Understanding patient non-transport decision theories in the pre-hospital setting: a narrative review

BACKGROUND

In pre-hospital emergency care, decisions regarding patient non-conveyance emerged as significant determinants of healthcare outcomes and resource utilization. These complex decisions became integral to the progress of emergency medical services, thus warranting an evolving exploration within the medical discourse.

OBJECTIVES AND METHODS

This narrative review aimed to synthesize and critically evaluate various theoretical stances on patient non-conveyance in the pre-hospital emergency. The focus on studies published between January 2012 and August 2022 was intentional to capture contemporary practices and insights. PubMed and Google Scholar served as the primary databases for the investigation, while the AL-Rayyan® software facilitated a thorough screening process.

RESULTS AND DISCUSSION

Twenty-nine studies-encompassing articles, books, and theses-were discovered through our search, each presenting unique perspectives on patient non-transport, thus highlighting its criticality as a healthcare concern. Predominant factors influencing non-transport decisions were classified into patient-initiated refusals (PIR), clinician-initiated decisions (CID), and dispatcher-initiated decisions (DID).

CONCLUSIONS

The issue of patient non-conveyance to hospitals continues to pose a crucial challenge to the seamless operation of emergency healthcare systems, warranting increased attention from various healthcare entities. To comprehend and pinpoint potential areas of improvement, a comprehensive analysis of pre-hospital non-transport events is imperative. A well-informed, strategic approach could prevent resource waste while ensuring patients receive the required and definitive care.

KEY MESSAGES

Why is this topic important? Some studies have suggested that non-transport to hospitals following emergency calls is safe. However, it is a concerning issue for health systems. It is also considered a key performance metric for health systems. What does this review attempt to show? This review aimed to map the various factors discussed in the literature regarding the decisions not to transport patients following emergency calls in a pre-hospital setting. What are the key findings? The existing theories regarding non-transport to hospitals after the provision of emergency care in the pre-hospital setting were identified. Non-transport due to non-clinical decisions jeopardizes emergency care outcomes for paediatric and elderly patients in particular. Hence, further research is required to identify and control the factors governing these decisions. How is patient care impacted? The decisions regarding patient transport following emergency calls in a pre-hospital setting are crucial for patient outcomes. They could impact the pre-hospital emergency care outcomes as well as patient safety. They can also affect the emergency services resources' ability to respond to other critical emergencies.

Outcomes in patients not conveyed by emergency medical services (EMS): a one-year prospective study

Background

The decision to not convey patients has become common in emergency medical services worldwide. A substantial proportion (12–51%) of the patients seen by emergency medical services are not conveyed by those services. The practice of non-conveyance is a result of the increasing and changing demands on the acute care system. Research focusing on the outcomes of the decision by emergency medical services to not convey patients is needed.

Aim

The aim was to describe outcomes (emergency department visits, admission to in-hospital intensive care units and mortality, all within seven days) and their association with the variables (sex, age, day of week, time of day, emergency signs and symptoms codes, triage level colour, and destination) for non-conveyed patients.

Methods

This was a prospective analytical study with consecutive inclusion of all patients not conveyed by emergency medical services. Patients were included between February 2016 and January 2017. The study was conducted in Region Örebro county, Sweden. The region consists of both rural and urban areas and has a population of approximately 295,000. The region had three ambulance departments that received approximately 30,000 assignments per year.

Results

The result showed that no patient received intensive care, and 18 (0.7%) patients died within seven days after the non-conveyance decision. Older age was associated with a higher risk of hospitalisation and death within seven days after a non-conveyance decision.

Conclusions

Based on the results of this one-year follow-up study, few patients compared to previous studies were admitted to the hospital, received intensive care or died within seven days. This study contributes insights that can be used to improve non-conveyance guidelines and minimise the risk of patient harm.

Supplementary information

The online version contains supplementary material available at 10.1186/s13049-022-01023-3.

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.

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.

Safety of on-scene medical care by EMS nurses in non-transported patients: a prospective, observational study

Background

After on-scene examination and /or treatment, emergency medical services (EMS) nurses must decide whether the patient requires further assessment or treatment, most frequently in a hospital. The primary objective of this study was to assess the reliability of the current EMS protocol by determining whether the decision not to transport the patient to a care provider was correct or not.

Methods

Adults receiving on-scene medical care by an EMS rapid responder or full team without transport to the hospital were included in this prospective observational study. The primary outcome measure was secondary consultation within 24 h after an on-scene EMS evaluation without transport for the same or a closely related complaint. The secondary outcome measures were patient satisfaction, type of secondarily consulted health care provider, provisional and definitive diagnosis, and correctness of the EMS members’ decision to provide on-scene medical care without transport.

Results

Of the 1095 participating patients, 271 (24.7%) patients requested secondary medical attention for the same complaint. This percentage was significantly larger in incidents attended by an ambulance team than by a rapid responder (N = 248 (26.5%) vs. N = 23 (14.4%); p < 0.05). In eleven (1.0%) cases an urgent medical diagnosis requiring admission was missed. A total of 873 (79.7%) patients were satisfied with the decision not to be transported. In 44 (4.0%) cases the EMS nurse’s decision was rated incorrect since the patient needed help contradictory to the EMS nurse’s recommendation.

Conclusions

The data show that EMS nurses can effectively examine patients, but a low threshold of referral for consultation should be considered because one in four patients requested secondary medical attention for the same complaint(s) again. However, due to a low response rate (11.3%) more research is needed to further determine the safety of the current EMS protocol.

Trial registration

Not applicable.