Non-conveyance Decisions Research Articles

Patient experience of non-conveyance in the EMS of Southwest Finland: a descriptive survey study

BackgroundEmergency Medical Services are dispatched more frequently than before. However, many non-urgent patients do not need ambulance transportation to a healthcare facility after evaluation and treatment on scene. This study explored the experiences of non-conveyed patients. Our research questions were: (1) How have non-conveyed patients experienced the service received from EMS? (2) Does a patient’s age, gender, or time of the emergency call impact the patient’s experience?MethodsThis descriptive survey study examined non-conveyed Emergency Medical Services patients in the Wellbeing Services County of Southwest Finland. The study period was from March 1, 2023, to March 31, 2023. The study population was 1017. They received a questionnaire that was sent by mail. The questionnaire was formed based on questions previously used in four different questionnaires. We received 247 answers (24.3% response rate). Percentages, medians with interquartile ranges, and non-parametric tests were used in the descriptive analyses.ResultsNon-conveyed patients were very satisfied with the paramedics’ expertise and behavior, their ability to meet their individual needs, the sense of safety provided by the paramedics, and the instructions given to the patients. Time to receive help (19% rated 3 or less on a scale from 1 to 5), how paramedics introduced themselves (16.5%), and satisfaction with non-conveyance decisions (14.6%) were more frequently rated lower than other areas. Further, pain management stood out in the less favorable evaluations. Still, patients’ experiences of the service were positive. The age group, gender, or time of the emergency call were not associated with patient experience.ConclusionsPatients were very satisfied with the paramedics’ interpersonal skills. A more focused approach to pain management and developing EMS to ensure faster patient outreach and clearer explanations of non-conveyance decisions could further enhance the patient experience.

The non-conveyance of trauma patients in Swedish emergency medical services: a retrospective observational study of the trauma population not transported to an emergency department

IntroductionDue to a systemic modification in Swedish emergency medical services (EMS) staffing in recent years, the nature of the Swedish EMS has changed. Transport to an emergency department (ED) is no longer the only option. Referrals and non-conveyance form a growing part of EMS assignments. Trauma is one of the most common causes of death and accounts for 17% of Swedish EMS assignments. The aim of this study was to describe the characteristics and clinical outcomes of non-conveyed trauma patients who were assessed, treated and triaged by the EMS to gain a better understanding of, and to optimise, transport and treatment decisions.MethodsThe study had a descriptive, retrospective and epidemiologic design and was conducted by reviewing EMS and hospital records for 837 non-conveyed trauma patients in the southwest of Sweden in 2019.ResultsThree in four non-conveyed trauma patients did not seek further medical care within 72 h following EMS assessment. The patients who were admitted to hospital later were often older, had suffered a fall and had a medical history. Half of all the incidents occurred in a domestic environment, and head trauma was the major complaint. Less than 1% of the studied patients died.ConclusionMost of the non-conveyed trauma patients did not seek further medical care after being discharged at the scene. Falling was the most common trauma event, and for the older population, this meant a higher risk of hospital admission. The reasons for falls should therefore be investigated thoroughly prior to non-conveyance decisions. Future studies should focus on the reasons for non-conveyance and measure the morbidity and invalidity outcomes rather than mortality.

Epidemiological Determinants of Patient Non-Conveyance to the Hospital in an Emergency Medical Service Environment.

The increasing prevalence of comorbidities worldwide has spurred the need for time-effective pre-hospital emergency medical services (EMS). Some pre-hospital emergency calls requesting EMS result in patient non-conveyance. Decisions for non-conveyance are sometimes driven by the patient or the clinician, which may jeopardize the patients' healthcare outcomes. This study aimed to explore the distribution and determinants of patient non-conveyance to hospitals in a Middle Eastern national Ambulance Service that promotes the transportation of all emergency call patients and does not adopt clinician-based non-conveyance decision. Using R Language, descriptive, bivariate, and binary logistic regression analyses were conducted for 334,392 multi-national patient non-conveyance emergency calls from June 2018 to July 2022, from a total of 1,030,228 calls to which a response unit was dispatched. After data pre-processing, 237,862 cases of patient non-conveyance to hospital were retained, with a monthly average of 41.96% (n = 8799) of the emergency service demands and a standard deviation of 5.49% (n = 2040.63). They predominantly involved South Asians (29.36%, n = 69,849); 64.50% (n = 153,427) were of the age category from 14 to 44 years; 61.22% (n = 145,610) were male; 74.59% (n = 177,424) from the urban setting; and 71.28% (n = 169,552) had received on-scene treatment. Binary logistic regression with full variables and backward methods identified the final models of the determinants of patient non-conveyance decisions with an Akaike information criterion prediction estimator, respectively, of (250,200) and (250,169), indicating no significant difference between both models (Chi-square test; p-value = 0.63). Despite exercising a cautious protocol by encouraging patient transportation to hospital, patient non-conveyance seems to be a problem in the healthcare system that strains the pre-hospital medical response teams' resources. Policies and regulations should be adopted to encourage individuals to access other primary care centers when required rather than draining emergency services for non-emergency situations.

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

BackgroundPredictors of subsequent events after Emergency Medical Services (EMS) non-conveyance decisions are still unclear, though patient safety is the priority in prehospital emergency care. The aim of this study was to find out whether machine learning can be used in this context and to identify the predictors of subsequent events based on narrative texts of electronic patient care records (ePCR).MethodsThis was a prospective cohort study of EMS patients in Finland. The data was collected from three different regions between June 1 and November 30, 2018. Machine learning, in form of text classification, and manual evaluation were used to predict subsequent events from the clinical notes after a non-conveyance mission.ResultsFastText-model (AUC 0.654) performed best in prediction of subsequent events after EMS non-conveyance missions (n = 11,846). The model and manual analyses showed that many of the subsequent events were planned before, EMS guided the patients to visit primary health care facilities or ED next or following days after non-conveyance. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-, infection-related and non-specific complaints. 1 in 5 the EMS documentation was inadequate and many of these led to a subsequent event.ConclusionMachine learning can be used to predict subsequent events after EMS non-conveyance missions. From the patient safety perspective, it is notable that subsequent event does not necessarily mean that patient safety is compromised. There were a number of subsequent visits to primary health care or EDs, which were planned before by EMS. This demonstrates the appropriate use of limited resources to avoid unnecessary conveyance to the ED. However, further studies are needed without planned subsequent events to find out the harmful subsequent events, where EMS non-conveyance puts patient safety at risk.

The effect of a specialist paramedic primary care rotation on appropriate non-conveyance decisions (SPRAINED) study: a controlled interrupted time series analysis.

NHS ambulance service non-conveyance rates in the United Kingdom are around 30%, despite an increase in non-emergency cases and a national policy of integrating urgent and emergency care to provide patients with the 'right care, in the right place, at the right time'. Emergency department overcrowding is a significant issue for patients, resulting in poorer quality of care, increased healthcare costs and potentially, increased mortality. It also contributes to increased ambulance turnaround times. Yorkshire Ambulance Service NHS Trust (YAS) introduced a specialist paramedic (SP) to improve the management of lower acuity cases, but non-conveyance rates in this group have not been as high as expected.In 2018, Health Education England funded a pilot scheme to rotate paramedics into a range of healthcare settings and in YAS, 10 SPs undertook a 10-week placement in a GP practice. This study aimed to evaluate whether a primary care placement appropriately increased the level and trend of non-conveyance decisions made by SPs following a 10-week GP placement, in a cost-effective manner. We conducted a controlled interrupted time series analysis using data from incidents between 1 June 2017 and 31 December 2019, to study appropriate non-conveyance rates before and after a GP placement. A costing analysis, examining the average cost per appropriate non-conveyance achieved for patients receiving care from intervention group SPs pre- and post-placement, was also conducted. A total of 7349 incidents attended by intervention group SPs were eligible for inclusion. Following removal of cases with missing data, 5537 (75.3%) cases remained. Post-placement, the intervention group demonstrated an increase in appropriate non-conveyance rate of 35.0% (95% CI 23.8%-46.2%), and a reduction in the trend of appropriate non-conveyance of -1.2% (95% CI -2.8%-0.5%), relative to the control group.Post-placement, the cost per appropriate non-conveyance for intervention group SPs was a mean of £509.41 (95% bootstrapped CI £454.92-£564.26) versus £1257.81 (95% bootstrapped CI £1233.42-£1283.95) for the same group in the pre-placement phase. In this single UK NHS ambulance service study, we found a clinically important and statistically significant increase in appropriate non-conveyance rates by SPs who had completed a 10-week GP placement. This improvement persisted for the 12-month period following the placement and demonstrated cost savings compared to usual care.

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

PurposeEmergency 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.MethodsNonrandomized 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.ResultsCategories 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.ConclusionThis 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.

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.

Emergency Patients' and Family Members' Experiences of Nonconveyance Situations and Counseling Received From Care Providers.

Making nonconveyance decisions can be demanding for care providers in prehospital emergency services. Studies have found homecare instructions and counseling of patients and family members partly insufficient. A descriptive cross-sectional design was applied for this pilot study to explore emergency patients' and family members' experiences of nonconveyance situations and counseling. Data were collected by questionnaires from acutely ill patients (n = 97) treated on-site and not transported to hospital and from their family members (n = 72) in 2015-2016. Responses to quantified statements were analyzed statistically, whereas responses to open questions were analyzed using qualitative inductive content analysis. Patients and family members had mostly received verbal home care instructions. Just more than 10% of patients found the instructions insufficient for their coping at home. Male patients were slightly more satisfied with counseling than female patients. One-fifth of female patients but only 6% of male patients were dissatisfied with nonconveyance decisions. In family members, the proportion of dissatisfied respondents was 14%. Older patients were more often dissatisfied than younger patients. Although the majority of the respondents were satisfied with the emergency medical services in general, patients suggested that home care instructions, staff competence, and availability of ambulances should be improved and resources and attention given to patients' opinions increased. Family members proposed more careful assessment of conveyance needs, increased resources, and attention given to the patient. The results highlight the importance of developing a more family-centered approach to emergency care.

Encountering and counselling patients and family members in out-of-hospital emergency care in non-conveyance situations: Follow-up study in Finland

Rather little is known about emergency care in out-of-hospital settings, for example in patients’ homes, where acute situations often emerge and require rapid action from those present. Research evidence concerning the issue is crucial for the development of emergency care services and for responding to patients’ and professionals’ needs. This study aims to describe how out-of-hospital emergency staff experience encountering and counselling patients and their family members and making non-conveyance decisions after having attended an educational intervention dealing with these issues. Data were collected by electronic questionnaires sent to all out-of-hospital emergency staff members (N=238) of a hospital district in Finland in 2014 and in 2016. Data were mainly analyzed using statistical methods. The educational intervention did not affect respondents’ self-perceived encountering and counselling skills much, although some positive development was observed. The educational intervention had some positive effect on emergency care providers’ encountering and counselling skills. Especially the attention given to family members in care situations increased. The training appears to be in the right direction, but it must be continued. The continuously increasing knowledge of patients’ and family members’ care and counselling experiences also helps staff to understand situations from client perspective, bringing a new dimension to emergency care services.

Implementation and use of computerised clinical decision support (CCDS) in emergency pre-hospital care: a qualitative study of paramedic views and experience using Strong Structuration Theory

BackgroundComputerised clinical decision support (CCDS) has been shown to improve processes of care in some healthcare settings, but there is little evidence related to its use or effects in pre-hospital emergency care. CCDS in this setting aligns with policies to increase IT use in ambulance care, enhance paramedic decision-making skills, reduce avoidable emergency department attendances and improve quality of care and patient experience. This qualitative study was conducted alongside a cluster randomised trial in two ambulance services of the costs and effects of web-based CCDS system designed to support paramedic decision-making in the care of older people following a fall. Paramedics were trained to enter observations and history for relevant patients on a tablet, and the CCDS then generated a recommended course of action which could be logged. Our aim was to describe paramedics’ experience of the CCDS intervention and to identify factors affecting its implementation and use.MethodsWe invited all paramedics who had been randomly allocated to the intervention arm of the trial to participate in interviews or focus groups. The study was underpinned by Strong Structuration Theory, a theoretical model for studying innovation based on the relationship between what people do and their context. We used the Framework approach to data analysis.ResultsTwenty out of 22 paramedics agreed to participate. We developed a model of paramedic experience of CCDS with three domains: context, adoption and use, and outcomes. Aspects of context which had an impact included organisational culture and perceived support for non-conveyance decisions. Experience of adoption and use of the CCDS varied between individual paramedics, with some using it with all eligible patients, some only with patients they thought were ‘suitable’ and some never using it. A range of outcomes were reported, some of which were different from the intended role of the technology in decision support.ConclusionImplementation of new technology such as CCDS is not a one-off event, but an ongoing process, which requires support at the organisational level to be effective.Trial registrationISRCTN Registry 10538608. Registered 1 May 2007. Retrospectively registered.

A self-completed questionnaire study of attitudes and perceptions of paramedic and prehospital practitioners towards acute seizure care in Northern Ireland

IntroductionParamedics are increasingly expected to take on wider roles in the management of epilepsy in the community by making nonconveyance decisions after patients have had seizures. Studies have identified barriers to the successful implementation of this clinical role. We sought to determine levels of confidence, training, perceived barriers, and self-identified learning needs and methods to address these needs regarding seizure management. Methods and materialsA questionnaire was developed by consensus and administered to 63 paramedic and prehospital clinicians at various mandatory training days occurring at the central headquarters of the regional ambulance service in Northern Ireland. Participants had no foreknowledge of the questionnaire, which was self-completed and returned immediately. ResultsA 75% return rate was obtained after 63 questionnaires were distributed. Paramedics had a mean of 11.5years of experiences, and 49% had treated 1–10 seizures in the last year. The Joint Royal Colleges Ambulance Liaison Committee guideline on seizure management is the most commonly utilized clinical guideline (100%). All could recall formal training on seizures in their qualification course. They identified a need to develop their knowledge in certain aspects of drug management and seizure subtype identification, including nonepileptic attack disorder (NEAD). Seventy percent of paramedics had a limited understanding of NEAD.Overall, paramedics rated their confidence as higher in drug treatment and the process of managing a seizure but rated their confidence lower in recognizing different seizure types as well as making nonconveyance decisions. The two factors which were cited as instilling high confidence included clinical experience and good use of provided protocols. Other barriers identified included lack of access to intramuscular midazolam, poor information availability in the prehospital setting, and a lack of a feedback mechanism to ensure follow-up. The methods by which learning needs would be addressed included tutorials, e-Learning, and simulation, with 30% preferring a combination of these methods. ConclusionsWe identified that the paramedic workforce feels a reasonable to high level of confidence in the management of acute seizures. However, there are areas where they experience less confidence including making nonconveyance decisions and the identification of nontonic–clonic seizure subtypes.

PP25 Using a linked health dataset to identify what happens to patients following prehospital care

BackgroundUK prehospital services receive poor information about what happens to patients beyond the prehospital phase of care; this limits the opportunity to assess patient outcomes following non-conveyance. We aimed to...

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

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

Should I stay or should I go?’ Deciding whether to go to hospital after a 999 call

In most UK ambulance services, crews attending someone who has phoned the emergency services on '999' will take the patient to hospital, unless the patient makes the decision to stay at home (or wherever they happen to be when the ambulance arrives). Safety concerns have been raised about non-conveyance decisions. We undertook a study of one UK Ambulance Service to examine ambulance crew members' views on how decision-making about non-conveyance works in practice in relation to non-urgent calls. A total of 25 paramedics took part in three focus groups. Focus groups were transcribed and analysed thematically. The ambulance service's apparently straightforward guidance on decision-making about non-conveyance proved tricky in the messiness of the real world, for two reasons. The first was to do with the notion of the patient's capacity to make decisions and how this was interpreted. The second was to do with the complexity of the decision-making process, in which the patient, the crew and, in many cases, family or carers often take part in negotiation and de facto joint decision-making. There is a mismatch between policy and practice in relation to non-conveyance decisions. Findings should be built into research and service development in this rapidly changing field of practice in emergency and/or unscheduled care. The commonly accepted perspective on shared decision-making should be extended to include the context of '999' ambulance calls.