collected data on non-conveyed EMS patients from three different regions in Finland between June 1 and November 30, 2018. The Adjusted International Classification of Primary Care (ICPC2) as the reason for care was compared to hospital discharge diagnoses (ICD10). Multivariable logistic regressions were used to determine factors that were independently associated with adverse outcomes. Results are presented with adjusted odds ratios (aORs) together with 95% confidence intervals (CIs). Data regarding deceased patients were reviewed by the study group.

RESULTS

Of the non-conveyed EMS patients (n = 11,861), 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalized, and 0.1% died 0-24 h after the EMS mission. The 0-24 h adverse event rate was higher than 24-48 h. After non-conveyance, 32 (0.3%) patients were admitted to an intensive care unit within 24 h. Primary non-urgent EMS mission (aOR 1.49; 95% CI 1.25 to 1.77), EMS arrival at night (aOR 1.82; 95% CI 1.58 to 2.09), ALS unit type vs BLS (aOR 1.43; 95% CI 1.16 to 1.77), rural area (aOR 1.74; 95% CI 1.51 to 1.99), and older patient age (aOR 1.41; 95% CI 1.20 to 1.66) were associated with subsequent primary health care visits (0-24 h).

CONCLUSIONS

Four in five non-conveyed patients did not have any re-contact in follow-up period. EMS non-conveyance seems to be a relatively safe method of focusing ED resources and avoiding ED crowding.

Implementing a person centred collaborative health care model - A qualitative study on patient experiences

BACKGROUND

Collaborative Health Care (CHC) is a unique model in which ambulance services, home health care, hospital care and the national telephone helpline for healthcare in Sweden - Swedish health care direct (SHD1177) collaborate to provide the fastest possible health care for inhabitants living in eleven municipalities in western region of Sweden.

AIM

To explore how patients experience and perceive health care received in the CHC.

METHOD

Qualitative descriptive study using open-ended individual telephone interviews with fifteen community dwelling persons with experiences of care throughthe model CHC were conducted.

RESULTS

Two main categories and six subcategories were identified. The category "Thoughts of time in regard to acute health care" include "CHC leads to shorter waiting time for health care", "Knowledge about the staff working hours" and "To alert or not alert". The category "Thoughts on unplanned health care from CHC" involved "Receiving health care in my home", "Coordination from SHD1177 surprises" and "Accessibility of health care values higher than continuity".

CONCLUSION

Integrated health care models such as CHC are time saving and highly appreciated by community dwelling persons. The benefits of provision of coherent health care like in CHC, addresses the need to implement innovative integrated healthcare models in today's health care.

Non-Conveyance Due to Patient-Initiated Refusal in Emergency Medical Services: A Retrospective Population-Based Registry Analysis Study in Riyadh Province, Saudi Arabia

This research study aimed to investigate the association between demographic and operational factors and emergency medical services (EMS) missions ending in non-conveyance (NC) due to patient-initiated refusal (PIR). We conducted a retrospective population-based registry study by analyzing 67,620 EMS missions dispatched to the scene during 2018 in the Riyadh province. First, the number and percentages of conveyances statuses were calculated. Then, using crude and adjusted linear and logistic regression analysis, we determined which characteristics were predictors of NC due to PIR. We found that 23,991 (34.4%) of missions ended in NC due to PIR, and 5969 ended in EMS-initiated refusal (8.6%). NC rates due to PIR were higher for women, adults, for missions in Riyadh city, during nighttime, for medical emergencies, and for advanced life support (ALS) crews. We also found the following additional predictors significantly associated with the odds of NC due to PIR in crude regression analyses: age category, geographical location, EMS-shift, time of call, emergency type, and response time. We conclude that the NC rate represents half of all missions for patients requesting EMS, and the rate in Riyadh city has increased compared to previous studies. Most NC cases occur for the highest urgency level of medical emergency type in Riyadh city during the nighttime with ALS crews. NC due to PIR involves younger patients more than elderly, and females more than males. This study’s findings have provided empirical evidence that indicate that conducting further studies involving EMS providers, patients, and the public to identify precise and detailed reasons is required.

Nurse's experiences of the caring encounter as single responder in prehospital emergency care

BACKGROUND

In the Swedish emergency medical services, single responder and assessment units have been implemented to meet the increasing need for ambulance assessment and care.

AIM

To describe registered nurseś experiences of care encounters as single responders in the emergency medical services.

METHOD

The study design was descriptive with a qualitative approach. Semi-structured interviews with eight single responders were used together with inductive content analysis.

RESULTS

From the theme which showed the experiences of being a single responder in the caring encounter in the ambulance care "meeting unique human care needs with conscious caution", three categories emerged: Increased risk-awareness, Lack of resource support creates vulnerability and Professional experiences and personal qualities contribute to patient safety.

CONCLUSION

The single responders was aware of their vulnerability and a consistent theme was "caution". Risk assessments had evolved and were constantly present to maintain their own and the patient's safety. In critical patients, the experience of frustration and insufficiency dominated but at the same time there was a sense of meaningfulness. The main experience among all single responders was the feeling of getting close to the patient and responding to them in their own way.

Prehospital risk stratification in patients with chest pain

Objectives

The History, ECG, Age, Risk Factors and Troponin (HEART) Score is a decision support tool applied by physicians in the emergency department developed to risk stratify low-risk patients presenting with chest pain. We assessed the potential value of this tool in prehospital setting, when applied by emergency medical services (EMS), and derived and validated a tool adapted to the prehospital setting in order to determine if it could assist with decisions regarding conveyance to a hospital.

Methods

In 2017, EMS personnel prospectively determined the HEART Score, including point-of-care (POC) troponin measurements, in patients presenting with chest pain, in the north of the Netherlands. The primary endpoint was a major adverse cardiac event (MACE), consisting of acute myocardial infarction or death, within 3 days. The components of the HEART Score were evaluated for their discriminatory value, cut-offs were calibrated for the prehospital setting and sex was substituted for cardiac risk factors to develop a prehospital HEART (preHEART) Score. This score was validated in an independent prospective cohort of 435 patients in 2018.

Results

Among 1208 patients prospectively recruited in the first cohort, 123 patients (10.2%) developed a MACE. The HEART Score had a negative predictive value (NPV) of 98.4% (96.4–99.3), a positive predictive value (PPV) of 35.5% (31.8–39.3) and an area under the receiver operating characteristic curve (AUC) of 0.81 (0.78–0.85). The preHEART Score had an NPV of 99.3% (98.1–99.8), a PPV of 49.4% (42.0–56.9) and an AUC of 0.85 (0.82–0.88), outperforming the HEART Score or POC troponin measurements on their own. Similar results were found in a validation cohort.

Conclusions

The HEART Score can be used in the prehospital setting to assist with conveyance decisions and choice of hospitals; however, the preHEART Score outperforms both the HEART Score and single POC troponin measurements when applied by EMS personnel in the prehospital setting.

Inequalities and short-term outcome among patients assessed as non-urgent in a Swedish ambulance service setting

BACKGROUND

Within the ambulance service, assessment and referral of patients, especially those with non-urgent conditions, is a difficult and complicated task. Studies indicate that 12 to 20 percent of all patients are subjected to non-conveyance and discharged at the scene. There is lack of knowledge of what characterizes conveyed and non-conveyed patients. The aim of this study was to explore non-urgent patients who are conveyed or not conveyed to hospital and the short-term outcome of non-conveyance in a Swedish Ambulance Service setting.

METHODS

This study has a descriptive, cross-sectional design. All patients who were prioritized as non-urgent were eligible for the study and 1,048 patients were followed-up in an administrative data system that stores information about the patients' trajectory in both primary and hospital care.

RESULTS

More women than men were subjected to non-conveyance and most of the non-conveyed patients were left at home out-of-hours. 53% sought care again within 72 h. A large proportion of the non-conveyed patients were assessed as having unspecific symptoms.

CONCLUSIONS

There are prominent gender differences in the context of non-conveyance where unspecific symptoms seem to be the main reason for being left at home. As many of the non-conveyed patients who did not receive any advice about further investigation or intervention sought care again within 72 h, the assessments may be insufficient or inaccurate.

Factors Associated with Emergency Medical Service Reattendance in Low Acuity Patients Not Transported by Ambulance

Background: The decision for emergency medical services (EMS) personnel not to transport a patient is challenging: there is a risk of subsequent deterioration but transportation of all patients to hospital would overburden emergency departments. The aim of this large-scale EMS study was to identify factors associated with an increased likelihood of ambulance reattendance within 48 hours in low acuity patients who were not transported by ambulance.Methods: We conducted a 2-year retrospective cohort study using data from the St John New Zealand EMS between 1 July 2016 and 30 June 2018 to investigate demographic and clinical associations with ambulance reattendance.Results: In total, 83,171 low acuity patients not transported by ambulance were included, of whom 4,512 (5.4%) had an EMS ambulance reattend within 48 hours. There were significant associations between EMS reattendance and patient age, sex, ethnicity, deprivation, and event location. Patients aged 60-74 years old had the highest likelihood of ambulance recall (OR 2.87, 95% CI: 2.51-3.28). Males were more likely to have an EMS ambulance reattend within 48 hours (OR 1.17, 95% CI: 1.09-1.25). Māori and Pacific Peoples had a similar likelihood of EMS recall to European/Others; however, the Asian cohort showed a reduced likelihood of reattendance (OR 0.76, 95% CI: 0.62-0.93).There were significant associations between EMS reattendance and non-transport reason, time spent on scene, event type, clinical acuity level (status), and pain score. Shorter (<30 minutes) on scene times were associated with a decreased likelihood of ambulance reattendance, whereas longer scene times (>45 minutes) were associated with an increased likelihood. Medical events were more likely to require reattendance than accident-related events (OR 1.22, 95% CI: 1.13-1.32). Non-transported patients with a severe pain score (7-10/10) were at increased likelihood of requiring reattendance (OR 1.60, 95% CI: 1.33-1.92).Discussion: The overall low rate of EMS reattendance is encouraging. Further research is needed into the clinical presentation of patients requiring ambulance reattendance within 48 hours to determine if there are early warning signs indicative of subsequent deterioration.

Characteristic patterns of emergency ambulance assignments for older adults compared with adults requiring emergency care at home in Sweden: a total population study

BACKGROUND

Since the vast majority of older adults in Sweden live in their private homes throughout life, the emergency medical services need to adapt accordingly. Hence, we aimed to describe characteristic patterns of dyadic staffed emergency ambulance assignments for older adults aged > 70 years compared with adults aged 18-69 years requiring emergency care at home in Sweden.

METHODS

A descriptive retrospective study was performed using anonymized registry data from the emergency medical services in a region of Sweden during 2017-2018. One-sample χ² test, one-way analysis of variance, and binary logistic regression models were used for investigating group differences. Variables for analysis were age, gender, clinical assessments, on-scene time, priority levels, result of response, and temporal patterns.

RESULTS

Of all included emergency ambulance assignments (n = 28,533), 59.9% involved older adults, of which 53.8% were women. The probability for older adults to receive the highest priority was decreased for both dispatch (p < 0.001, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.59-0.66), and transport priorities (p < 0.001, OR 0.74, 95% CI 0.68-0.80). Older adults were more likely to receive dispatch priority levels 2 (p < 0.001, OR 1.48, 95% CI 1.40-1.56), and 3 (p < 0.001, OR 1.73, 95% CI 1.46-2.06). The older adults were similarly more likely to receive transport priority level 3 (p < 0.001, OR 1.40, 95% CI 1.28-1.52) compared with adults. Age had a small but additive effect in relation to on-scene time (p < 0.001, R² = 0.01, F = 53.82). Distinguishing initial clinical assessments for older adults were circulatory, respiratory, trauma, infection, and nonspecific assessments. Emergency ambulance assignments for older adults were more frequently occurring on Mondays (p < 0.001, χ² = 232.56), and in the 08:00-11:59 interval (p < 0.001, χ² = 1224.08).

CONCLUSION

The issues of the lower priority level preponderance, and the decreased probability for receiving the highest priority warrant further attention in future research and clinical practice.

Patients' aged ≥65 years dispositions during ambulance assignments, including factors associated with non-conveyance to hospital: a longitudinal and comparative study

OBJECTIVES

Patients ≥65 years old represent 30%-50% of all ambulance assignments (AAs), and the knowledge of which care level they are disposed to is limited and diverging. The aim of this study was therefore to describe and compare characteristics of patients' aged ≥65 years dispositions during AA, including determining changes over time and factors associated with non-conveyance to hospitals.

DESIGN

A longitudinal and comparative database study.

SETTING

Ambulance service in a Swedish region.

PARTICIPANTS

32 085 AAs with patients ≥65 years old during the years 2014, 2016 and 2018.

EXCLUSION CRITERIA

AAs with interhospital patient transfers and lack of patients' dispositions data.

OUTCOME MEASURES

Dependent factors: conveyance and non-conveyance to hospitals. Independent factors: age, sex, symptom, triage level, scene, time, day and season.

RESULTS

The majority (n=29 060; 90.6%) of patients' dispositions during AA were conveyance to hospitals. In total, the most common symptoms were circulatory (n=4953; 15.5%) and respiratory (n=4529; 14.1%). A significant increase, p<0.01, of non-conveyance to hospitals was shown during 2014 and 2018, from 801 (7.8%) to 1295 (11.4%). Increasing age was associated with decreasing odds of non-conveyance, 85-89 years (OR=0.85, 95 % CI=0.72 to 0.99) and 90 years or older (OR=0.80, 95 % CI=0.68 to 0.93). Several factors were associated with non-conveyance, for example, symptoms of diabetes (OR=8.57, 95 % CI=5.99 to 12.26) and mental disorders (OR=5.71, 95 % CI=3.85 to 8.48) in comparison with infections.

CONCLUSIONS

The study demonstrates several patient characteristics, and factors associated with non-conveyance to hospitals, such as age, symptom, triage level, scene, time, day and season. The increasing non-conveyance trend highlights the importance of further studies on optimal care levels for patients ≥65 years old.

Translation and further validation of a global rating scale for the assessment of clinical competence in prehospital emergency care

Global rating scales are useful to assess clinical competence at a general level based on specific word dimensions. The aim of this study was to translate and culturally adapt the Paramedic Global Rating Scale, and to contribute validity evidence and instrument usefulness in training results and clinical competence assessments of students undergoing training to become ambulance nurses and paramedics at Swedish and Finnish universities. The study included translation, expert review and inter-rater reliability (IRR) tests. The scale was translated and culturally adapted to clinical and educational settings in both countries. A content validity index (CVI) was calculated using eight experts. IRR tests were performed with five registered nurses working as university lecturers, and with six clinicians working as ambulance nurses. They individually rated the same simulated ambulance assignment. Based on the ratings IRR was calculated with intra-class correlation (ICC). The scale showed excellent CVI for items and scale. The ICC indicated substantial agreement in the group of lecturers and a high degree of agreement in the group of clinicians. This study provides validity evidence for a Swedish version of the scale, supporting its use in measuring clinical competence among students undergoing training to become ambulance nurses and paramedics.

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

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 case-mix 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 non-conveyance 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.

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

Background

Crowding in the emergency department (ED) is a safety concern, and pathways to bypass the ED have been introduced to reduce the time to definitive care. Conversely, a number of low-acuity patients in the ED could be assessed by the emergency medical services (EMS) as requiring a lower level of care. The limited access to primary care in Sweden leaves the EMS nurse to either assess the patient as requiring the ED or to stay at the scene. This study aimed to assess patient characteristics and evaluate the initial assessment by and utilisation of the ambulance triage system and the appropriateness of non-transport decisions.

Methods

A prospective observational study including 6712 patients aged ≥16 years was conducted. The patient records with 72 h of follow-up for non-transported patients were reviewed. Outcomes of death, time-critical conditions, complications within 48 h and final hospital assessment were evaluated. The Mann-Whitney U test, Fisher’s exact test, and Spearman’s rank correlation were used for statistical analysis.

Results

The median patient age was 66 years, and the most common medical history was a circulatory diagnosis. Males received a higher priority from dispatchers and were more frequently assessed at the scene as requiring hospital care. A total of 1312 patients (19.7%) were non-transported; a history of psychiatric disorders or no medical history was more commonly noted among these patients. Twelve (0.9%) of the 1312 patients not transported were later admitted with time-critical conditions. Full triage was applied in 77.4% of the cases, and older patients were triaged at the scene as an ‘unspecific condition’ more frequently than younger patients. Overall, the 30-day mortality was 4.1% (n = 274).

Conclusions

Age, sex, medical history, and presentation all appear to influence the initial assessment. A number of patients transported to ED could be managed at a lower level of care. A small proportion of the non-transported patients were later diagnosed with a time-critical condition, warranting improved assessment tools at the scene and education of the personnel focusing on the elderly population. These results may be useful in addressing resource allocation issues aiming at increasing patient safety.