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

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Abstract

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.

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Most cited references 28

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Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

Nasim Farrohknia, Maaret Castrén, Anna Ehrenberg … (2011)

Emergency department (ED) triage is used to identify patients' level of urgency and treat them based on their triage level. The global advancement of triage scales in the past two decades has generated considerable research on the validity and reliability of these scales. This systematic review aims to investigate the scientific evidence for published ED triage scales. The following questions are addressed: 1. Does assessment of individual vital signs or chief complaints affect mortality during the hospital stay or within 30 days after arrival at the ED? 2. What is the level of agreement between clinicians' triage decisions compared to each other or to a gold standard for each scale (reliability)? 3. How valid is each triage scale in predicting hospitalization and hospital mortality? A systematic search of the international literature published from 1966 through March 31, 2009 explored the British Nursing Index, Business Source Premier, CINAHL, Cochrane Library, EMBASE, and PubMed. Inclusion was limited to controlled studies of adult patients (≥15 years) visiting EDs for somatic reasons. Outcome variables were death in ED or hospital and need for hospitalization (validity). Methodological quality and clinical relevance of each study were rated as high, medium, or low. The results from the studies that met the inclusion criteria and quality standards were synthesized applying the internationally developed GRADE system. Each conclusion was then assessed as having strong, moderately strong, limited, or insufficient scientific evidence. If studies were not available, this was also noted. We found ED triage scales to be supported, at best, by limited and often insufficient evidence. The ability of the individual vital signs included in the different scales to predict outcome is seldom, if at all, studied in the ED setting. The scientific evidence to assess interrater agreement (reliability) was limited for one triage scale and insufficient or lacking for all other scales. Two of the scales yielded limited scientific evidence, and one scale yielded insufficient evidence, on which to assess the risk of early death or hospitalization in patients assigned to the two lowest triage levels on a 5-level scale (validity).

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Increasing utilisation of emergency ambulances.

Judy Lowthian, Peter A. Cameron, Johannes Stoelwinder … (2011)

Increased ambulance utilisation is closely linked with Emergency Department (ED) attendances. Pressures on hospital systems are widely acknowledged with ED overcrowding reported regularly in the media and peer-reviewed literature. Strains on ambulance services are less well-documented or studied. To review the literature to determine the trends in utilisation of emergency ambulances throughout the developed world and to discuss the major underlying drivers perceived as contributing to this increase. A search of online databases, search engines, peer-reviewed journals and audit reports was undertaken. Ambulance utilisation has increased in many developed countries over the past 20 years. Annual growth rates throughout Australia and the United Kingdom are similar. Population ageing, changes in social support, accessibility and pricing, and increasing community health awareness have been proposed as associated factors. As the extent of their contribution has not yet been established these factors were reviewed. The continued rise in utilisation of emergency ambulances is placing increasing demands on ambulance services and the wider health system, potentially compromising access, quality, safety and outcomes. A variety of factors may contribute to this increase and targeted strategies to reduce utilisation will require an accurate identification of the major drivers of demand.

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

Remco H.A. Ebben, Lilian Vloet, Renate F. Speijers … (2017)

Background This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process. Methods We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction. Results We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%–93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h–48 h after non-conveyance, 2.5%–6.1% of the patients have EMS representations, and 4.6–19.0% present themselves at the ED. Mortality rates vary from 0.2%–3.5% after 24 h, up to 0.3%–6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card). Conclusions Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0409-6) contains supplementary material, which is available to authorized users.

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Author and article information

Contributors

Erik Höglund:

ORCID: http://orcid.org/0000-0001-7885-694X

erik.hoglund@oru.se

Journal

Journal ID (nlm-ta): BMC Emerg Med

Journal ID (iso-abbrev): BMC Emerg Med

Title: BMC Emergency Medicine

Publisher: BioMed Central (London )

ISSN (Electronic): 1471-227X

Publication date (Electronic): 10 August 2020

Publication date PMC-release: 10 August 2020

Publication date Collection: 2020

Volume: 20

Electronic Location Identifier: 61

Affiliations

[1 ]GRID grid.15895.30, ISNI 0000 0001 0738 8966, University Health Care Research Center, Faculty of Medicine and Health, Örebro University, ; Box 1613, 701 16 Örebro, Sweden

[2 ]GRID grid.412442.5, ISNI 0000 0000 9477 7523, Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, , University of Borås, ; Borås, Sweden

[3 ]GRID grid.5947.f, ISNI 0000 0001 1516 2393, Department of Health Sciences in Gjøvik, Faculty of Medicine and Health Sciences, , NTNU – Norwegian University of Science and Technology, ; Gjøvik, Norway

[4 ]GRID grid.15895.30, ISNI 0000 0001 0738 8966, Department of Surgery, Faculty of Medicine and Health, , Örebro University, ; Örebro, Sweden

Author information

Erik Höglund http://orcid.org/0000-0001-7885-694X

Article

Publisher ID: 353

DOI: 10.1186/s12873-020-00353-8

PMC ID: 7418316

PubMed ID: 32778074

SO-VID: e8b23b8c-b923-4380-a67a-74e8cfdf2271

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 20 March 2020

Date accepted : 21 July 2020

Funding

Funded by: FundRef http://dx.doi.org/10.13039/501100009228, Region Örebro län;

Award ID: OLL-674451, OLL-767301, OLL-811401, OLL-840471

Award Recipient : Erik Höglund

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: ambulance,emergency medical services,non-conveyance,non-transport,triage

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: ambulance, emergency medical services, non-conveyance, non-transport, triage

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

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Conclusions

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Preventive and Emergency Medicine Insights

Most cited references 28

Emergency Department Triage Scales and Their Components: A Systematic Review of the Scientific Evidence

Increasing utilisation of emergency ambulances.

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

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