A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review

Linking health service utilisation and mortality data-unravelling what happens after fall-related paramedic care

BACKGROUND

A randomised controlled trial implemented and evaluated a new model of care for non-transported older fallers to prevent future falls and unplanned health service use. This current study uses linked data to evaluate the effects of the intervention beyond the initial 12-month study period.

METHOD

Study data from an established cohort of 221 adults were linked to administrative data from NSW Ambulance, Emergency Department Data Collection, Admitted Patient Data Collection and Registry of Births, Deaths and Marriages evaluating health service use at 12, 24 and 36 months following randomisation including time to event (health service utilisation) and mortality. Negative binomial and Cox's proportional hazard regression were performed to capture the impact of the study between groups and adherence status.

RESULTS

At 36 months follow-up, 89% of participants called an ambulance, 87% attended the Emergency Department and 91% were admitted to hospital. There were no significant differences in all-cause health service utilisation between the control and intervention group (IG) at 12, 24 and 36 months follow-up. Fall-related health service use was significantly higher within the IG at 12 (IRR:1.40 (95%CI:1.01-1.94) and 24 months (IRR:1.43 (95%CI:1.05-1.95)). Medication use, impaired balance and previous falls were associated with subsequent health service use. Over 40% of participants died by the follow-up period with risk of death lower in the IG at 36 months (HR:0.64, 95%CI:0.45-0.91).

CONCLUSION

Non-transported fallers have a high risk of future health service use for fall and other medical-related reasons. Interventions which address this risk need to be further explored.

A model to explain the challenges of emergency medical technicians' decision making process in emergency situations: a grounded theory

BACKGROUND

To manage life-threatening conditions and reduce morbidity and mortality, pre-hospital's on-scene decision making is an influential factor. Since pre-hospital's decision making is a challenging process, it is necessary to be identified this process. This study was conducted to explore the model of Iranian emergency medical technicians' decision making in emergency situations.

METHODS

This study was applied through grounded theory method using direct field observations and semi-structured interviews. Purposeful sampling with 26 participants including 17 emergency medical technicians including dispatchers, physicians of medical directions, managers and 1 representative for court affairs was performed. Interviews were lasted from October 2018 to July 2019. Corbin and Strauss approach, 2015 (open, axial and selective coding) were used to analyze data.

RESULTS

A paradigm model was developed to explain the relationships among the main categories. Decision making in the context of fear and concern was emerged as the core category. Unclear duties, insufficient authorities and competencies as well as lack of enough decision making's protocols and guidelines were categorized as casual conditions. Other important categories linked to the core category were interactions, feelings and "customer focus approach". Action-interaction strategies were taken by Emergency Medical technicians lead to some negative consequences that can threaten clinical outcome and patient safety.

CONCLUSIONS

Based on the finding of this study, Emergency Medical technicians' decision making in the context of fear and concern, as the core concept of this model, lead to decrease in quality of the pre-hospital services, stakeholders' dissatisfaction, hospital emergency units' overload, decrease in reputation of the Emergency Medical Technicians, threat to patient clinical outcome and patient safety. To prevent of these negative consequences, facilitation of the Emergency Medical Technicians' on-scene decision making is recommended.

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

Background

Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively.

Methods

This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses.

Results

Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients.

Conclusions

Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00548-7.

The updated national research agenda 2021-2026 for prehospital emergency medical services in the Netherlands: a Delphi study

Background

In 2015, a national research agenda was established for Dutch prehospital EMS to underpin the evidence base of care delivery and inform policymakers and funders. The continuously increasing demand for ambulance care and the reorientation towards the role of EMS in recent years may have changed research priorities. Therefore, this study aimed to update the Dutch national EMS research agenda.

Methods

A three-round online Delphi survey was used to explore and discuss different viewpoints and to reach consensus on research priorities (i.e., themes and special interest groups, e.g. patient types who require specific research attention). A multidisciplinary expert panel (n = 62) was recruited in the field of prehospital EMS and delegates of relevant professional organizations and stakeholders participated. In round one, fifty-nine research themes and six special interest groups (derived from several resources) were rated on importance on a 5-point scale by the panel members. In round two, the panel selected their priority themes and special interest groups (yes/no), and those with a positive difference score were further assessed in round three. In this final round, appropriateness of the remaining themes and agreement within the panel was taken into account, following the RAND/UCLA appropriateness method, which resulted in the final list of research priorities.

Results

The survey response per round varied between 94 and 100 percent. In round one, a reduction from 59 to 25 themes and the selection of three special interest groups was realized. Round two resulted in the prioritization of six themes and one special interest group ('Vulnerable elderly'). Round three showed an adequate level of agreement regarding all six themes: 'Registration and (digital) exchange of patient data in the chain of emergency care'; 'Mobile care consultation/Non conveyance'; 'Care coordination'; 'Cooperation with professional partners within the care domain'; 'Care differentiation' and 'Triage and urgency classification'.

Conclusions

The updated Dutch national EMS research agenda builds further on the previous version and introduces new EMS research priorities that correspond with the future challenges prehospital EMS care is faced with. This agenda will guide researchers, policymakers and funding bodies in prioritizing future research projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00971-6.

Characteristics and Outcomes of Pediatric Nonindex Readmission: Evidence From Florida Hospitals

OBJECTIVES

Increasing pediatric care regionalization may inadvertently fragment care if children are readmitted to a different (nonindex) hospital rather than the discharge (index) hospital. Therefore, this study aimed to assess trends in pediatric nonindex readmission rates, examine the risk factors, and determine if this destination difference affects readmission outcomes.

METHODS

In this retrospective cohort study, we use the Healthcare Cost and Utilization Project State Inpatient Database to include pediatric (0 to 18 years) admissions from 2010 to 2017 across Florida hospitals. Risk factors of nonindex readmissions were identified by using logistic regression analyses. The differences in outcomes between index versus nonindex readmissions were compared for in-hospital mortality, morbidity, hospital cost, length of stay, against medical advice discharges, and subsequent hospital visits by using generalized linear regression models.

RESULTS

Among 41 107 total identified readmissions, 5585 (13.6%) were readmitted to nonindex hospitals. Adjusted nonindex readmission rate increased from 13.3% in 2010% to 15.4% in 2017. Patients in the nonindex readmissions group were more likely to be adolescents, live in poor neighborhoods, have higher comorbidity scores, travel longer distances, and be discharged at the postacute facility. After risk adjusting, no difference in in-hospital mortality was found, but morbidity was 13% higher, and following unplanned emergency department visits were 28% higher among patients with nonindex readmissions. Length of stay, hospital costs, and against medical advice discharges were also significantly higher for nonindex readmissions.

CONCLUSIONS

A substantial proportion of children experienced nonindex readmissions and relatively poorer health outcomes compared with index readmission. Targeted strategies for improving continuity of care are necessary to improve readmission outcomes.

Pre-hospital suPAR, lactate and CRP measurements for decision-making: a prospective, observational study of patients presenting non-specific complaints

Background

In the pre-hospital setting, non-urgent patients with non-specific chief complaints pose assessment challenges for the emergency medical systems (EMS). Severely ill patients should be identified among these patients, and unnecessary transport to the emergency department (ED) should be avoided. Unnecessary admissions burden EDs, deplete EMS resources and can even be harmful to patients, especially elderly patients. Therefore, tools for facilitating pre-hospital decision-making are needed. They could be based on vital signs or point-of-care laboratory biomarkers. In this study, we examined whether the biomarker soluble urokinase plasminogen activator receptor (suPAR), either alone or combined with C-reactive protein (CRP) and/or lactate, could predict discharge from the ED and act as a pre-hospital support tool for non-conveyance decision-making.

Methods

This was a prospective, observational study of adult patients with normal or near-normal vital signs transported by an EMS to an ED with a code referring to deteriorated general condition. The levels of suPAR, CRP and lactate in the patients’ pre-hospital blood samples were analysed. The values of hospitalized patients were compared to those of discharged patients to determine whether these biomarkers could predict direct discharge from the ED.

Results

A total of 109 patients (median age: 81 years) were included in the study. Of those, 52% were hospitalized and 48% were discharged from the ED. No statistically significant association was found between suPAR and the ED discharge vs hospitalization outcome (OR: 1.04, 95% CI 0.97–1.13, AUROC: 0.58, 95% CI 0.47–0.69). Adding CRP (AUROC: 0.64, 95% CI 0.54–0.75) or lactate (AUROC: 0.60, 95% CI 0.49–0.71) to the regression models did not improve their diagnostic accuracy. None of the patients with a suPAR value of less than 2 ng/ml were admitted to hospital, while 64% of the patients with a suPAR value of more than 6 ng/ml were hospitalized.

Conclusion

Pre-hospital suPAR measurements alone or combined with CRP and/or lactate measurements could not predict the ED discharge or hospital admission of 109 non-urgent EMS patients with non-specific chief complaints and normal or near-normal vital signs.

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.

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.

Barriers and requirements in the off-line emergency medical protocols implementation in Iranian Pre-hospital system: A qualitative study

BACKGROUND

To avoid making decisions based on the unproven opinions of emergency medical technicians (EMTs), many emergency medical service (EMS) systems rely on emergency medical protocols. As protocol-based on-scene decision-making is influenced by many challenges, identifying these challenges can result in providing appropriate conditions for EMTs' decision-making. Therefore, this study aimed to identify the barriers and requirements in the off-line emergency medical protocols implementation m in the prehospital emergency medical system.

MATERIALS AND METHODS

To conduct this study, qualitative content analysis using 10 field observations, 22 interviews, and 2 rounds of focus group discussions was applied. The duration of interviews lasted from October 2019 to January 2020. The Graneheim and Lundman approach was used to analyze the data.

RESULTS

Seven categories (15 subcategories) including education and awareness (professional training and education and community-based education); attitudes (professional attitude and community attitude); interactions and coordination (interpersonal interactions, organizational interferences, and community's interactions); rules and instructions (instructions and supportive rules); control system (monitoring and evaluation and motivational system); accessibility (recourses and communication); and organization (structure and process) were obtained as the obstacles and challenges in the offline emergency medical protocol implementation in the prehospital system.

CONCLUSIONS

There are many challenges in implementing offline emergency medical protocols in the prehospital emergency system. To achieve the effectiveness and efficiency of offline prehospital emergency protocols, it is necessary to facilitate these challenges and improve the EMTs' knowledge, attitude, and performance through cooperative and skill-based education. The findings of this study can be useful for EMS systems from national to local levels.

The dialogue as decision support; lived experiences of extended collaboration when an ambulance is called

Purpose

This study aimed to describe extended collaboration in situations when an ambulance was called, as experienced by older patients, a significant other, and ambulance- and primary healthcare (PHC) centre personnel.

Methods

The study used a phenomenological reflective lifeworld research (RLR) approach. Participants included in three specific situations with extended collaboration were interviewed: three older patients, one significant other, three ambulance personnel and four personnel at the PHC centre. The transcribed interviews were analysed for meanings of the phenomenon.

Results

The extended collaboration means that decisions were supported through dialogue by bridging knowledge spaces between person, within-team and across-team levels. Through dialogue experience and knowledge were shared and certainty in decisions was increased. The extended collaboration was built on trust, responsibility taken, shared and entrusted, and the common goal of adapted care for the unique patient. A need for further improvement and transparency was elucidated.

Conclusions

The difficulty of making care decisions stresses the importance of available extended collaboration based on the dialogue between patients, significant others, and ambulance- and PHC centre personnel to increase certainty in decisions. Collaboration further requires respectful encounters, trust, responsibility and a common goal of adapting the care for the unique patient.

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.

Do patients suffering an out-of-hospital cardiac arrest present to the ambulance service with symptoms in the preceding 48 h?

AIMS

In-hospital cardiac arrests are often preceded by a period of physiological deterioration that has often gone unnoticed. We proposed that the same might be true for out-of-hospital cardiac arrests (OHCAs) where ambulance crews leave patients at home who then subsequently go on to suffer a cardiac arrest.

METHODS AND RESULTS

We identified all OHCA over a 12-month period that had been seen and assessed by an ambulance crew within the 48 h preceding their cardiac arrest. We retrospectively calculated the patient's NEWS2 score at the time of their initial assessment as a marker of their physiological status and need for hospital admission. Of 1960 OHCA patients, 184 (9.4%) had been assessed by ambulance crews within the preceding 48 h. Excluding those who had been taken to hospital (and then discharged), declined hospital conveyance or were on end-of-life care pathways, 79 (56% of total) were left at home through crew discretion. Thirty-four out of 79 (43%) patients not conveyed had either a NEWS score of 3 in a single parameter or a score of ≥5, which in hospital would mandate an urgent medical review. The most overlooked observation was respiratory rate.

CONCLUSIONS

In total, 1.7% of all OHCA had been assessed in the previous 48 h and inappropriately left at home by ambulance crews. This represents a missed opportunity to avert cardiac arrest. NEWS scoring has the potential to improve pre-hospital triage of these patients and avoid missing the deteriorating patient.

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.

Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care

BACKGROUND

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.

METHODS

The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.

RESULTS

PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.

CONCLUSION

Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Worse Cardiac Arrest Outcomes During The COVID-19 Pandemic In Boston Can Be Attributed To Patient Reluctance To Seek Care

Delays in seeking emergency care stemming from patient reluctance may explain the rise in cases of out-of-hospital cardiac arrest and associated poor health outcomes during the COVID-19 pandemic. In this study we used emergency medical services (EMS) call data from the Boston, Massachusetts, area to describe the association between patients' reluctance to call EMS for cardiac-related care and both excess out-of-hospital cardiac arrest incidence and related outcomes during the pandemic. During the initial COVID-19 wave, cardiac-related EMS calls decreased (-27.2 percent), calls with hospital transportation refusal increased (+32.5 percent), and out-of-hospital cardiac arrest incidence increased (+35.5 percent) compared with historical baselines. After the initial wave, although cardiac-related calls remained lower (-17.2 percent), out-of-hospital cardiac arrest incidence remained elevated (+24.8 percent) despite fewer COVID-19 infections and relaxed public health advisories. Throughout Boston's fourteen neighborhoods, out-of-hospital cardiac arrest incidence was significantly associated with decreased cardiac-related calls, but not with COVID-19 infection rates. These findings suggest that patients were reluctant to obtain emergency care. Efforts are needed to ensure that patients seek timely care both during and after the pandemic to reduce potentially avoidable excess cardiovascular disease deaths.

Identification of new demands regarding prehospital care based on 35,188 missions in 2018

BACKGROUND

Population ageing and increased prevalence of chronic diseases result in the emergence of new demands in prehospital care. The prehospital system is facing an increase of cases without acute threat to life (so-called "non-urgent"), which generates tension due to a higher number of admissions to emergency departments and a greater use of prehospital resources. Our aim is to understand this transition in prehospital activities and to delineate the primary missions performed by paramedics in 2018 with a focus on the population concerned, the severity of cases encountered and the typology of health issues.

METHOD

The study is retrospective, and descriptive, using a statistical description of 35,188 primary missions realized in 2018 in the State of Vaud (Switzerland). The characteristics taken into consideration are the age and gender of patients, as well as the health issue, the severity of cases based on National Advisory Committee for Aeronautics score (NACA score), and the time and place of intervention.

RESULTS

The results describe the primary missions in the State of Vaud in 2018 and show that 87% of missions concern "non-urgent" situations (without acute threat to life). Over half of patients are 65 or older, the highest proportion of health issues, 49%, are medical and only 23% of missions are for traumas. Mission related to mental health issues reach 7% and those for intoxication 6%. Most missions take place between 7:00 am and 6:00 pm (67%), and around 12% of missions lead to the non-transport of the patient.

CONCLUSION

The prehospital sector is confronted with a major transition in terms of patient care. An increase of non-urgent cases is observed, associated with the care of persons aged 65 or more. Our results question the adequacy between the needs in terms of prehospital care and the paramedic profession as it is currently defined, as well as the place of this profession within the health network. Reflecting upon the role of paramedics with respect to the socio-demographic evolution of populations appears necessary, to analyse the adequacy of the paramedics' skills to respond to the current needs.

Emergency department admission and mortality of the non-transported emergency medical service patients: a cohort study from Northern Finland

OBJECTIVES

A high number of emergency medical service (EMS) patients are not transported to hospital by ambulance. Various non-transport protocols and guidelines have been implemented by different EMS providers. The present study examines subsequent tertiary care ED and hospital admission and mortality of the patients assessed and not transported by EMS in Northern Finland and evaluates the factors predicting these outcomes.

METHODS

Data from EMS missions with a registered non-transportation code during 1 January 2018-31 December 2018 were screened retrospectively. EMS charts were retrieved from a local EMS database and data concerning hospital admission and mortality were collected from the medical records of Oulu University Hospital, Oulu, Finland.

RESULTS

A total of 12 530 EMS non-transport missions were included. Of those, a total of 344 (2.7%) patients were admitted to tertiary care ED in 48 hours after the EMS contact, and 229 (1.8%) of them were further admitted to the hospital. Patients with the dispatch code 'abdominal pain', clinical presentation with fever or hyperglycaemia, physician phone consultation and a decision not to transport during night hours were associated with a higher risk of ED admission within 48 hours after EMS contact. Overall 48-hour and 30-day mortalities of non-transported patients were 0.2% (n=25) and 1.0% (n=128), respectively.

CONCLUSION

In this cohort, the rate of subsequent tertiary care ED admission and mortality in the non-transported EMS patients was low. Dispatch code abdominal pain, clinical presentation with fever or hyperglycaemia, physician phone consultation and night-hours increased the risk of ED admission within 48 hours after EMS contact.

Care of frail and older adults: A content analysis of paramedic operational clinical practice guidelines

INTRODUCTION

Frailty rates are increasing with population ageing. In paramedicine, Clinical Practice Guidelines (CPGs) are essential documents that support decision making, yet little evidence exists regarding the support CPGs provide paramedics in the care of frail and older adults.

AIM

To investigate how CPGs support paramedics' care of frail and older adults.

METHODS

CPGs from nine Australasian paramedic services were collected in 2019. Content analysis was used to explore two hundred and thirty-seven individual CPGs for decision support information regarding frail and older adults.

RESULTS

Evidence-based content relating to older adults was sparse compared to paediatric content. Two overarching decision support domains were identified, patient assessment and management. Inconsistent age descriptors were widespread, particularly in pharmacological guidelines. Five service providers' CPGs contained validated assessment instruments for use with older adults.

CONCLUSION

Decision support documentation regarding frail and older adults varies across Australasian paramedic services. Frailty and older adult specific CPGs, and validated assessment instruments suitable to the paramedicine environment could improve paramedic decision making and minimise patient risk. A collaborative approach encompassing service providers and educational institutions is crucial to develop consistent, evidence-based CPGs relevant to older adults.

Experience of using video support by prehospital emergency care physician in ambulance care - an interview study with prehospital emergency nurses in Sweden

Introduction

When in need of emergency care and ambulance services, the ambulance nurse is often the first point of contact for the patient with healthcare. This role requires comprehensive knowledge of the ambulance nurse to be able to assign the right level of care and, if necessary, to provide self-care advice for patients with no further conveyance to hospital. Recently, an application was developed for transmitting real-time video to facilitate consultation between ambulance nurses and prehospital physicians in the role of regional medical support (RMS) for ambulance care. The use of video communication as a complement of medical support when referring to self-care is still an unexplored method in a prehospital setting.

Our study aimed to elucidate ambulance nurses’ experience of video consultation with RMS physician during the assessment of patients considered to be triaged to self-care.

Method

We conducted a qualitative design study using semi-structured interviews with open questions. Twelve ambulance nurses were included in the study. To explore the ambulance nurses’ experience of performing video consultation with RMS physician, in cases when a patient was assessed and triaged to self-care, a content analysis was performed.

Results

A main category emerged from the results: “ Video consultation as decision support in the ambulance care promotes increased patient participation and for the ambulance nurses, it creates a feeling of increased patient safety “. The main category was based and formed on the following categories: “ Simultaneous presence of ambulance nurse and a physician increases patient participation during the assessment resulting in a confident care decision “. “Interprofessional collaboration strengthens the medical assessment”. “Video technology promotes accessibility for patients needs in the ambulance care regardless of emergency level”.

Conclusions

Ambulance nurses experienced that the use of video consultation increases patient involvement and confidence in healthcare when both the ambulance nurse and the physician were present when deciding on self-care advice. The live imaging allowed the ambulance nurse and prehospital physician to reach a consensus on the patient’s current medical care needs, which in turn led to a feeling of increased patient safety for the ambulance nurses.

A qualitative study to identify factors that influence patients' decisions to call Emergency Medical Services for syncope

BACKGROUND

Protocols that support paramedics to assess, treat and refer low-risk syncope (fainting) may allow for ED transport of only high-risk patients. The development and uptake of such protocols is limited by a dearth of information about factors patients consider when deciding to seek EMS care following syncope.

OBJECTIVE

We explored decision-making processes of individuals with syncope regarding whether (or not) to call EMS after fainting as a starting point in the development of prehospital risk-stratification protocols for syncope.

METHODS

Twenty-five Canadian adults (aged 18-65 years) with a history of ≥ 1 syncopal episode were recruited. Individual semi-structured interviews were conducted, recorded, and transcribed. Straussian grounded theory methods were used to identify common themes and a core (overarching) category.

RESULTS

Four themes were identified: (a) previous experiences with the healthcare system (e.g., feeling dismissed), (b) individual patient factors (e.g., age, medical history), (c) attitudes and beliefs (e.g., burdening the health care system, syncope is "not serious"), and (d) contextual factors (e.g., influence of important others, symptom severity). Perceived judgement, including judgement from EMS and negative self-evaluations, was identified as the core category that influenced patients' decisions to seek care.

CONCLUSION

We theorize that, while patients consider many factors in deciding to contact EMS for syncope, previous experiences of feeling judged and unfavorable beliefs about syncope may interfere with patients' receptiveness to traditional EMS protocols for syncope. The findings highlight potential patient needs that program developers may wish to consider in the development of prehospital protocols to improve care and satisfaction among patients with syncope.

Outpatient care in acute and prehospital emergency medicine by emergency medical and patient transport service over a 10-year period: a retrospective study based on dispatch data from a German emergency medical dispatch centre (OFF-RESCUE)

Background

The number of operations by the German emergency medical service almost doubled between 1994 and 2016. The associated expenses increased by 380% in a similar period. Operations with treatment on-site, which retrospectively proved to be misallocated (OFF-Missions), have a substantial proportion of the assignment of the emergency medical service (EMS). Besides OFF-Missions, operations with patient transport play a dominant role (named as ON-Missions). The aim of this study is to work out the medical and economic relevance of both operation types.

Methods

This analysis examined N = 819,780 missions of the EMS and patient transport service (PTS) in the catchment area of the emergency medical dispatch centre (EMDC) Bad Kreuznach over the period from 01/01/2007 to 12/31/2016 in terms of triage and disposition, urban-rural distribution, duration of operations and economic relevance (p < .01).

Results

53.4% of ON-Missions are triaged with the indication non-life-threatening patient transport; however, 63.7% are processed by the devices of the EMS. Within the OFF-Mission cohort, 78.2 and 85.8% are triaged or dispatched for the EMS. 74% of all ON-Missions are located in urban areas, 26% in rural areas; 81.3% of rural operations are performed by the EMS. 66% of OFF-Missions are in cities. 93.2% of the remaining 34% of operations in rural locations are also performed by the EMS. The odds for both ON- and OFF-Missions in rural areas are significantly higher than for PTS (OR_ON 3.6, 95% CI 3.21–3.30; OR_OFF 3.18, 95% CI 3.04–3.32). OFF-Missions last 47.2 min (SD 42.3; CI 46.9–47.4), while ON-Missions are processed after 79.7 min on average (SD 47.6; CI 79.6–79.9). ON-Missions generated a turnover of more than € 114 million, while OFF-Missions made a loss of almost € 13 million.

Conclusions

This study particularly highlights the increasing utilization of emergency devices; especially in OFF-Missions, the resources of the EMS have a higher number of operations than PTS. OFF-Missions cause immensely high costs due to misallocations from an economic point of view. Appropriate patient management appears necessary from both medical and economic perspective, which requires multiple solution approaches.

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.

Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence

Background

The role of ambulance services is shifting, due in part to more intermediate, non-urgent patients who do not require direct emergency department conveyance, yet who cannot be safely left at home alone. Evidence surrounding the safety, effectiveness and efficiency of alternate care routes is not well known.

Methods

This scoping review sought to identify all studies that examined alternate routes of care for the non-urgent “intermediate” patient, as triaged on scene. Search terms for the sample (ambulances, paramedics, etc.) and intervention (e.g. referrals, alternate care route, non-conveyance) were combined. Articles were systematically searched using four databases and grey literature sources (February 2020). Independent researchers screened title-abstract and full text stages.

Results

Of 16,037 records, 41 examined alternate routes of care after triage by the on-scene paramedic. Eighteen articles considered quantitative patient data, 12 studies provided qualitative perspectives while 11 were consensus or opinion-based articles. The benefits of alternative schemes are well-recognised by patients, paramedics and stakeholders and there is supporting evidence for a positive impact on patient-centered care and operational efficiency. Challenges to successful use of schemes included: patient safety resulting from incorrect triage decisions, inadequate training, lack of formal partnerships between ambulance and supporting services, and insufficient evidence to support safe implementation or continued use. Studies often inaccurately defined success using proxies for patient safety (e.g. decision comparisons, rates of secondary contact). Finally, patients expressed willingness for such schemes but their preference must be better understood.

Conclusions

This broad summary offers initial support for alternate routes of care for intermediate, non-urgent patients. Even so, most studies lacked methodologically rigorous evidence and failed to evaluate safe patient outcomes. Some remedies appear to be available such as formal triage pathways, targeted training and organisational support, however there is an urgent need for more research and dissemination in this area.

The experience of non-conveyance following emergency medical service triage from the perspective of patients and their relatives: A qualitative study

BACKGROUND

As many as 25% of all Dutch ambulance emergency service assignments result in non-conveyance of the patient to the hospital. Little is known about how patients and their relatives experience being left at home by an ambulance nurse after an acute request for medical help.

AIM

To gain insight into the experience of patients and their relatives with a high urgency request for ambulance assistance that results in non-conveyance, with the ultimate goal of offering adequate follow-up.

METHOD

A qualitative design based on semi-structured interviews with fifteen patients and seven relatives, conducted between September and November 2018.

RESULTS

Four themes emerged from the thematic analysis: Fear as the prominent emotion, four components of confidence in decision-making, different consequences and coping between patient and relative(s) over time and the perceived need for evaluation afterwards.

CONCLUSION

The experience after non-conveyance has several phases in which fear, reassurance, confirmation (for relatives) and shame (for patients) follow each other throughout the care process. Complex interpersonal skills of ambulance nurses congruent with the concept of person-centred care can modulate this impact. These findings offer starting points for the optimisation of training programmes within the ambulance care sector.

Nontransported Cases after Emergency Medical Service Callout in the Rural and Urban Areas of the Riyadh Region

Background

Callouts resulting in patient nontransportation can impact the overall quality of prehospital Emergency Medical Service (EMS), as resources in health care are finite. While some studies have investigated the causes of nontransportation, few have examined whether there are differences between urban and rural patients. Similarly, there has been limited research focused on rural EMS in locations such as the Middle East.

Objectives

This study investigated EMS cases that resulted in nontransportation in the urban and rural areas of the Riyadh region in the Kingdom of Saudi Arabia.

Methods

A cross-sectional study of 800 (400 rural and 400 urban) patient records was undertaken, using 12 months (January 1 to December 31, 2017) of data from the Saudi Red Crescent EMS. A random sampling method was used to select ambulance records from the 78 urban and rural EMS stations in the Riyadh region, with demographic data and reasons for patient nontransport analyzed comparatively.

Results

A total of 310 cases were nontransported (39%) (rural: 146; urban = 164). The highest rates of nontransportation cases were of medical and trauma callouts (44.6% and 39.6%, respectively), which was consistent in both areas. The most common reason for nontransportation in both urban and rural areas was refusal of treatment and transportation (66.5% and 59.9%, respectively). Further, 10 patients were treated on-scene and released by rural EMS, while no urban patients were treated and released. Overall, the case presentations of nontransported patients did not differ significantly between both areas, and it was found that gender, age, and geographic location were not predictors for nontransportation.

Conclusions

The high rate of nontransportation, particularly in medical and trauma callouts, indicates that a review of current EMS protocols may be required, along with consideration of relevant community education programs.

Relationship Between Nonconveyed Cases and On-Scene Time Intervals for Emergency Medical Services

Purpose

Emergency medical service (EMS) consumption is increasing worldwide. Some EMS cases in Saudi Arabia result in nonconveyance of patients. The aim of the present study was to determine the relationship between nonconveyed EMS cases and on-scene time intervals in Riyadh EMS centers.

Methods

Nonrandomized retrospective data obtained from EMS providers of nonconveyed emergency cases were gathered and analyzed. Data were taken from the ten busiest EMS centers in Riyadh, Saudi Arabia from January 1 to April 30, 2019. Analyses of means ± SD, bivariate comparisons, multivariate analysis, CI correlations, and regressionwere performed.

Results

Categories of nonconveyed cases were “Treatment given at the scene” V1 = 66, “Refused by patient/relative” (V2 = 876), “Patient not found” (V3 = 67), “Dead patient” (V4 = 80”, “Other (police, etc)” (V5 = 34), and NA (96). We found highly significant differences (p<0.001) among several categories of nonconveyed cases and on-scene time intervals among EMS centers.

Conclusion

This study found that there were highly significant differences among several categories of nonconveyed cases in relation to on-scene time intervals for different EMS centers. Results indicated that the probability of nonconveyance decisions was more likely to increase in the categories “Refused by patient/relative,” “Patient not found,” and “Dead patient.” The results did not reveal details of what happened on scene during or after the nonconveyance decision had been made, which needs to be investigated.

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.

Knowledge, skills and attitudes of older people and staff about getting up from the floor following a fall: a qualitative investigation

Background

Falls are the most common reason for ambulance callouts resulting in non-conveyance. Even in the absence of injury, only half of those who fall can get themselves up off the floor, often remaining there over an hour, increasing risk of complications.

There are recognized techniques for older people to learn how to get up after a fall, but these are rarely taught. The aim of this study was to develop an understanding of attitudes of older people, carers and health professionals on getting up following a fall.

Methods

A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people with experience of a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and first responders. Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and service users advised during analysis.

Results

The data highlighted three areas contributing to an individual’s capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors fell within the wider context of making a decision about needing help, which included what training and knowledge each person already had to manage their fall response.

Staff described how they balance their responsibilities, prioritising the individual’s immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to.

Conclusion

Neither therapists nor ambulance service staff routinely teach strategies on how to get up, meaning that healthcare professionals largely have a reactive role in managing falls. Interventions that address the environment, physical ability and self-efficacy could positively impact on peoples’ capability to get up following a fall. Therefore, a more proactive approach would be to teach people techniques to manage these aspects of future falls and to provide them easily accessible information.

Patient experience of non-conveyance following emergency ambulance service response: A scoping review of the literature

INTRODUCTION

Evolution of ambulance service response models has resulted in significant numbers of patients not being conveyed to Emergency Departments. Prior research has attempted to measure patient-safety aspects of non- conveyance with inconclusive results. Several authors have recommended investigation of patient experience as an alternative metric. Understanding patient experience is acknowledged as a core requirement for design and evaluation of changes to healthcare delivery. However, it is unclear to what extent patient experience of non-conveyance is described in academic literature.

AIMS

To map scholarly literature that describes patient experience of non-conveyance and identify knowledge gaps that guide future research.

METHODS

Scoping review guided by the Joanna Briggs Institute (JBI) framework.

RESULTS

Ten studies of heterogenous methodology were included. Commonly, high levels of satisfaction with paramedic care were reported, yet contributing factors to satisfaction were generally not described. Qualitative studies provided deeper insight into experience. Value was attributed to reassurance and being empowered in the decision-making process. Not having concerns validated by paramedics led to negative experiences.

CONCLUSION

There is a scarcity of quality research that has investigated patient experience of non-conveyance following emergency ambulance service response. Methods used by existing research is of low-quality. Patient experience of non-conveyance is not fully known.

Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden

Background

There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data.

Methods

A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients’ medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test.

Results

Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women.

Conclusions

Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

Non-conveyance in the ambulance service: a population-based cohort study in Stockholm, Sweden

OBJECTIVES

Non-conveyed patients represent a significant proportion of all patients cared for by ambulance services in the western world. However, scientific knowledge on non-conveyance is sparse. Therefore, the aim of this study was to describe the prevalence of non-conveyance, investigate associations and compare patients' characteristics, drug administration, initial problems and vital signs between non-conveyed and conveyed patients.

DESIGN

A population-based retrospective cohort study.

SETTING

The study setting area, Stockholm, Sweden, has a population of 2.3 million inhabitants, with seven emergency hospitals. Annually, approximately 210 000 assignments are performed by 73 ambulances. All ambulance assignments performed from 1 January to 31 December 2015 were included.

RESULTS

In total, 23 603 ambulance assignments ended in non-conveyance-13.8% of all ambulance assignments performed in 2015. Compared with conveyed patients, non-conveyed patients were younger and more often female (median age 50.1 years for non-conveyed vs 61.7 years for conveyed; female=52 %, both p values <0.001). Approximately half of all ambulance assignments ending in non-conveyance were initially prioritised and dispatched as the highest priority. Non-conveyed patients were more often assessed by ambulance clinicians as presenting non-specific symptoms or symptoms related to psychiatric problems. Low blood glucose levels were highly associated with non-conveyance (adjusted OR (AOR): 15; 95 % CI 11.18 to 20.13), although non-conveyed patients presented abnormal vital signs across all categories of vital signs. Moreover, drugs were more often administered to younger non-conveyed patients. Older patients were more often conveyed and administered drugs once conveyed (AOR: 1.29; 95 % CI 1.07 to 1.56).

CONCLUSIONS

This study shows that non-conveyed patients represent a non-negligible proportion of all patients in contact with ambulance services. In general, most cases of non-conveyance occur at the highest dispatch level, to a large extent involve younger patients, and features problems assessed by ambulance clinicians as non-specific or related to psychiatric symptoms.

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.

A survey of general practitioner's opinion on the proposal to introduce 'treat and referral' into the Irish emergency medical service

BACKGROUND

The introduction of treat and referral by ambulance practitioners is under active consideration in Ireland. The Irish ambulance services have traditionally transported all patients following an emergency (112/999) call to an emergency department. The introduction of treat and referral will present a significant care pathway change.

AIMS

To engage GPs in relation to the proposed introduction of treat and referral.

METHODS

A postal survey of 50 general practices in the southeast of Ireland was completed in 2019 to identify their opinion on the introduction of treat and referral. Descriptive statistics were calculated, and Pearson's chi-square tests were used to identify statistically significant differences among GP cohorts.

RESULTS

A 78% response rate was achieved. Respondents indicated that informal treat and referral was practised by 40% of GPs. A significant majority of GPs indicated that their patients with diabetes or epilepsy would benefit from treat and referral and were happy for paramedics to make appointments posthypoglycaemia or seizure. There was no clear consensus in relation to confining treat and referral to adults only. Barriers to the implementation of treat and referral were a significant issue for GPs.

CONCLUSIONS

GPs are in the main supportive of the introduction of treat and referral; however, they have identified several barriers that may inhibit successful introduction. Importantly, a GP appointment within 48 h does not appear to be a barrier. The adequacy of the working relationships between GPs and the ambulance service and its practitioners appears to have reduced since 2006, which is concerning.

Telephone triage performed by nurses reduces non-urgent ambulance missions: A prospective observational pilot study in Finland

BACKGROUND

The increased workload in emergency medical services (EMS) is a global phenomenon in welfare states. It has been suggested that telephone triage by nurses may reduce the increasing use of EMS services, by directing patient flow to appropriate care. This study aimed to investigate whether, after an emergency medical communication centre (EMCC) provider assessed risk, a telephone nurse could assess the patient's needs and guide patients to social and health care services in non-urgent cases.

METHODS

This prospective observational study was performed in the Kainuu Hospital District in northern Finland from March to April 2018. All EMS requests classified as non-urgent by the EMCC were transferred to a telephone triage nurse. Subsequent patient guidance was recorded. The International Classifications of Primary Care categories were recorded.

RESULTS

We studied phone calls of 700 patients with non-urgent needs. Of these, the nurse transferred 63.7% to EMS and 17.3% were guided to other social and health care services. Nineteen per cent of the calls were handled over the phone by the nurse, who provided health advice and instructions. The most common needs for care were general and unspecified symptoms, musculoskeletal symptoms, mental health problems and substance abuse.

CONCLUSION

By providing telephone counseling, care instructions and patient guidance to other social and health services than EMS, the telephone triage reduced non-urgent EMS missions by one third. The results imply that telephone triage could be a viable model for managing non-urgent missions. Patient safety issues should be monitored when developing new service concepts.

Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study

OBJECTIVES

This study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients.

DESIGN

An observational study of patients referred by dispatch nurses to non-emergency care.

SETTING

Dispatch centres in two Swedish regions.

PARTICIPANTS

A total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care.

RESULTS

Of 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to.

CONCLUSION

The use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve 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.

A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

Background

Paramedics are increasingly required to make complex decisions as to whether they should convey a patient to hospital or manage their condition at the scene. Dementia can be a significant barrier to the assessment process. However, to our knowledge no research has specifically examined the process of decision-making by paramedics in relation to people with dementia. This qualitative study was designed to investigate the factors influencing the decision-making process during Emergency Medical Services (EMS) calls to older people with dementia who did not require immediate clinical treatment.

Methods

This qualitative study used a combination of observation, interview and document analysis to investigate the factors influencing the decision-making process during EMS calls to older people with dementia. A researcher worked alongside paramedics in the capacity of observer and recruited eligible patients to participate in case studies. Data were collected from observation notes of decision-making during the incident, patient care records and post incident interviews with participants, and analysed thematically.

Findings

Four main themes emerged from the data concerning the way that paramedics make conveyance decisions when called to people with dementia: 1) Physical condition; the key factor influencing paramedics’ decision-making was the physical condition of the patient. 2) Cognitive capacity; most of the participants preferred not to remove patients with a diagnosis of dementia from surroundings familiar to them, unless they deemed it absolutely essential. 3) Patient circumstances; this included the patient’s medical history and the support available to them. 4) Professional influences; participants also drew on other perspectives, such as advice from colleagues or information from the patient’s General Practitioner, to inform their decision-making.

Conclusion

The preference for avoiding unnecessary conveyance for patients with dementia, combined with difficulties in obtaining an accurate patient medical history and assessment, mean that decision-making can be particularly problematic for paramedics. Further research is needed to find reliable ways of assessing patients and accessing information to support conveyance decisions for EMS calls to people with dementia.

Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians

OBJECTIVES

To combat overcrowding in emergency departments, ambulance clinicians (ACs) are being encouraged to make on-site assessments regarding patients' need for conveyance to hospital, and this is creating new and challenging demands for ACs. This study aimed to describe ACs' experiences of assessing non-conveyed patients.

DESIGN

A phenomenological interview study based on a reflective lifeworld research approach.

SETTING

The target area for the study was Stockholm, Sweden, which has a population of approximately 2.3 million inhabitants. In this area, 73 ambulances perform approximately just over 200 000 ambulance assignments annually, and approximately 25 000 patients are non-conveyed each year.

INFORMANTS

11 ACs.

METHODS

In-depth open-ended interviews.

RESULTS

ACs experience uncertainty regarding the accuracy of their assessments of non-conveyed patients. In particular, they fear conducting erroneous assessments that could harm patients. Avoiding hasty decisions is important for conducting safe patient assessments. Several challenging paradoxes were identified that complicate the non-conveyance situation, namely; responsibility, education and feedback paradoxes. The core of the responsibility paradox is that the increased responsibility associated with non-conveyance assessments is not accompanied with appropriate organisational support. Thus, frustration is experienced. The education paradox involves limited and inadequate non-conveyance education. This, in combination with limited support from non-conveyance guidelines, causes the clinical reality to be perceived as challenging and problematic. Finally, the feedback paradox relates to the obstruction of professional development as a result of an absence of learning possibilities after assessments. Additionally, ACs also described loneliness during non-conveyance situations.

CONCLUSIONS

This study suggests that, for ACs, performing non-conveyance assessments means experiencing a paradoxical professional existence. Despite these aggravating paradoxes, however, complex non-conveyance assessments continue to be performed and accompanied with limited organisational support. To create more favourable circumstances and, hopefully, safer assessments, further studies that focus on these paradoxes and non-conveyance are needed.

Ambulance nurses' experiences of deciding a patient does not require ambulance care

AIM

To describe ambulance nurses' experience of deciding a patient does not require ambulance care.

DESIGN

An inductive, empirical study with a qualitative approach.

METHODS

Data collection was conducted through semi-structured interviews, and collected data were analysed with qualitative manifest content analysis. Data were collected during the spring 2017, and eight ambulance nurses participated.

RESULTS

The findings are presented in one main category, which is "Not very ill but a difficult decision" with totally three subcategories. The ambulance nurse's experience of making the assessment when the patient has no need for ambulance care is like walking the balance of slack line. This means that the assessment can be both easy and very difficult but something that definitely requires experience, knowledge and dedication.

Parents' experiences of the caring encounter in the ambulance service-A qualitative study

AIMS AND OBJECTIVES

To explore the experiences of the caring encounter in the ambulance service among parents to children aged 0-14 years.

BACKGROUND

The care provided by the ambulance team is often associated with emergency medicine, traumatology and disaster medicine. But to develop care in the ambulance service, it is imperative to understand what the parents want and value in the care for their child.

DESIGN

A qualitative study design was used.

METHODS

Interviews was used for data collection, 16 caring encounters described by 14 parents were analysed using qualitative content analysis. Reporting of this research adheres to the COREQ guidelines.

RESULTS

The parents described the importance of giving the family enough time in the situation, creating a safe environment and involving the parents in the care. In cases where the parents felt insecure, there had been lack of communication and lack of sensitivity, and the ambulance team did not invite the parents to be participate in the care.

CONCLUSIONS

There is a need to strengthen the family-centred care in the ambulance service. Not inviting the parents in the care and use of equipment that was nonfunctioning or not adjustable for the children's age caused lack of trust and increased the level of stress among the parents. The parents had a positive experience and felt included when the team were calm, responsive and gave them the chance to be participants in their child's care.

RELEVANCE TO CLINICAL PRACTICE

The prehospital emergency care nurses need to be prepared for caring of children and their parents. The ambulance team also need to understand their role in providing care of children. Lack of confidence in treating children may be perceived as nonfamily-centred care. There is need of further training concerning family-centred care in the ambulance service.

Using vignettes to assess the accuracy and rationale of paramedic decisions on conveyance to the emergency department

INTRODUCTION

Paramedics make important decisions about whether a patient needs transport to hospital, or can be discharged on scene. These decisions require a degree of accuracy, as taking low acuity patients to the emergency department (ED) can support ambulance ramping. In contrast, leaving mid-high acuity patients on scene can lead to incidents and recontact. This study aims to investigate the accuracy of conveyance decisions made by paramedics when looking at real life patient scenarios with known outcomes. It also aims to explore how the paramedic made the decision.

METHODS

We undertook a prospective mixed method triangulation design. Six individual patient vignettes were created using linked ambulance and ED data. These were then presented in an online survey to paramedics in Yorkshire. Half the vignettes related to mid-high acuity attendances at the ED and the other half were low acuity. Vignettes were validated by a small expert panel. Participants were asked to determine the appropriate conveyance decision and to explain the rationale behind their decisions using a free-text box.

RESULTS

A total of 143 paramedics undertook the survey and 858 vignettes were completed. There was clear agreement between paramedics for transport decisions (ƙ = 0.63). Overall accuracy was 0.69 (95% CI 0.66-0.73). Paramedics were better at 'ruling in' the ED, with sensitivity of 0.89 (95% CI 0.86-0.92). The specificity of 'ruling out' the ED was 0.51 (95% CI 0.46-0.56). Text comments were focused on patient safety and risk aversion.

DISCUSSION

Paramedics make accurate conveyance decisions but are more likely to over-convey than under-convey, meaning that while decisions are safe they are not always appropriate. It is important that paramedics feel supported by the service to make safe and confident non-conveyance decisions. Reducing over-conveyance is a potential method of reducing demand in the urgent and emergency care system.

Prehospital National Early Warning Score predicts early mortality

BACKGROUND

National Early Warning Score (NEWS) has been shown to be the best early warning score to predict in-hospital mortality but there is limited information on its predictive value in a prehospital setting. The aim of the current study was to investigate the diagnostic accuracy of NEWS in a prehospital setting using large population-based databases in terms of short-term mortality.

METHODS

We calculated the NEWS scores from retrospective prehospital electronic patient record data and analysed their possible relationship to mortality. We included all patient records for patients 18 years or older with sufficient prehospital data to calculate NEWS from 17 August 2008 to 18 December 2015 encountered by the emergency medical services (EMS) in the Hospital District of Helsinki and Uusimaa, Finland. The primary outcome measure was death within 1 day of EMS dispatch.

RESULTS

35 800 patients were included. Their mean (SD) age was 65.8 (19.9) years. The median value of NEWS was 3 (IQR 1-6). The primary outcome of death within 1 day of EMS dispatch occurred in 378 (1.1%) cases. Area under receiver operating characteristic curve (AUROC) for primary outcome of death within 1 day was 0.840 (95% CI 0.823-0.858). AUROC for 1 day mortality in trauma subgroup was 0.901 (95% CI 0.859-0.942).

CONCLUSION

Prehospital NEWS predicts mortality within 1 day of EMS dispatch with good diagnostic accuracy.

Outcomes for Patients Who Contact the Emergency Ambulance Service and Are Not Transported to the Emergency Department: A Data Linkage Study

Objectives: Emergency ambulance services do not transport all patients to hospital. International literature reports non-transport rates ranging from 3.7-93.7%. In 2017, 38% of the 11 million calls received by ambulance services in England were attended by ambulance but not transported to an Emergency Department (ED). A further 10% received clinical advice over the telephone. Little is known about what happens to patients following a non-transport decision. We aimed to investigate what happens to patients following an emergency ambulance telephone call that resulted in a non-transport decision, using a linked routine data-set. Methods: Six-months individual patient level data from one ambulance service in England, linked with Hospital Episode Statistics and national mortality data, were used to identify subsequent health events (ambulance re-contact, ED attendance, hospital admission, death) within 3 days (primary analysis) and 7 days (secondary analysis) of an ambulance call ending in non-transport to hospital. Non-clinical staff used a priority dispatch system e.g. Medical Priority Dispatch System to prioritize calls for ambulance dispatch. Non-transport to ED was determined by ambulance crew members at scene or clinicians at the emergency operating center when an ambulance was not dispatched (telephone advice). Results: The data linkage rate was 85% for patients who were discharged at scene (43,108/50,894). After removal of deaths associated with end of life care (N = 312), 9% (3,861/42,796) re-contacted the ambulance service, 12.6% (5,412/42,796) attended ED, 6.3% (2,694/42,796) were admitted to hospital, and 0.3% (129/42,796) died within 3 days of the call. Rates were higher for events occurring within 7 days. For example, 12% re-contacted the ambulance service, 16.1% attended ED, 9.3% were admitted to hospital, and 0.5% died. The linkage rate for telephone advice calls was low because ambulance services record less information about these patients (24% 2,514/10,634). A sensitivity analysis identified a range of subsequent event rates: 2.5-10.5% of patients were admitted to hospital and 0.06-0.24% of patient died within 3 days of the call. Conclusions: Most non-transported patients did not have subsequent health events. Deaths after non-transport are an infrequent event that could be selected for more detailed review of individual cases, to facilitate learning and improvement.

Outcomes in children evaluated but not transported by ambulance personnel: retrospective cohort study

BACKGROUND

Not all children with an out-of-hospital emergency medical contact are transported by ambulance to the emergency department (ED). Non-transport means that after on-scene evaluation and possible treatment, ambulance personnel may advise the patient to monitor the situation at home or may refer the patient to seek medical attention by other means of transport. As selecting the right patients for ambulance transport is critical for optimising patient safety and resource use, we studied outcomes in non-transported children to identify possible risk groups that could benefit from ambulance transport.

METHODS

In a population-based retrospective cohort study of all children aged 0-15 years encountered but not transported by ambulance in Helsinki, Finland, between 1 January 2014 and 31 December 2016, we evaluated (1) 12-month mortality, (2) intensive care admissions, (3) unscheduled ED contacts within the following 96 hours after the non-transport decision and (4) the clinical status of the child on presentation to ED in the case of a secondary ED visit.

RESULTS

Of all children encountered by out-of-hospital emergency medical services, 3579/7765 (46%) were not transported to ED by ambulance. There was no mortality or intensive care admissions related to the non-transport. The risk factors for an unscheduled secondary ED visit after a non-transport decision were young age (p=0.001), non-transport decision during the early morning hours (p<0.001) and certain dispatch codes, including 'dyspnoea' (p<0.001), 'vomiting/diarrhoea' (p=0.030) and 'mental illness' (p=0.019). We did not detect deterioration in patients' clinical presentation at ED traceable to non-transport decisions.

CONCLUSIONS

Not transporting all children by ambulance after an out-of-hospital emergency medical contact was not associated with deaths, intensive care admissions or significant deterioration in general condition in our study population and healthcare system. Special attention and a formal non-transport protocol are warranted in certain subgroups, including infants.

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city

BACKGROUND

The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes.

METHODS

We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes.

RESULTS

Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome.

CONCLUSION

The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.

Exploring variation in how ambulance services address non-conveyance: a qualitative interview study

OBJECTIVES

There is considerable variation in non-conveyance rates between ambulance services in England. The aim was to explore variation in how each ambulance service addressed non-conveyance for calls ending in telephone advice and discharge at scene.

DESIGN

A qualitative interview study.

SETTING

Ten large regional ambulance services covering 99% of the population in England.

PARTICIPANTS

Between four and seven interviewees from each ambulance service including managers, paramedics and healthcare commissioners, totalling 49 interviews.

METHODS

Telephone semistructured interviews.

RESULTS

The way interviewees in each ambulance service discussed non-conveyance within their organisation varied for three broad themes. First, ambulance service senior management appeared to set the culture around non-conveyance within an organisation, viewing it either as an opportunity or as a risky endeavour. Although motivation levels to undertake non-conveyance did not appear to be directly affected by the stability of an ambulance service in terms of continuity of leadership and externally assessed quality, this stability could affect the ability of the organisation to innovate to increase non-conveyance rates. Second, descriptions of workforce configuration differed between ambulance services, as well as how this workforce was used, trained and valued. Third, interviewees in each ambulance service described health and social care in the wider emergency and urgent care system differently in terms of availability of services that could facilitate non-conveyance, the amount of collaborative working between health and social care services and the ambulance service and complexity related to the numbers of services and healthcare commissioners with whom they had to work.

CONCLUSIONS

This study suggests that factors within and outside the control of ambulance services may contribute to variation in non-conveyance rates. These findings can be tested in a quantitative analysis of factors affecting variation in non-conveyance rates between ambulance services in England.

A retrospective comparison between non-conveyed and conveyed patients in ambulance care

BACKGROUND

Not all patients where an ambulance is dispatched are conveyed to an emergency department. Although non-conveyance is a substantial part of ambulance care, there is limited insight in the non-conveyance patient population. Therefore, the study aim was to compare demographics, initial on-scene reasons for care, and vital signs between conveyed and non-conveyed patients attended by an ambulance.

METHODS

A retrospective study of ambulance runs from 2 EMS regions in the Netherlands in 2016 was performed. For each ambulance run demographics (age, gender and geographical location), initial reasons for care categorised into the ICD-10 classification system, and vital functions or observational scales (according to the national ambulance care protocol) were collected and analyzed.

RESULTS

54.797 ambulance runs met the inclusion criteria, of which 14.383/54.797 (26.2%) resulted in non-conveyance. There was no significant difference in gender, but the non-conveyance group was significantly younger (48.5 (±26.4) years) compared to the conveyance group (60.7 (±22.2) years) (p = .000). The most common initial reasons for care for the conveyance group could be classified into chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and chapter-10 diseases of the respiratory system. The most common reasons for care in the non-conveyance group could be classified into the chapter-9 diseases of the circulatory system, chapter-19 injury, poisoning and certain other consequences of external causes, and -chapter-5 mental, behavioral and neurodevelopmental disorders. The total percentage abnormal vital functions/observation scales between the conveyance (69.5%) and non-conveyance group (58.6%) was significantly different (p = .000). 15 out of 17 vital functions/observation scales are significantly different between the conveyance and non-conveyance group.

CONCLUSIONS

This study shows that non-conveyed patients are younger, are more likely to be in (highly) rural areas, and more often have initial reasons for care related to mental, behavioral and neurodevelopmental disorders (ICD-10 chapter 5). Although abnormal vital functions/observation scale were more prevalent in the conveyance group, 58.6% of the non-conveyed patients had at least one abnormal vital function/observation scale.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

Background

The assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.

Methods

A prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.

Results

The dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.

Conclusions

Despite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.