Open access Research Factors influencing the decision to ...Johan Oosterwold,1,2 Dennis Sagel,3 Sivera Berben,4,5,6 Petrie Roodbol,1 Manda Broekhuis7 To cite: Oosterwold J, Sagel D,

1Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732

Open access

Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review

Johan Oosterwold,1,2 Dennis Sagel,3 Sivera Berben,4,5,6 Petrie Roodbol,1 Manda Broekhuis7

To cite: Oosterwold J, Sagel D, Berben S, et al. Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732

► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2018- 021732).

Received 16 January 2018Revised 16 July 2018Accepted 18 July 2018

For numbered affiliations see end of article.

Correspondence toMr. Johan Oosterwold; j. oosterwold@ umcg. nl

Research

© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

AbstrACtbackground The decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital’s emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest.Objective To provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions.Data sources A mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included.study eligibility criteria Only studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included.setting Prehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance.study appraisal and synthesis methods The Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a ‘best fit’ framework synthesis approach.results ED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male–female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision’s outcomes.Conclusion Many non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.

IntrODuCtIOn rationaleAn increasing demand for emergency medical service (EMS) responses is noticeable in many developed countries.1–4 The demand is highest with people aged over 65, and expo-nentially grows with increasing age.4–7 These elderly people need to get appropriate care after ambulance attendance, and this may not always be referral to a hospital’s emergency department (ED). If EMS staff decide that ED attendance is not necessary, the patient can be left at home or referred to another healthcare facility. The possibilities vary by country, and their use is influenced by protocols, protocol adherence and alternative pathways.8–12 Both the increase in numbers of older people and the demand for EMS set challenges for future patient safety and providing the best possible healthcare.13

strengths and limitations of this study

► The broad and empirical nature of the study has made it possible to identify multiple factors that influence the referral decision by emergency med-ical service staff after ambulance emergency atten-dance, and the outcomes of this decision.

► Building on existing general decision-making frame-works, an overarching framework was developed that proved helpful in structuring the influential fac-tors identified.

► A weakness is that not all of the factors identified can be definitely related to the elderly population because, in many studies, the elderly formed part of a broader study population, and the results were not specified by age group.

► The low methodological quality in some of the stud-ies and the considerable age of some of them are limitations of the study.

on March 22, 2020 by guest. P

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2 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732

Open access

Non-conveyance after an emergency ambulance response is an increasing trend in many West-European countries.14 15 Non-conveyance can partly be attributed to patient refusals, minor injuries that are easy to handle and the death of patients. Incorrect decisions by EMS staff on not to convey patients to the ED can lead to health-threat-ening situations and even to death.16–19 Referral to the ED may result in overcrowding and, especially for the elderly population, is associated with higher mortality, delays in receiving critical therapy, patient dissatisfaction, iatrogenic illness, functional decline and adverse events during care.20–25 Correct conveyance decision-making by ambulance staff is therefore relevant, but also very complex due to the many influencing factors.26 27 Further, national protocols do not always provide adequate guid-ance to EMS staff in making conveyance decisions, and guidelines and protocols are not always followed.12 19 28 29 Reasons for non-adherence to protocols are attributed to the individual professional, the organisation, external factors and protocol characteristics (Grol, cited in Ebben et al).30 Due to the large variety in situations, EMS staff often have to rely on their own professional judgement. Factors such as the use of guidelines and protocols, patient preferences, experience of EMS staff, time aspects and the presence of carers can influence ambulance staff when deciding whether to take a patient to the ED.31

Whether EMS staff can adequately determine the medical necessity for an ED evaluation is not easy to define and to measure. A systematic review and meta-analysis showed that there is insufficient evidence to support para-medics determining the medical necessity for ambulance transport.32 A retrospective analysis of ED data showed that 7.1% of patients aged 75+ taken there by ambulance were considered as non-urgent, with the largest number of non-urgent conveyances following falls.33 Currently, researchers are focusing on adequate, community-based, alternative referrals by EMS staff for older people who have fallen.34 35

National protocols can guide EMS staff in making a deci-sion over the conveyance or non-conveyance of an elderly person after an emergency ambulance call, but these protocols cannot cover the full scope of practice. Other factors also influence the conveyance decision-making process in which negotiation or joint decision-making between EMS staff, the patient and sometimes their family in deciding what is best for the patient can also play a pivotal role.19 36 37 In the future, the growing ageing population will have major consequences for the utilisa-tion of EMS and so the conveyance decision, to the ED or elsewhere, after emergency ambulance attendance is of growing importance. Insight into factors that influence this conveyance decision-making is especially important for the population of elderly because avoidable admis-sions may result in functional decline, iatrogenic illness, adverse events, ED overcrowding, excessive interventions and high healthcare costs.38 To increase knowledge about factors that may influence the conveyance decision for the specific group of elderly vulnerable people, after EMS

attendance, there is a need for a full overview of these factors and the impact of the decision.

ObjectivesThe aim of this study is to provide an overview of those factors that influence the decision whether or not to convey an elderly person to the ED after ambulance attendance and the outcomes of such decisions. The find-ings will be summarised in a conceptual framework and are intended to inform practice, policy-makers and future researchers. They can also serve as a basis for developing future EMS conveyance decision-making guidelines for vulnerable elderly people, where special attention is paid to minimising the risk of inappropriate conveyance and use of EMS and ED resources, adverse outcomes and medical legal consequences.

MethODA systematic mixed-studies review (MSR) was chosen to synthesise primary qualitative, quantitative and mixed-methods research studies.39 The integrated design selected is appropriate for complex and context-sensitive interventions, and can provide a deep and highly practical understanding of phenomena in the health sciences.40 This MSR follows recognised guidelines for systematic mixed-studies reviews.39

eligibility criteriaStudies were included if they contained empirical evidence on one or more factors that influenced the conveyance or non-conveyance decision to an ED for an elderly person after being attended by ambulance personnel. In more detail, studies were incorporated if they specifically addressed elderly patients, elderly people were part of a broader age group (eg, all adults), the factors considered could be linked to elderly patients (eg, end-of-life situations, falls) or when general factors were identified that affected all age groups (eg, EMS staff-re-lated factors). Searches were not restricted by publication date or by country, although only publications written in English, Dutch or German were eligible for inclusion. Detailed inclusion and exclusion criteria are provided in online supplementary appendix 1.

Information sourcesThree database searches (PubMed, Embase and CINAHL) were executed in October 2016, and these were updated in April 2018 to identify any relevant research published since the initial search. The search terms covered three areas: (1) ambulance or emergency medical services, (2) ‘conveyance or non-conveyance of patients’ or ‘treat and release’ or ‘referral and consultation’, and (3) ‘deci-sion-making’. The research team performed a broad search in order to include all the potentially relevant articles, meaning that a high percentage of the initial list would not be relevant. Only peer-reviewed articles were included in order to ensure a generally accepted level



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of quality. The full electronic search strategy is shown in online supplementary appendix 2.

study selectionIn this systematic MSR, the support tool ‘StArt’—State of the Art through systematic review—was used in the process of screening for relevant articles.41 All the articles retrieved (n=2412) were checked by one researcher for duplicates and irrelevant studies, and these were removed; the latter phase employed the exclusion criteria shown in table 1. A second reviewer (MB) independently screened a small random sample (5%), and there was full agree-ment on the accepted and rejected studies. Two reviewers (JO and DS) independently assessed the full texts of the remaining subset of 108 articles. Cohen’s kappa was calculated to determine if there was agreement between the two reviewers. The strength of agreement was consid-ered to be ‘good’, κ=0.786 (95% CI 0.652 to 0.919), and differences were resolved by discussion. Finally, 29 articles were accepted for inclusion in the systematic literature review (figure 1).

Data collection processOne researcher (JO) extracted data from the included studies. Characteristics extracted included setting, aim of the study, study design and study population (table 1). Data were also extracted describing factors that influenced the conveyance decision after ambulance attendance. A brief summary of these factors and the subjective/objec-tive outcomes of the decision are shown in table 2.

AppraisalOne author (JO) assessed all the included articles and four authors (PR, DS, SB and MB) each assessed some of them using a multimethod appraisal tool (MMAT, version 2011).39 42 The MMAT has been tested for validity and been used in various systematic MSRs to evaluate the methodological quality by answering four questions regarding recruitment, randomisation (if applicable), appropriateness of outcome measures and attrition rate/completeness of data. The final score reflects the number of criteria satisfied, varying from one criterion met (reported as *) to all criteria met (****). Any disagree-ments in ratings between reviewers were discussed until a consensus was reached.

synthesis of resultsIn this systematic review, a ‘best fit’ framework was used as a starting point for data synthesis.43 Since no suitable framework existed for the topic studied, a ‘best fit’ frame-work was constructed based on two existing models, one describing the process of clinical decision-making by Gillespie and Peterson and the other, the Input-Process-Output (IPO) model of Steiner and Hackman.44–47

The Situated Clinical Decision-Making framework by Gillespie and Peterson is a tool that is often used to assist educators in analysing nursing students, or novice nurses, in their complex and multidimensional clinical decision-making process.44 45 It can also be applied within

EMS practice since these decisions are also made within a dynamic context, knowledge is used from multiple sources, is influenced by all that the profession brings to knowledge and experience and is supported by a range of thinking processes.44 The themes covered by the Situated Clinical Decision-Making framework were incorporated within an IPO model (figure 2).

Finally, the objective and subjective outcomes are added to the framework. The process of data extraction, coding and analysis in this MSR leads to a conceptual framework that describes the factors that actually influence the deci-sion of conveyance, and the subjective and/or objective outcomes of such decisions.

Patient and public involvementThere was no involvement of patients and or public in this study.

resultsstudy selection and characteristicsThis systematic literature review covers 29 articles all published between 1995 and 2018 with the majority (n=19) published after 2010. The studies were mostly carried out in the UK (n=13) and the USA (n=12). The four remaining studies were from Sweden, Poland, Australia and Iran. Sixteen of the studies used quantita-tive research designs, 12 were qualitative and only 1 study used mixed methods. There were eight studies which focused exclusively on elderly people (aged ≥65), and in 10 studies, elderly people were part of a broader age group. In the remaining 11 studies, factors were identi-fied that affected all age groups.

Quality of the studiesUsing the quality criteria discussed earlier, four studies were classed as of low quality (* or **),48–51 15 as average (***)52–66 and 10 as good (****).67–76 Nevertheless, we included all the studies in our analysis but ranked them according to their quality score within the conceptual framework. Ranking was done by taking the average of the MMAT score of the related articles per theme and categorising them as A (≥3 asterisks), B (≥2 and <3 aster-isks) or C (<2 asterisks).

summarising and synthesisThe analysis resulted in a table presenting a priori themes within the ‘best fit’ framework with the relevant specific factors and a short summary of these factors (table 1). If described in the reviewed papers, the subjective and/or objective outcomes were also presented alongside the specific factors.

Macro-level themesGovernmental, societal and professional themes were identified in the literature that influenced the convey-ance decision-making process. One study by Déziel concluded that private EMS services were more likely to convey a patient to the hospital than public EMS services



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Lead

aut

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Eng

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hod

st

udy

incl

udin

g a

ethn

ogra

phi

c st

udy.

Tw

o p

hase

s of

dat

a co

llect

ion:

(1

) sem

istr

uctu

red

in

terv

iew

s, (2

) ob

serv

atio

n, d

igita

l d

iarie

s, fo

cus

grou

ps.

n=88

Pm

edic

, n=

57; S

P

, n=

13; E

MT,

n=

18. E

xper

ienc

e E

MS

st

aff,

<1–

20 y

ears

.

NA

NA

No

***

Sel

ectio

n on

par

ticip

ants

is

uncl

ear,

no in

form

atio

n on

sa

mp

ling.

Per

sse48

(200

2), U

SA

City

of H

oust

on

Em

erge

ncy

Med

ical

S

ervi

ce

To d

eter

min

e if

pro

vid

ing

follo

w-u

p in

form

atio

n ab

out

non-

conv

eyed

eld

erly

p

atie

nts

wou

ld c

hang

e th

e fu

ture

dec

isio

n-m

akin

g b

y p

aram

edic

s.

QU

AN

—p

rosp

ectiv

e ch

art

revi

ew (d

escr

iptiv

e st

udy)

NA

Pm

edic

’sn=

260

≥65

year

s of

age

Yes,

pat

ient

sag

ed ≥

65 re

que

sted

911

serv

ices

.

**D

emog

rap

hic

info

rmat

ion

com

par

ing

grou

ps

in p

hase

1,

2 an

d 3

is m

issi

ng. D

iffer

ence

s b

etw

een

grou

ps

may

ac

coun

t fo

r an

y d

iffer

ence

s in

out

com

es. L

ess

than

60

% b

eing

con

tact

ed a

fter

no

n-co

nvey

ance

. No

pow

er

calc

ulat

ion.

Mur

phy

-Jon

es66

(201

6),

UK

Eng

lish

NH

S a

mb

ulan

ce

trus

t

To e

xplo

re h

ow P

med

ics

mak

e co

nvey

ance

dec

isio

ns

in e

nd-o

f-lif

e ca

re s

ituat

ions

.

QU

AL—

phe

nom

enol

ogic

al

stud

y. S

emis

truc

ture

d

inte

rvie

ws.

n=6

(3 fe

mal

es,3

m

ales

)P

med

ics

age,

24–

42

year

s. W

ork

exp

erie

nce

rang

e 2–

8 ye

ars.

NA

ND

Yes,

nur

sing

hom

ere

sid

ents

.

***

Sm

all s

amp

le s

ize

(n=

6).

Unk

now

n if

dat

a sa

tura

tion

is

reac

hed

. Wor

king

exp

erie

nce

of P

med

ics

≤8 y

ears

.

Sch

aefe

r68 (2

002)

, US

AK

ing

coun

ty E

MS

To d

eter

min

e if

EM

S s

taff

coul

d d

ecre

ase

the

rate

of

con

veya

nce

to t

he E

D,

in p

atie

nts

with

no

urge

nt

conc

erns

, by

iden

tifyi

ng

and

saf

ely

tria

ging

the

m t

o al

tern

ate

care

des

tinat

ions

.

QU

AN

—co

hort

stu

dy.

M

atch

ed h

isto

rical

co

ntro

l gro

up.

ND

EM

T an

d B

LS t

rain

ing.

P

med

ic a

nd A

LS t

rain

ing.

n=36

33;

45.9

% v

ersu

s 47

.4%

m

ales

.

Ran

ge, 0

–104

, M

dn=

33.

No

****

Stu

dy

took

pla

ce w

ithin

B

LS r

esp

onse

tea

ms.

O

ne p

hysi

cian

det

erm

ined

th

e el

igib

ility

for

alte

rnat

e d

estin

atio

n of

car

e b

ased

on

pre

defi

ned

crit

eria

. No

leve

l of a

gree

men

t b

etw

een

phy

sici

ans

was

mea

sure

d.

The

sign

ifica

nt d

iffer

ence

in

des

tinat

ion

of c

are

shou

ld b

e in

terp

rete

d w

ith

caut

ion

bec

ause

of t

he n

on-

rand

omis

ed s

tud

y d

esig

n.

Sno

oks75

(200

4), U

KTw

o am

bul

ance

se

rvic

es in

Wes

t Lon

don

To e

valu

ate

the

effe

ctiv

enes

s of

‘tre

at a

nd

refe

r’ p

roto

cols

.

QU

AN

—co

ntro

lled

tria

l w

ithou

t ra

ndom

isat

ion.

R

un s

heet

ana

lysi

s an

d

anal

ysis

of E

D a

nd G

P

reco

rds.

Fol

low

-up

q

uest

ionn

aire

of n

on-

conv

eyed

pat

ient

s.

ND

Pm

edic

s an

d E

MTs

INT,

n=

788

CO

N,

n=25

1 ,

52%

vs

51%

mal

es (p

=0.

69).

Mea

n ag

e,54

vs

47 y

ears

(p=

0.08

).

No

****

Pow

er c

alcu

latio

n w

as

cond

ucte

d b

ut w

as r

educ

ed

bec

ause

of l

ower

rec

ruitm

ent

to s

tud

y gr

oup

s th

an

antic

ipat

ed. N

o ta

ble

of

pat

ient

cha

ract

eris

tics,

dat

a re

por

ted

in t

ext.

Sno

oks61

(200

5), U

KTw

o am

bul

ance

sta

tions

in

Lon

don

To r

epor

t th

e vi

ews

and

at

titud

es o

f EM

S s

taff

in

conv

eyan

ce d

ecis

ion-

mak

ing

in a

nd in

a n

ew

tria

ge in

terv

entio

n on

for

non-

conv

eyan

ce.

QU

AL—

Phe

nom

enol

ogic

al s

tud

y fo

cus

grou

ps.

n=21

(20

mal

es,1

fe

mal

e)D

urat

ion

of s

ervi

ce,

mea

n (r

ange

in y

ears

): Fo

cus

grou

p 1

, 7

(4–1

6); F

ocus

gro

up 2

, 12

(0.5

–25)

; Foc

us g

roup

3,

8 (4

–16)

.

NA

NA

No

***

Brie

f des

crip

tion

on

qua

litat

ive

dat

a an

alys

is/

cod

ing

pro

ced

ure.

Sno

oks55

(201

4), U

K9

Am

bul

ance

sta

tions

ac

ross

a m

ixed

rur

al

and

urb

an a

rea

in

the

UK

To in

vest

igat

e th

e ef

fect

iven

ess

of a

co

mp

uter

ised

clin

ical

d

ecis

ion

sup

por

t to

ol fo

r em

erge

ncy

par

amed

ics

in c

onve

yanc

e d

ecis

ions

of

old

er p

eop

le w

ho h

ave

falle

n.

QU

AN

—cl

uste

r ra

ndom

ised

con

trol

led

tr

ial.

n=42

Pm

edic

's .

INT,

n=

436

CO

N,

n=34

3≥6

5 ye

ars.

Md

n ag

e IN

T 83

yea

rs C

ON

82 y

ears

.

Yes,

old

er p

eop

le w

ho h

ave

falle

n.**

*S

tud

y is

slig

htly

un

der

pow

ered

.

Tab

le 1

C

ontin

ued

Con

tinue

d



jopen.bmj.com

/B

MJ O


ugust 2018. Dow

nloaded from



Open access

Lead

aut

hor

(yea

r),

coun

try

Aim

Met

hod

Stu

dy

po

pul

atio

n

Qua

lity

app

rais

al

MM

AT

sco

re *

/***

*

Sho

rt o

vera

llcr

itic

al c

ons

ider

atio

nsS

etti

ng

EM

S s

taff

(n)

Pro

fess

iona

lb

ackg

roun

dP

atie

nts

(n)

Ag

e ra

nge

or

mea

n (S

D)

of

pat

ient

sS

pec

ific

eld

erly

po

pul

atio

n

Stu

hlm

iller

54 (2

005)

, U

SA

Cle

vela

nd E

MS

To a

sses

s th

e ab

ility

of

EM

S t

o d

eter

min

e m

edic

al

dec

isio

n-m

akin

g ca

pac

ity

and

in o

bta

inin

g an

info

rmed

re

fusa

l of t

rans

por

t.

QU

AN

—re

tros

pec

tive

obse

rvat

iona

l stu

dy.

A

naly

sis

of r

un

shee

ts, n

on-t

rans

por

t w

orks

heet

s an

d

asso

ciat

ed r

ecor

ded

re

fusa

l cal

ls.

ND

Pm

edic

s an

d o

nlin

e m

edic

al c

omm

and

p

hysi

cian

s.

n=13

745

.9 (2

2.6)

,ra

nge

0–91

No

***

Cal

ls r

and

omly

gen

erat

ed.

Vilk

e50 (2

002)

, US

AS

an D

iego

Med

ical

S

ervi

ces

Ent

erp

rise

To o

bta

in in

form

atio

n an

d

exp

erie

nces

of p

atie

nts

(≥65

yea

rs o

f age

) who

r e

fuse

d t

rans

por

t b

y E

MS

an

d d

eter

min

e th

e p

oten

tial

role

of o

nlin

e p

hysi

cian

–p

atie

nt c

onta

ct.

QU

AN

—p

rosp

ectiv

e ob

serv

atio

nal s

tud

y,

tele

pho

ne s

urve

y an

d

amb

ulan

ce r

ecor

ds

anal

ysis

.

NA

EM

T-P

s, E

MT-

Ds.

n=10

072

.2 (6

.4)

Yes,

pat

ient

s ag

ed ≥

65 a

nd

sign

ed o

ut a

gain

st m

edic

al

advi

ce .

**T e

lep

hone

sur

vey

with

p

ossi

bili

ty o

f rep

ortin

g b

ias.

Of

the

tota

l sam

ple

pop

ulat

ion,

16

% o

f the

pat

ient

s w

ere

reac

hed

by

tele

pho

ne a

nd

agre

ed (1

00/6

36).

Dat

a co

llect

ion

tool

was

not

va

lidat

ed.

Wal

dro

n56 (2

012)

, US

AH

osp

ital-

bas

ed

amb

ulan

ce s

ervi

ce in

N

ew Y

ork

To d

eter

min

e if

ther

e is

an

ass

ocia

tion

bet

wee

n E

MT

gend

er a

nd t

he

pat

ient

s d

ecis

ion

to r

efus

e co

nvey

ance

to

the

hosp

ital

by

amb

ulan

ce.

QU

AN

—ca

se–c

ontr

ol

stud

y. R

etro

spec

tive

amb

ulan

ce r

ecor

ds

anal

ysis

.

n=32

2 M

ale/

mal

e=27

1 M

ale/

fem

ale

and

fem

ale/

fem

ale=

51

EM

T-B

s, E

MT-

Ps.

Ref

usin

g m

edic

al a

id,

n= 1

61; 4

7.2%

m

ale

Non

ref

usin

g m

edic

al a

id,

n=16

1; 4

8.4%

mal

e

Non

-ref

usal

,53

.1 (2

.6);

Ref

usal

, 53.

6 (1

.5).

No

***

Dat

a on

ass

ocia

tion

and

re

fusa

l of m

edic

al a

id r

ate

retr

ieve

d a

fter

pro

pen

sity

sc

ore

mat

chin

g to

con

trol

for

varia

ble

s.

Wal

dro

p57

(201

5), U

SA

EM

S s

taff

from

an

emer

genc

y m

edic

al

serv

ice

To e

xplo

re a

nd d

escr

ibe

how

EM

S s

taff

asse

ss

and

man

age

end

-of-

life

emer

genc

y ca

lls.

QU

AL—

phe

nom

enol

ogy

in-d

epth

inte

rvie

ws.

n=43

, 77%

mal

esP

med

ic, n

=33

; EM

Ts,

n=10

; age

, 21–

65 y

ears

, m

ean

39 (S

D11

).

NA

NA

No

***

Rig

our

or t

he t

rust

wor

thin

ess

of q

ualit

ativ

e d

ata

anal

ysis

is

des

crib

ed. R

esea

rche

r–p

artic

ipan

t re

latio

nshi

p

uncl

ear.

Wal

dro

p58

(201

4), U

SA

EM

S s

taff

from

an

emer

genc

y m

edic

al

serv

ice

To id

entif

y ho

w E

MS

p

rovi

der

s d

eal w

ith e

nd o

f lif

e ca

lls a

nd d

eter

min

e th

eir

per

ceiv

ed c

onfid

ence

in

man

agin

g th

ese

situ

atio

ns,

and

per

spec

tives

on

imp

rove

d p

rep

arat

ion.

QU

AL—

cros

s-se

ctio

nal

surv

ey. Q

uest

ionn

aire

.n=

178,

79%

mal

es76

EM

T-B

, 102

Pm

edic

. M

ean

year

s of

wor

king

ex

per

ienc

e 12

(SD

9.5

).

NA

NA

No

***

Pow

er a

naly

ses

was

not

co

nduc

ted

. Par

ticip

ants

wer

e in

vite

d t

o b

e in

terv

iew

ed.

Zor

ab59

(201

5), U

KS

outh

Wes

tern

A

mb

ulan

ce S

ervi

ce

NH

S F

ound

atio

n Tr

ust

To id

entif

y ho

w E

MS

sta

ff as

sess

hea

lth in

form

atio

n;

asce

rtai

n if

a la

ck o

f in

form

atio

n co

uld

lead

to

a su

bop

timal

car

e p

athw

ay;

exp

lore

whe

ther

incr

easi

ng

amou

nt o

f inf

orm

atio

n le

ads

to a

mor

e ap

pro

pria

te

pat

hway

.

QU

AL—

cros

s-se

ctio

nal s

urve

y. O

nlin

e q

uest

ionn

aire

.

n=30

2, 6

3% m

ales

Em

CP

or

CC

P

n=36

Pm

edic

, n=

185

Em

CA

, stu

den

t U

P,

n=58

. Mos

t re

spon

den

ts

(85.

6%) w

ere

aged

b

etw

een

26 a

nd 5

5 ye

ars.

NA

NA

No

***

Res

pon

se r

ate

of 1

2%.

Déz

iel70

(201

7), U

SA

Virg

inia

Dep

artm

ent

of

Hea

lth O

ffice

of E

MS

To id

entif

y an

y d

iffer

ence

s in

the

tra

nsp

ort

dec

isio

n am

ong

agen

cy o

wne

rshi

p

typ

es.

QU

AN

— r

etro

spec

tive

obse

rvat

iona

l stu

dy.

NA

Fire

-bas

ed E

MS

. Non

-fir

e b

ased

EM

S. P

rivat

e or

gani

satio

n no

n-p

rofit

. P

rivat

e or

gani

satio

n fo

r-p

rofit

.

4.6

mill

ion

Mea

n ag

e52

yea

rs.

No

****

Very

larg

e d

atas

et.

Lang

abee

r65 (2

016)

, U

SA

Hou

ston

EM

S

To c

omp

are

the

effe

ctiv

enes

s of

an

alte

rnat

ive

EM

S t

eleh

ealth

d

eliv

ery

mod

el r

elat

ive

to

trad

ition

al E

MS

car

e.

QU

AN

—ob

serv

atio

nal

case

–con

trol

stu

dy.

NA

NA

n=28

7M

dn

age,

IN

T 44

yea

rs C

ON

45 y

ears

.

No

***

Cas

e–co

ntro

l stu

dy,

con

trol

s ar

e m

atch

ed a

fter

war

ds.

C

ontr

ol g

roup

not

mat

ched

on

incl

usio

n cr

iteria

but

on

dem

ogra

phi

c d

ata.

Larr

son71

(201

7),

Sw

eden

Am

bul

ance

org

anis

atio

n of

Sw

eden

To e

xam

ine

early

pre

hosp

ital

asse

ssm

ent

of n

on-u

rgen

t p

atie

nts

and

its

imp

act

on t

he c

hoic

e of

the

ap

pro

pria

te le

vel o

f car

e.

QU

AN

—ex

plo

rato

ry

stud

y b

ased

on

a co

nsec

utiv

e an

d

retr

osp

ectiv

e re

view

of

pat

ient

rec

ord

s.

ND

Am

bul

ance

nur

ses.

INT,

n=

184

CO

N, n

=21

0 A

ged

≥18

yea

rs.

Mea

n ag

e, IN

T 75

.4 y

ears

C

ON

74.

1 ye

ars.

Ran

ge IN

T 23

–96

year

s C

ON

18–

98 y

ears

.

No

****

Com

par

ison

with

retr

osp

ectiv

e co

ntro

l gro

up.

Tab

le 1

C

ontin

ued

Con

tinue

d



jopen.bmj.com

/B

MJ O


ugust 2018. Dow

nloaded from



Open access

Lead

aut

hor

(yea

r),

coun

try

Aim

Met

hod

Stu

dy

po

pul

atio

n

Qua

lity

app

rais

al

MM

AT

sco

re *

/***

*

Sho

rt o

vera

llcr

itic

al c

ons

ider

atio

nsS

etti

ng

EM

S s

taff

(n)

Pro

fess

iona

lb

ackg

roun

dP

atie

nts

(n)

Ag

e ra

nge

or

mea

n (S

D)

of

pat

ient

sS

pec

ific

eld

erly

po

pul

atio

n

Nob

le72

(201

6), U

KN

HS

Am

bul

ance

Tru

sts

To e

xplo

re t

he e

xper

ienc

es

of E

MS

sta

ff m

anag

ing

pat

ient

s w

ith s

eizu

res.

QU

AL—

sem

i str

uctu

red

in

terv

iew

s.n=

19P

med

ic, n

=19

.N

AN

AN

o**

**In

dep

end

ent

and

exp

erie

nced

in

terv

iew

er w

ith a

lread

y va

lidat

ed t

opic

too

l.

Por

ter64

(200

7), U

KN

HS

Am

bul

ance

S

ervi

ce T

rust

To e

xam

ine

EM

S s

taff

’s v

iew

on

how

dec

isio

n-m

akin

g ab

out

non-

conv

eyan

ce

wor

ks in

pra

ctic

e.

QU

AL—

thre

e fo

cus-

grou

p in

terv

iew

s us

ing

a to

pic

gui

de.

n=25

Pm

edic

s, n

=25

.N

AN

AN

o**

*S

hort

and

com

pro

mis

ed

met

hod

sec

tion.

Deg

ree

of in

dep

end

ence

bet

wee

n re

sear

cher

and

gro

up u

ncle

ar.

Sim

pso

n73 (2

017)

, A

ustr

alia

Sta

te-b

ased

Aus

tral

ian

amb

ulan

ce s

ervi

ce

To e

xplo

re t

he d

ecis

ion-

mak

ing

pro

cess

use

d b

y p

aram

edic

s w

hen

carin

g fo

r ol

der

falle

rs.

QU

AL—

grou

nded

th

eory

met

hod

olog

y.

Sem

istr

uctu

red

in

terv

iew

s an

d fo

cus

grou

ps.

n=33

(21

mal

es, 1

2 fe

mal

es)

QP

=16

, IC

P=

11, E

CP

=6

Year

s of

wor

king

ex

per

ienc

e 12

(SD

6)

NA

NA

Yes,

old

er p

eop

le w

ho h

ave

falle

n.**

**D

ata

anal

ysis

and

cod

ing

wer

e d

one

by

one

sing

le

rese

arch

er (a

lso

par

amed

ic),

but

sub

ject

ivity

was

reg

ular

ly

chec

ked

dur

ing

the

anal

ysis

an

d c

halle

nged

by

mem

ber

s of

the

res

earc

h te

am.

Sno

oks74

(201

7), U

KTh

ree

UK

am

bul

ance

se

rvic

es

To d

eter

min

e cl

inic

al a

nd

cost

-effe

ctiv

enes

s of

a

par

amed

ic p

roto

col f

or

the

care

of o

lder

peo

ple

w

ho fa

ll.

QU

AN

—cl

uste

r ra

ndom

ised

tria

l.n=

215

Pm

edic

s, n

=21

5.IN

T, n

=23

91

CO

N, 2

264

INT

82.5

4 (7

.97)

CO

N 8

2.14

(8.1

1)

Yes,

age

d≥6

5 ye

ars.

****

Sel

f-re

por

ted

out

com

e re

sults

sh

ould

be

inte

rpre

ted

with

ca

utio

n. R

esp

onse

rat

e w

as

very

low

, with

hig

h ris

k of

se

lect

ion

bia

s.

Vill

arre

al76

(201

7), U

KW

est

Mid

land

s A

mb

ulan

ce S

ervi

ce

To e

valu

ate

the

imp

act

of a

ser

vice

dev

elop

men

t in

volv

ing

a p

artn

ersh

ip

bet

wee

n E

MS

cre

w a

nd G

Ps

on r

educ

ing

conv

eyan

ce

rate

s to

the

ED

.

QU

AN

—on

e gr

oup

pos

t-te

st o

nly

des

ign.

ND

Pm

edic

sn=

1903

63.1

% o

f stu

dy

pop

ulat

ion

aged

≥6

1 ye

ars.

No

****

No

cont

rol g

roup

, no

dat

a on

ou

tcom

e.

Will

iam

s67 (2

018)

, US

AW

ake

Cou

nty

Em

erge

ncy

Med

ical

S

ervi

ces

To d

eter

min

e w

heth

er

unne

cess

ary

tran

spor

t ca

n b

e av

oid

ed.

QU

AN

—P

rosp

ectiv

e co

hort

stu

dy.

ND

Pm

edic

sn=

840

85.5

(8.3

) yea

rs.

Yes

****

‘Tim

e-se

nsiti

ve’ o

utco

me

mea

sure

s se

em t

o b

e so

mew

hat

rand

om c

hose

n.

ALS

, ad

vanc

ed li

fe s

upp

ort;

BLS

, bas

ic li

fe s

upp

ort;

ED

, em

erge

ncy

dep

artm

ent;

Em

CP,

em

erge

ncy

med

ical

car

e p

ract

ition

er; E

MS

, em

erge

ncy

med

ical

ser

vice

; EM

T 2,

em

erge

ncy

med

ical

tec

hnic

ian

(sup

ervi

sed

pat

ient

ass

essm

ent);

EM

T 3,

em

erge

ncy

med

ical

te

chni

cian

(uns

uper

vise

d p

atie

nt a

sses

smen

t); G

P, g

ener

al p

ract

ition

er; M

MAT

, mix

ed-m

etho

ds

app

rais

al t

ool;

NA

, not

ap

plic

able

; ND

, not

des

crib

ed; N

HS

, Nat

iona

l Hea

lth S

ervi

ce; P

med

ics,

par

amed

ics;

PTL

, par

amed

ic t

eam

lead

er; Q

UA

L, q

ualit

ativ

e re

sear

ch; Q

UA

N,

qua

ntita

tive

rese

arch

; RN

, reg

iste

red

nur

se.

Tab

le 1

C

ontin

ued



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(likelihood of conveyance by private EMS service is 4.5 times greater than with a public service).70

Within the society theme, the factor ‘Presence or absence of alternative care destinations for low-acuity diagnoses’ was mentioned as an important reason for conveyance to the ED.52 63 68 72 Where there were alter-native destinations (other than referral to the hospital), Schaefer et al found a decrease in the proportion of non-acuity patients who were referred to the ED relative to a historical control group (51.8% vs 44.6%, p=0.001). No increase in medical morbidity resulted from this reduction in hospital referrals, and the patients with alternative care destinations were satisfied with their care.68

Within the profession theme, ‘being held liable’ was found to be an important factor leading to possibly unnecessary conveyance to the ED.52 62–64 66 EMS staff feared being held responsible for a patient’s welfare, and opted for the safe option of referral to the ED rather than ‘treat and release’.

Meso-level themesThree themes on the meso level had been identified as influencing the conveyance decision after an emer-gency ambulance call: ‘EMS organisational structure’, ‘availability of appropriate resources and/or persons’ and ‘workload’. Most of the factors identified were within the ‘EMS organisational structure’ theme. Four studies52 63 64 73 reported that low confidence in the organisational support led to decisions reflecting mini-mising risk and thus conveyance to the ED. Opera-tional demands, such as minimising on-scene time and reducing the number of conveyance rates, were factors in the decision-making process, but were counter-produc-tive. Non-conveyance decisions are often more complex and time consuming and therefore increasing on-scene time.61 62 72 73

An important factor within the ‘availability of appro-priate resources and/or persons’ theme is the presence of clear directives or protocols. EMS staff indicated that conveyance protocols could give legitimacy to informal

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the selection process. EMS, emergency medical service.



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Tab

le 2

D

ata

extr

actio

n ta

ble

Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

Gov

ernm

ent

Typ

e of

org

anis

atio

n, p

ublic

or

priv

ate.

Priv

ate

EM

S s

ervi

ces

are

mor

e lik

ely

to c

onve

y a

pat

ient

to

the

hosp

ital t

han

pub

lic E

MS

se

rvic

es (l

ikel

ihoo

d o

f con

veya

nce

by

priv

ate

EM

S s

ervi

ce is

4.5

tim

es g

reat

er t

han

with

a

pub

lic s

ervi

ce).

70A

1

Soc

iety

Pre

senc

e or

ab

senc

e of

al

tern

ativ

e ca

re d

estin

atio

ns

(for

low

-acu

ity d

iagn

oses

).

Com

par

ed w

ith t

he p

rein

terv

entio

n gr

oup

:

►S

mal

ler

pro

por

tion

of p

atie

nts

in t

he

inte

rven

tion

grou

p r

ecei

ved

car

e in

the

ED

(p

=0.

001)

.

►G

reat

er p

rop

ortio

ns o

f pat

ient

s in

the

in

terv

entio

n gr

oup

rec

eive

d c

linic

car

e (p

=0.

001)

or

hom

e ca

re (p

=0.

043)

.Fa

ctor

s in

crea

sing

con

veya

nce:

►N

o sa

fe e

nviro

nmen

t fo

r re

cove

ry o

r ab

senc

e of

inve

stig

atio

n an

d t

reat

men

t op

tions

, if

req

uire

d.

►

Lack

of a

cces

s to

alte

rnat

ive

serv

ice

and

co

mm

unity

res

ourc

es.

►

Lim

ited

aw

aren

ess

of a

ltern

ativ

e ca

re o

ptio

ns

by

EM

S s

taff.

5 ou

t of

81

pat

ient

s w

ere

initi

ally

re

ferr

ed t

o an

alte

rnat

ive

care

d

estin

atio

n b

efor

e p

roce

edin

g on

to

the

ED

. No

med

ical

mor

bid

ity r

esul

ted

from

th

is d

elay

.P

atie

nts

who

wer

e re

ferr

ed t

o an

al

tern

ativ

e ca

re d

estin

atio

n w

ere

satis

fied

with

the

ir ca

re.

68A

4

►

Con

veya

nce

dec

isio

ns a

fter

a p

rimar

y ca

re

or p

sych

osoc

ial r

esp

onse

are

com

ple

x an

d

time-

cons

umin

g, m

akin

g co

nvey

ance

mor

e lik

ely.

52 6

3 72

Shi

ft o

f em

erge

ncy

call

pro

file

(from

prim

arily

em

erge

ncy

care

d

ecis

ions

to

prim

ary

care

and

p

sych

osoc

ial c

are)

.

63A

1

Pro

fess

ion

52 6

1 63

64

66 6

9

Bei

ng h

eld

liab

le.

Pot

entia

lly in

crea

ses

conv

eyan

ce r

ate

due

to:

►

Fear

of E

MS

pro

vid

ers

of b

eing

hel

d

resp

onsi

ble

and

liab

le fo

r a

pat

ient

’s w

elfa

re.

►

Anx

iety

ass

ocia

ted

with

dec

isio

ns a

nd

pot

entia

l rep

ercu

ssio

ns w

hen

dec

idin

g no

t to

con

vey—

conv

eyan

ce t

o th

e E

D w

as

cons

ider

ed t

he ‘d

efau

lt sa

fety

net

’.

52 6

1 63

64

66 6

9A

6 Con

tinue

d



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Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

EM

S

orga

nisa

tiona

l st

ruct

ure

52 6

3 64

Lack

of p

erce

ived

or

gani

satio

nal s

upp

ort/

cove

rage

.

►

Less

per

ceiv

ed s

upp

ort

lead

s to

low

-ris

k d

ecis

ions

, tha

t is

, con

veya

nce

to t

he E

D.

►

Lack

of c

onfid

ence

in o

rgan

isat

iona

l sup

por

t af

ter

an in

cid

ent.

52 6

3 64

A4

Op

erat

iona

l dem

and

s.

►P

ress

ure

exp

erie

nced

by

EM

S s

taff

to

min

imis

e on

-sce

ne t

ime

and

to

red

uce

conv

eyan

ce r

ates

(cou

nter

-pro

duc

tive

per

form

ance

ind

icat

ors)

.

►N

on-c

onve

yanc

e d

ecis

ions

: oft

en m

ore

com

ple

x an

d t

ime

cons

umin

g (in

crea

sed

on-

scen

e tim

e).

►

Hos

pita

l del

ays

imp

act

heav

ily o

n E

MS

sta

ff d

ecis

ion-

mak

ing.

►

Non

-con

veya

nce

rate

s go

up

in s

ituat

ions

of

exte

nsiv

e ho

spita

l del

ays.

63 6

4 72

73

A5

Eq

uip

men

t.

►N

o ac

cess

to,

or

def

ectiv

e, e

ssen

tial

equi

pm

ent

lead

ing

to c

onve

yanc

e.62

A1

Wor

kloa

d

61 6

2

Influ

ence

of s

ervi

ce s

truc

ture

.

►O

per

atio

nal c

ircum

stan

ces

such

as

a d

ifficu

lt sh

ift, a

bus

y sh

ift o

r b

eing

at

the

end

of a

sh

ift le

adin

g to

the

eas

iest

op

tion,

tha

t is

, co

nvey

ance

.

61 6

2A

2

Ava

ilab

ility

of

app

rop

riate

re

sour

ces/

per

sons

58

Tab

le 2

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ontin

ued

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tinue

d



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Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

Ava

ilab

ility

of c

lear

dire

ctiv

es

or p

roto

cols

.

►Fi

eld

-bas

ed d

ecis

ion-

mak

ing

with

out

clea

r d

irect

ives

in e

nd-o

f-lif

e ca

re is

con

sid

ered

p

rob

lem

atic

and

driv

es u

p c

onve

yanc

e ra

tes.

►

Intr

oduc

tion

of T

&R

pro

toco

ls d

id n

ot c

hang

e th

e p

rop

ortio

n of

pat

ient

s le

ft a

t th

e sc

ene

(inte

rven

tion

grou

p 9

3/25

1 vs

con

trol

gro

up

195/

537,

(p=

0.9)

).

58A

3

1. P

atie

nt s

atis

fact

ion

scor

es w

ere

sign

ifica

ntly

hig

her

afte

r in

trod

ucin

g T&

R g

uid

elin

es: r

ight

am

ount

of

advi

ce (p

=0.

04);

reas

sure

d b

y th

e ad

vice

(p=

0.02

); cl

arity

whe

n as

king

fo

r m

ore

help

(p=

0.03

).2.

Pat

ient

s’ s

atis

fact

ion

with

EM

S c

rew

in

crea

sed

(p=

0.02

).3.

Med

ian

job

cyc

le t

ime

was

8 m

in

long

er fo

r no

n-co

nvey

ed p

atie

nts

(p<

0.00

01).

4. 3

/93

pat

ient

s in

the

inte

rven

tion

grou

p a

nd 3

/195

pat

ient

s in

the

co

ntro

l gro

up w

ere

left

at

hom

e b

ut

shou

ld h

ave

bee

n ta

ken

to t

he E

D.

75

►

EM

S s

taff

rep

orte

d in

crea

sed

con

fiden

ce,

job

sat

isfa

ctio

n an

d c

onsi

sten

cy in

the

ir as

sess

men

t an

d d

ecis

ion-

mak

ing

afte

r th

e in

trod

uctio

n of

pro

toco

ls.

61

Pro

visi

on o

f ob

ject

ive

feed

bac

k in

form

atio

n.

►C

hang

es in

the

pra

ctic

e of

par

amed

ics

whe

n p

rovi

ded

with

ob

ject

ive

outc

ome

dat

a. P

aram

edic

s b

ecam

e se

lf-m

otiv

ated

to

imp

rove

car

e.

1. N

o si

gnifi

cant

diff

eren

ce b

efor

e an

d a

fter

the

inte

rven

tion

in r

elat

ion

to p

atie

nts

who

sou

ght

med

ical

he

lp a

nd r

equi

red

ad

mis

sion

with

in

24 h

ours

of E

MS

con

tact

and

pat

ient

r e

fusa

ls.

2. P

atie

nt s

atis

fact

ion

incr

ease

d a

fter

th

e in

terv

entio

n to

100

% (p

=0.

03).

48B

3

►

Lack

of f

eed

bac

k on

ref

erra

l out

com

e w

as

exp

erie

nced

as

frus

trat

ing.

69

►

Lim

ited

acc

ess

to fe

edb

ack

on r

efer

ral

dec

isio

ns w

as b

arrie

r to

ind

ivid

ual a

nd

orga

nisa

tiona

l lea

rnin

g an

d im

pro

vem

ent.

63

Per

sona

l and

rol

e-re

late

d fa

ctor

s 51

Tab

le 2

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ontin

ued

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Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

Kno

win

g th

e p

rofe

ssio

nE

duc

atio

nal b

ackg

roun

d,

com

pet

enci

es a

nd s

kills

.

►P

aram

edic

s on

the

ir ow

n p

rovi

ded

si

gnifi

cant

ly m

ore

aid

and

less

freq

uent

ly

conv

eyed

tha

n nu

rses

in a

sim

ilar

pos

ition

(p

=0.

000)

.

51B

5

►

Par

ticul

ar E

CP

s us

e a

hyp

othe

tico-

ded

uctiv

e ap

pro

ach

to d

ecis

ion-

mak

ing

com

par

ed

with

the

pat

tern

-bas

ed d

ecis

ion-

mak

ing

app

roac

h.

►E

CP

s w

ere

mor

e lik

ely

to t

reat

pat

ient

s at

the

sc

ene

than

par

amed

ics

(p=

0.00

7).

►

The

trai

ning

, com

pet

ence

and

con

fiden

ce

of t

he E

CP

s se

emed

to

imp

rove

the

ir d

ecis

ion-

mak

ing

pro

cess

, with

a s

igni

fican

t im

pac

t on

res

ourc

es (a

mb

ulan

ce u

se, E

D

pre

sent

atio

ns).

►

EC

Ps

wer

e m

ore

likel

y to

con

sid

er t

he la

test

ev

iden

ce in

det

erm

inin

g th

eir

pra

ctic

e.

Non

e of

the

EC

Ps’

or

par

amed

ics’

p

atie

nts

who

wer

e tr

eate

d a

t th

e sc

ene

wer

e su

bse

que

ntly

con

veye

d w

ithin

24

hou

rs (o

ne r

epea

t ca

ll to

an

EC

P-

trea

ted

pat

ient

who

had

falle

n fo

r a

seco

nd t

ime)

.E

duc

atio

n an

d e

xper

ienc

e in

min

or

inju

ry u

nit

gave

the

EC

Ps

the

com

pet

ence

and

con

fiden

ce t

o tr

eat

pat

ient

s at

the

sce

ne.

53 7

3

►

Lack

of t

rain

ing,

dev

elop

men

t an

d s

kill

use

inhi

bits

the

com

pet

ence

and

con

fiden

ce

of p

aram

edic

s in

dea

ling

with

sp

ecifi

c, a

nd

esp

ecia

lly lo

w a

cuity

, dec

isio

n-m

akin

g in

ca

ses

of n

on-c

onve

yanc

e.

63 7

2 73

Rol

e p

erce

ptio

n.

►In

div

idua

l par

amed

ic p

erce

ptio

n of

wha

t th

e ro

le o

f a p

aram

edic

is d

eter

min

es t

he n

atur

e th

e d

ecis

ion-

mak

ing

pro

cess

.

►P

aram

edic

s se

e th

emse

lves

as

high

ly t

rain

ed

to m

anag

e p

atie

nts

with

life

-thr

eate

ning

co

nditi

ons

and

do

not

see

‘low

-acu

ity’ w

ork

as t

heir

job

.

73A

1

Per

sona

l and

rol

e-re

late

d fa

ctor

s 52

61–

64 6

9 72

73

Kno

win

g th

e se

lfE

xper

ienc

e an

d c

onfid

ence

.

►P

rior

exp

erie

nce

or w

orki

ng e

xper

ienc

e af

fect

s co

nvey

ance

-rel

ated

dec

isio

ns.

52 6

1–64

69

72 7

3A

9

►

EM

S s

taff

mus

t ha

ve a

hig

h le

vel o

f co

nfid

ence

and

/or

exp

erie

nce

in d

ealin

g w

ith

do-

not-

resu

scita

te a

nd m

edic

al o

rder

s fo

r lif

e-su

stai

ning

tre

atm

ent

situ

atio

ns.

58

Tab

le 2

C

ontin

ued

Con

tinue

d



jopen.bmj.com

/B

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ugust 2018. Dow

nloaded from



Open access

Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

Gen

der

of E

MS

sta

ff.

►M

ale/

mal

e te

ams

wer

e 4.

75 t

imes

mor

e lik

ely

to g

ener

ate

an R

MA

tha

n te

ams

with

at

leas

t on

e fe

mal

e (O

R 4

.75,

95%

CI 1

.63

to 1

3.96

, p

<0.

0046

).

56A

1

Hea

lth s

tatu

s of

EM

S s

taf f.

►

EM

S s

taff

’s p

hysi

cal c

ond

ition

affe

cts

thei

r d

ecis

ion-

mak

ing

abili

ty. P

hysi

cal

pro

ble

ms

may

neg

ativ

ely

affe

ct E

MS

sta

ff’s

co

ncen

trat

ion,

res

ultin

g in

inad

equa

te

conv

eyan

ce d

ecis

ions

.

62A

1

Per

sona

l and

rol

e-re

late

d fa

ctor

s 56

62

69

Kno

win

g th

e ca

seA

deq

uate

kno

wle

dge

-rel

ated

to

pat

hop

hysi

olog

y.

►P

rese

nce

of a

ser

ious

dis

ease

, ob

viou

s ac

ute

sign

s an

d s

ymp

tom

s, a

nd p

erce

ived

un

pre

dic

tab

ility

of t

he d

isea

se r

esul

t in

tr

ansp

orta

tion

to t

he E

D.

56 6

2 69

A3

Kno

win

g th

e p

erso

n/p

atie

ntE

duc

atio

nal s

tatu

s of

pat

ient

(o

r fa

mily

).

►C

omm

unic

atin

g an

d in

tera

ctin

g w

ith p

atie

nt

and

fam

ily m

emb

ers

with

hig

her

or lo

wer

ed

ucat

iona

l sta

tus

can

affe

ct t

he c

onve

yanc

e d

ecis

ion

bot

h p

ositi

vely

and

neg

ativ

ely.

62A

1

Men

tal c

apac

ity o

f the

pat

ient

.

►P

olic

y an

d p

roto

cols

dic

tate

ED

con

veya

nce

in c

ases

wer

e E

MS

sta

ff fin

ds

the

pat

ient

s in

cap

able

of m

akin

g th

eir

own

dec

isio

ns (e

g,

drin

king

alc

ohol

).

64A

1

Per

sona

l and

rol

e-re

late

d fa

ctor

s 62

Kno

win

g th

e p

erso

n/p

atie

ntFi

nanc

ial s

tatu

s/in

sura

nce

cove

rage

.

►Th

ose

who

hav

e b

ette

r fin

anci

al s

tatu

s ca

n in

sist

, des

pite

the

ad

vice

of E

MS

, on

conv

eyan

ce t

o E

D. P

atie

nts

in fi

nanc

ial

pro

ble

ms

and

no

insu

ranc

e as

k to

man

age

thei

r p

rob

lem

s at

hom

e.

62B

2

►

Fina

ncia

l rea

sons

pla

y a

maj

or r

ole

in t

he

dec

isio

n-m

akin

g in

eld

erly

pat

ient

s af

ter

an

emer

genc

y ca

ll.

70%

of e

lder

ly p

atie

nts

who

ref

use

tran

spor

t to

the

hos

pita

l rec

eive

d

follo

w-u

p c

are,

of w

hom

32%

wer

e ad

mitt

ed t

o ho

spita

l. A

vera

ge r

atin

g of

p

aram

edic

car

e w

as 8

.1±

1.1.

50

Tab

le 2

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ontin

ued

Con

tinue

d



jopen.bmj.com

/B

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ugust 2018. Dow

nloaded from



Open access

Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

Sp

ecia

l pat

ient

gro

ups.

Sp

ecia

l pat

ient

gro

ups,

suc

h as

:1.

Pat

ient

s w

ho h

old

str

ateg

ic m

anag

emen

t or

ad

min

istr

ativ

e p

ositi

ons.

2. E

lder

ly p

eop

le w

ho li

ve a

lone

. Stu

den

ts w

ho

dev

elop

pro

ble

ms

at s

choo

l.3.

Cul

prit

s an

d p

rison

ers.

4. F

orei

gner

s.Th

ese

pat

ient

s ha

ve t

o b

e co

nvey

ed

irres

pec

tive

of t

he s

ever

ity o

r th

e se

rious

ness

of

the

pro

ble

m.

62A

1

Lack

of a

cces

s to

bac

kgro

und

m

edic

al in

form

atio

n.

►La

ck o

f hea

lth in

form

atio

n in

crea

ses

likel

ihoo

d o

f bei

ng c

onve

yed

as

it is

see

n as

th

e ‘e

asy

optio

n’.

52 5

7 59

69

72A

5

PR

OC

ES

S

61 6

9

Cue

sIn

tuiti

on/in

stin

ct.

►

Inst

inct

and

intu

ition

, aft

er t

alki

ng t

o a

pat

ient

, wer

e na

med

as

fact

ors

that

in

fluen

ced

the

con

veya

nce

dec

isio

n.

61 6

9A

2

Use

of d

ecis

ion

sup

por

t to

ols

Use

of a

dec

isio

n to

ol.

►

In c

ases

of i

nitia

l ref

usal

, con

veya

nce

of

high

-ris

k p

atie

nts

to t

he E

D in

crea

sed

aft

er

usin

g a

high

-ris

k cr

iteria

che

cklis

t b

y E

MS

st

aff (

3% v

s 10

%).

Tran

spor

t of

pat

ient

s w

ithou

t hi

gh-r

isk

dec

reas

ed (1

8% v

s 5%

, si

gnifi

cant

find

ing)

.

Pat

ient

s w

ith h

igh-

risk

crite

ria w

ho

wer

e tr

ansp

orte

d t

o th

e E

D w

ere

mor

e lik

ely

to b

e ad

mitt

ed t

o th

e ho

spita

l th

an p

atie

nts

who

did

not

hav

e hi

gh-

risk

crite

ria (4

8% v

s 5%

, p=

0.03

).

50B

3

►

In c

ases

of f

alls

, pat

ient

s at

tend

ed b

y in

terv

entio

n p

aram

edic

s us

ing

com

put

eris

ed

clin

ical

sup

por

t to

ol w

ere

twic

e as

like

ly t

o b

e re

ferr

ed t

o a

fall

serv

ice

(42/

436,

9.6

%)

com

par

ed w

ith (1

7/34

3, 5

.0%

); O

R 2

.04,

95

% C

I 1.1

2 to

3.7

2). N

on-c

onve

yanc

e ra

te w

as h

ighe

r in

the

inte

rven

tion

grou

p

(non

-sig

nific

ant).

No

diff

eren

ce in

out

com

e b

etw

een

inte

rven

tion

and

con

trol

gro

ups.

55

Tab

le 2

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ontin

ued

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tinue

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jopen.bmj.com

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nloaded from



Open access

Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

►

In c

ases

of f

alls

, pat

ient

s at

tend

ed b

y in

terv

entio

n p

aram

edic

s us

ing

a cl

inic

al

dec

isio

n flo

w c

hart

wer

e m

ore

likel

y to

be

refe

rred

to

falls

ser

vice

s.

Ther

e w

as li

ttle

diff

eren

ce in

the

rat

e of

occ

urre

nce

of s

erio

us a

dve

rse

even

ts b

etw

een

grou

ps.

The

re w

as n

o d

iffer

ence

in o

vera

ll he

alth

care

cos

ts

at 1

or

6 m

onth

s. In

terv

entio

n p

atie

nts

rep

orte

d h

ighe

r sa

tisfa

ctio

n w

ith

inte

rper

sona

l asp

ects

of c

are.

74

PR

OC

ES

S

49 5

4

Inp

ut o

f sig

nific

ant

othe

rsC

onsu

lting

(EM

S) p

hysi

cian

.

►In

cas

es o

f ref

usal

, pho

ne c

onta

ct w

ith

phy

sici

an im

pro

ved

tra

nsp

orta

tion

to t

he E

D

of h

igh-

risk

pat

ient

s w

ithou

t in

crea

sing

the

on

-sce

ne t

ime

(from

3%

to

35%

, sig

nific

ant

find

ing)

.

►Tr

ansp

ort

of p

atie

nts

with

out

high

ris

k d

ecre

ased

(18%

vs

0%, s

igni

fican

t fin

din

g).

►

Sim

ilar

rese

arch

sho

wed

tha

t on

line

cont

act

with

phy

sici

an in

crea

sed

con

veya

nce

to t

he

ED

(32.

1% v

s 8.

3%, p

<0.

001)

.

Pat

ient

s w

ith h

igh-

ris

k cr

iteria

who

w

ere

tran

spor

ted

to

the

ED

wer

e m

ore

likel

y to

be

adm

itted

to

the

hosp

ital

than

pat

ient

s w

ho d

id n

ot m

eet

high

-ris

k cr

iteria

(48%

vs

5%, p

=0.

03).

49 5

4A

9

►

49%

of t

he p

atie

nts

who

ref

used

con

veya

nce

to t

he h

osp

ital s

tate

d t

hat

spea

king

to

a p

hysi

cian

wou

ld in

fluen

ce t

heir

dec

isio

n in

fa

vour

of t

rans

por

t to

the

hos

pita

l.

50

►

Diffi

culty

in m

akin

g co

ntac

t w

ith (o

ut o

f ho

urs)

GP

was

a v

aria

ble

tha

t le

ads

to

conv

eyan

ce t

o th

e E

D.

63

►

Con

sulti

ng a

nov

ice

emer

genc

y p

hysi

cian

us

ually

lead

s to

the

pat

ient

bei

ng c

onve

yed

, w

hile

exp

erie

nced

phy

sici

ans

pro

vid

ed

cons

truc

tive

advi

ce.

62

►

Con

sulti

ng a

n E

MS

phy

sici

an, a

fter

EM

S

asse

ssm

ent

com

bin

ed w

ith a

tria

ge

tool

, lea

ds

to 5

6% a

bso

lute

dec

reas

e in

co

nvey

ance

to

the

ED

(74%

con

trol

vs

18%

in

terv

entio

n, p

<0.

001)

.

65

Tab

le 2

C

ontin

ued

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tinue

d



jopen.bmj.com

/B

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ugust 2018. Dow

nloaded from



Open access

Ref

eren

ces

Cum

ulat

ive

sco

re*

Fact

ors

infl

uenc

ing

the

d

ecis

ion

for

conv

eyan

ceIm

pac

t an

d in

terp

lay

of

the

fact

ors

Sub

ject

ive/

ob

ject

ive

out

com

e

►

Ear

ly d

ialo

gue

bet

wee

n am

bul

ance

nu

rse

and

a G

P, in

pat

ient

s w

ith n

on-

urge

nt m

edic

al c

ond

ition

s, in

fluen

ces

the

conv

eyan

ce d

ecis

ion

in fa

vour

of n

on-

conv

eyan

ce. G

P h

ad a

cces

s to

the

med

ical

hi

stor

y of

the

pat

ient

.

Num

ber

of n

on-c

onve

yanc

e w

as h

ighe

r in

the

inte

rven

tion

grou

p (7

3.9%

vs

36.5

%, p

<0.

001)

. Mea

n tim

e to

ret

urn

to s

ervi

ce w

as s

igni

fican

tly lo

wer

in t

he

inte

rven

tion

grou

p (8

6.88

vs

94.1

2 m

in,

p=

0.00

4).

71

►

Eld

erly

are

less

like

ly t

o b

e co

nvey

ed t

o th

e E

D a

fter

EM

S a

sses

smen

t co

mb

ined

with

a

tria

ge t

ool a

nd G

P c

onsu

ltatio

n (te

lep

hone

ad

vice

or

face

-to-

face

ass

essm

ent

by

GP

).

A t

ime-

sens

itive

con

diti

on o

ccur

red

in

2% o

f the

non

-con

veye

d p

atie

nts

afte

r a

grou

nd le

vel f

all,

des

pite

the

pro

toco

l us

ed (W

illia

ms,

201

8).

67 7

6

PR

OC

ES

S

63

Con

sulti

ng c

olle

ague

s or

oth

er

serv

ices

.

►P

aram

edic

s ha

d p

ositi

ve e

xper

ienc

es

and

rel

atio

nshi

ps

with

out

-of-

hour

s an

d

othe

r se

rvic

es s

uch

as fa

lls t

eam

s, t

here

by

pre

vent

ing

conv

eyan

ce t

o th

e E

D.

63A

1

Unf

amili

arity

with

enh

ance

d

skill

s an

d r

esp

onsi

bili

ties

by

othe

r he

alth

care

pro

fess

iona

ls.

►

Hea

lthca

re p

rofe

ssio

nals

wer

e un

awar

e of

th

e p

aram

edic

’s s

kills

and

res

pon

sib

ilitie

s m

akin

g co

mm

unic

atio

n an

d c

omm

unity

-b

ased

ref

erra

ls d

ifficu

lt.

63A

1

Fram

ing

crew

s ex

pec

tatio

ns

by

dis

pat

cher

.

►In

form

atio

n b

y d

isp

atch

er h

ad t

he p

oten

tial

to in

form

and

fram

e cr

ew e

xpec

tatio

ns,

but

thi

s in

form

atio

n w

as o

ften

lim

ited

and

p

oten

tially

mis

lead

ing.

63 7

3A

2

Vie

ws

of t

he p

atie

nt.

►

EM

S s

taff

felt

that

ep

ilep

sy p

atie

nts

und

erst

ood

the

ir co

nditi

on w

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practice, but did not necessarily influence conveyance rates.61 Effects that were reported after the introduction of new guidelines/protocols were: higher patient satisfac-tion rates,61 increased mean job-cycle time,55 better docu-mentation of clinical assessment,61 75 and increased job satisfaction and confidence of EMS staff.61 Another factor found within this theme was making use of a ‘feedback loop’. When EMS staff were provided with objective feed-back information on non-conveyance responses, their self-motivation to improve care increased,48 63 and this led to individual and organisational learning.63 Under the workload theme, two studies found that attending incidents during difficult or busy shifts, or at the end of a shift, led to taking the easy option of conveying the patient to hospital.61 62

Micro-level themes: dynamics in the decision-making processThe micro level consists of the knowledge that informs EMS staff on the scene, and can be subdivided into six themes: ‘personal and role-related factors’, ‘cues’, ‘judgement’, ‘input of significant others’, ‘thinking’ and ‘evaluation’.

Theme 1: personal and role-related factorsIn terms of personal and role-related factors, deci-sion-making is informed by four knowledge-related aspects: ‘knowing the self’, ‘knowing the profession’, ‘knowing the case’ and ‘knowing the person/patient’.

Most of the information uncovered from our review related to the ‘knowing the self’ aspect. Several factors

influence the conveyance decision: their experience and confidence (where experience was reported as more important than training),58 61 62 64 69 72 73, previous nega-tive experiences,52 63 gender56 and the health status of the EMS staff.62 One study that examined the influence of EMS staff gender on non-conveyance due to patient refusal found that all-male teams were 4.75 times more likely to be confronted with a refusal of medical aid and subsequent conveyance to the ED than all-female and mixed-gender teams.56

Educational background, labelled as the ‘knowing the profession’, also influenced the conveyance decision. It has been reported that paramedics less frequently convey patients to a hospital than nurses.51 Cooper et al and Simpson et al reported that patients seen by an emergency care practitioner (ECP), someone who combines extensive nursing and paramedic skills, were less likely to be conveyed to the ED than those seen by paramedics.53 73 None of the articles investigating this topic provided information on objective outcomes linked to the educational background of the EMS providers. However, Cooper et al did note that there was no differ-ence between paramedics and ECPs in terms of non-con-veyed patients requiring subsequent conveyance to the ED within 24 hours. Simpson et al also reported exten-sively on paramedic role perception as a factor that influ-enced decision-making. Many felt that engagement in fall risk assessment or injury prevention did not fall within the scope of their function.73

Figure 2 A priori theoretical framework of the decision-making process on conveyance by emergency medical service staff (based on Gillespie and Peterson, Steiner and Hackman).44 46 47



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Adequate pathophysiology knowledge was classified under the ‘knowing the case’ aspect. Here, recognition of the presence of a serious disease, obvious acute signs or perceived unpredictability of a disease resulted in direct conveyance to the ED.56 62 69

Finally, five factors were linked to the ‘knowing the person/patient’ aspect. Patients with a better financial status were more likely to be conveyed to the ED.50 62 The majority of the elderly (70%) who were denied convey-ance to the ED because of their poor financial status did receive follow-up care, of which 32% were later admitted to a hospital. Furthermore, the ‘educational status of the patient’ and being a ‘special case’, such as elderly patients who lived alone, prisoners or foreigners, someone who had become incapable of making his/her own decisions were reported as influencing the convey-ance decision.62 64 Lastly, having access to the medical history and/or baseline health information influenced the conveyance decision. In the absence of such informa-tion, conveyance to the ED may be seen as the easiest and safest option.52 58 59 69 72

Theme 2: cuesTwo studies described how intuition or ‘instinct’ influ-enced the conveyance decision.61 69 That is, a feeling based on previous work or clinical experience became a lesson that informed later decisions.

Theme 3: use of decision support toolsUse of a decision support tool increased the conveyance of patients to a specific service for those who had suffered falls rather than to the ED.61 74 No differences in eventual outcomes between the two referral options were found. The EMS staff indicated that experience and intuition had more influence on the conveyance decision than the standardised assessment tool, although high-risk patients who initially refused conveyance were more likely to agree if a checklist tool was used.49

Theme 4: input of significant othersConsulting a physician, either by the EMS staff or by the patient, influenced conveyance rates. When a patient initially refused transport to the hospital, contact with a physician could change the decision in favour of convey-ance to the ED.49 50 54 Telephone discussions between the paramedic, patient and an EMS physician led in one study to a major reduction in ED conveyance rate and in the median response time (from notification to ambulance back in service).71 Another study similarly found that when EMS staff were unable to consult a physician, the patient was more likely to be conveyed to the ED.63 Research investigating partnerships between general practitioners (GPs) and EMS staff showed that face-to-face contact between GP and patient led to lower conveyance rates than when the GP support was only by telephone.67 76

Consulting a colleague or other healthcare provider (members of teams specialising in falls) was also

mentioned as a factor that could prevent unnecessary conveyance to the ED.63

Two studies reported that confident EMS staff were steered by the views of a patient (known to suffer from epilepsy) and believed that the patient understood their situation sufficiently well to be able to make the decision for themselves.52 66

When responding to patients in end-of-life situations, EMS staff would prefer to meet the wishes of the patient if a patient had the capacity for decision-making or if the situation was correctly documented.66

Finally, there is the influence of the dispatcher. EMS crews reported that the information provided by the dispatcher could frame their expectations and influence the decision-making.63 73

Theme 5: judgementJudgement of contextual factors can be used to gather information to support decision-making. A decision to convey to the ED could be influenced by others. Strong reactions from family members, carers or bystanders were mentioned as a reason to prevent or stabilise a crisis and choose the safest option.52 58 64 In addition, any dissat-isfaction by the patient or their family due to a lengthy response time was mentioned as a factor leading to conveyance to alleviate the situation.62

Sometimes, paramedics can seek confirmation from their colleague, and one could be influenced by the other. There were also situations where the colleague had an alternative approach to theirs, including conveying patients against their perceived best interests.66

When non-conveyance is being considered as an option, the EMS staff take into account whether someone should and could be involved in taking further care of the patient. The presence of adequate care/carers was reported as having an influence on this decision.61 69

Conceptual frameworkThe process of data extraction and coding led to a small revision of the framework. The theme ‘Decisions’ was redefined as 'Input of significant others', in order to give a more accurate description of the factors found from the studies. ‘Use of decision support tools’ was added as a new theme. No factors were found related to the theme ‘eval-uation’ and is therefore removed from the conceptual framework. Factors linked to ‘outcomes’ were displayed as objective and subjective outcomes. The revised concep-tual framework is displayed in figure 3.

DIsCussIOnsummary of evidenceThe main aim of this MSR was to provide insight and a deeper understanding of factors that influence the deci-sion regarding conveyance of elderly patients to an ED after an emergency ambulance attendance. Further, we looked at both objective and subjective outcomes related to the conveyance decision such as the occurrence of



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undesirable outcomes and patient-reported outcomes. Findings are presented in an overarching framework that primarily reflects the relatively large influence of factors unrelated to a patient’s condition on the conveyance decision.

Decisions over whether to convey someone to an ED after an emergency ambulance attendance often concern elderly people. An incorrect decision over an elderly person can lead to an increased risk of adverse or health-threatening effects as a result of chronic or multiple diseases, frailty, disability, polypharmacy and social isola-tion.20 21 24 25 77 Consequently, we decided to focus on the elderly in this study. We found 8 of the 29 studies included in our review primarily focused on elderly patients. Most of the studies focused on elderly were related to convey-ance decisions after a fall. The presence or absence of informal carers was mentioned as factor influencing the conveyance decision. In the absence of informal carers, elderly patients are likely to be taken to an ED even if there is no underlying life-threatening condition. These avoidable referrals to the ED can be hazardous, especially for vulnerable elderly people, and puts an additional strain on those treating a large number of acute admis-sions to the ED, and its resources, and also leads to higher healthcare costs.38 78

When broadening our scope and including all age groups, our first relevant finding is that the majority of factors that influence the conveyance decision are not determined by the direct contact between patient and EMS staff. Mainly on the macro and meso levels, and in personal and role-related factors, a variety of non-medical factors are influential. Our review of the literature shows that EMS staff are more likely to decide to convey a patient to the ED if they perceive a lack of organisational support, lack access to, or have defective, equipment, have coun-teracting performance indicators or sense that they are being held responsible for a patient’s health. These find-ings indicate the relevance of patient-unrelated factors in conveyance decisions that might have a significant impact on patient safety, resource use and, ultimately, healthcare costs. Being held liable while, at the same time, experi-encing insufficient organisational support and a ‘shame and blame’ culture can obstruct organisational learning and patient safety, whereas boosting the competences and working conditions of healthcare staff and leader-ship are known to increase the quality of healthcare.79–81 When managers are aware that macro and meso factors can have a major impact on conveyance decisions, and act accordingly, EMS staff can make more effective and efficient decisions.

Figure 3 Conceptual framework of factors affecting the decision of ambulance service personnel regarding conveying adult patients to an emergency department. ED, emergency department; ECP, emergency care practitioner; EMS, emergency medical service; GP, general practitioner; MMAT, mixed-methods appraisal tool; Pmedic, paramedic.



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Several factors, from both the EMS staff and patient perspectives, have been identified as affecting the convey-ance decision-making process. Work experience, and its impact on the confidence of EMS professionals, was often cited as a factor that influenced the conveyance decision. Research on registered nurses in hospitals has similarly demonstrated a positive link between work expe-rience and competence, and showed this had an influ-ence on patient outcomes.82 Higher education levels, permanent employment and participation in educa-tional programmes also boosted employees’ feelings of competence.82 As such, investing in increasing the knowl-edge and skills needed to assess the elderly, and in the expanding options for non-emergency responses, would seem to pay off. Introducing EMS staff with additional specialised knowledge and competences regarding elderly care could improve on-scene care and avoid unnecessary ED admissions. Here, our MSR shows that EMS special-ists were more likely to treat patients at the scene than paramedics, although there was little evidence in terms of different outcomes during the follow-up period.53 73 Further exploring the effect of using EMS specialists in assessing, treating and referring elderly patients should be considered and linked to objective and subjective outcomes.

EMS staff can find it helpful if they can contact a physi-cian in questionable and doubtful situations since this may provide EMS staff with the necessary medical infor-mation to make a correct referral decision. On the micro level, we saw that enabling EMS staff to consult a physi-cian could increase the likelihood of conveying, possibly overlooked, high-risk patients and a decrease in unneces-sary referrals of non-emergency cases to the ED.49 There are also multiple studies that describe how contacting a physician (EMS physician or GP) has a positive influence in cases where a patient initially refuses transfer to the ED.49 50 54 Facilities such as telecare and telehealth can support this consultation process and could be further investigated in order to improve the decision-making process.

A recent systematic review provided us with consider-able data on the outcomes of a decision not to convey a patient to the ED.16 The researchers concluded that, after non-conveyance, 6.1% of the patients again contacted EMS within 24 hours, and up to 19% visited an ED within 48 hours of the initial interaction. In our MSR, we found evidence that being able to refer to alternative care facil-ities, using EMS specialists (ECPs), using referral tools, providing objective feedback to EMS staff and enabling EMS staff to contact a physician were all feasible and safe options to increase the likelihood that patients received the right care in the appropriate place.

However, we also found several factors leading to referrals to the ED when alternative care destinations or non-referral could be a better option. Despite there being a lack of research on the proportion of patients being conveyed while not strictly requiring hospital care, previous research shows that such a decision comes with

risks and disadvantages, such as increased pressure on the ED, longer and often overnight stays in the ED and hospital, which all add to costs.21 23–25 38 To improve the future quality of EMS responses, more data are needed on avoidable conveyance decisions, in terms of the actual numbers, and subsequent research on how to reduce this.

lIMItAtIOnsA possible weakness is that the factors identified cannot be assumed to relate to elderly people because, in many studies, the elderly were just part of a broader study popu-lation, and the results were not specified by age group. In addition, the low methodological quality in some of the studies and the considerable age of some of them are also limitations of the study.

COnClusIOnsMaking a decision to convey an elderly person to the hospital after an emergency ambulance response is not only determined by the assessment of medical conditions, but additional factors also influences this decision. These factors should be taken into account when new guidelines are being developed, or when new research is conducted into conveyance decisions, to ensure that greater insight will be developed on how multiple factors and their inter-play influence the conveyance decision. Given the rapidly increasing number of vulnerable elderly individuals, it is, from both social and medical perspectives, highly rele-vant that EMS responses avoid unnecessary hospitalisa-tion, and that evidence is provided to support future safe conveyance guidelines.

IMPlICAtIOns fOr future reseArChThe low methodological quality in some of the studies, the considerable age of some of them and the broader population covered in many of them mean that further research focused on exploring the factors found in this review within EMS practice and the population of elderly people is warranted. In addition, study could be carried out to quantify the occurrence of preventable admissions to EDs based on the factors identified in this review.

Author affiliations1Department of Health Sciences – Nursing Research, UMC Groningen, Groningen, The Netherlands2NHL Stenden, University of Applied Sciences, Leeuwarden, The Netherlands3Ambulance Department, University Medical Center Groningen, Roden, The Netherlands4Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands5Eastern Regional Emergency Healthcare Network, Radboud University Medical Centre, Nijmegen, The Netherlands6IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands7Operations Department, Faculty of Economics and Business, Groningen, The Netherlands



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Acknowledgements We would like to thank Giles Stacey for his detailed comments on the manuscript.

Contributors All the authors contributed to the study design. Data were collected and selected by JO, DS and MB. Critical appraisal of all the selected articles was divided among PR, DS and MB. JO independently reviewed all the articles and results were compared. Agreement on a definitive appraisal was obtained by discussion. The manuscript was drafted by JO in close collaboration with MB and SB. All the authors approved the final manuscript before submitting.

funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement Additional documentation on the data-collection process and appraisal is available from the corresponding author on reasonable request.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

referenCes 1. Lowthian JA, Cameron PA, Stoelwinder JU, et al. Increasing

utilisation of emergency ambulances. Aust Health Rev 2011;35:63–9. 2. Lowthian JA, Jolley DJ, Curtis AJ, et al. The challenges of population

ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015. Med J Aust 2011;194:574–8.

3. Munjal KG, Silverman RA, Freese J, et al. Utilization of emergency medical services in a large urban area: description of call types and temporal trends. Prehosp Emerg Care 2011;15:371–80.

4. Peacock PJ, Peacock JL, Victor CR, et al. Changes in the emergency workload of the London ambulance service between 1989 and 1999. Emerg Med J 2005;22:56–9.

5. Clark MJ, Purdie J, FitzGerald GJ, et al. Predictors of demand for emergency prehospital care: an Australian study. Prehosp Disaster Med 1999;14:60–6.

6. Svenson JE. Patterns of use of emergency medical transport: a population-based study. Am J Emerg Med 2000;18:130–4.

7. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med 2006;47:317–26.

8. Metcalfe J. Enhancing the care of older people in the community. Nurs Stand 2006;21:35–9.

9. Logan PA, Coupland CA, Gladman JR, et al. Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. BMJ 2010;340:c2102.

10. Gray JT, Walker A. Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire. Emerg Med J 2008;25:168–71.

11. Snooks HA, Halter M, Close JC, et al. Emergency care of older people who fall: a missed opportunity. Qual Saf Health Care 2006;15:390–2.

12. Ebben RH, Vloet LC, van Grunsven PM, et al. Factors influencing ambulance nurses' adherence to a national protocol ambulance care: an implementation study in the Netherlands. Eur J Emerg Med 2015;22:199–205.

13. Samaras N, Chevalley T, Samaras D, et al. Older patients in the emergency department: a review. Ann Emerg Med 2010;56:261–9.

14. Hjälte L, Suserud BO, Herlitz J, et al. Why are people without medical needs transported by ambulance? A study of indications for pre-hospital care. Eur J Emerg Med 2007;14:151–6.

15. Victor CR, Peacock JL, Chazot C, et al. Who calls 999 and why? A survey of the emergency workload of the London Ambulance Service. J Accid Emerg Med 1999;16:174–8.

16. Ebben RHA, Vloet LCM, Speijers RF, et al. A patient-safety and professional perspective on non-conveyance in ambulance care: a systematic review. Scand J Trauma Resusc Emerg Med 2017;25:71.

17. Schmidt MJ, Handel D, Lindsell CJ, et al. Evaluating an emergency medical services-initiated nontransport system. Prehosp Emerg Care 2006;10:390–3.

18. Tiedemann A, Mikolaizak AS, Sherrington C, et al. Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls. Aust N Z J Public Health 2013;37:179–85.

19. Zachariah BS, Bryan D, Pepe PE, et al. Follow-up and outcome of patients who decline or are denied transport by EMS. Prehosp Disaster Med 1992;7:359–64.

20. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993;118:219–23.

21. Covinsky KE, Palmer RM, Fortinsky RH, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc 2003;51:451–8.

22. Schull MJ, Vermeulen M, Slaughter G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004;44:577–85.

23. Wilber ST, Gerson LW, Terrell KM, et al. Geriatric emergency medicine and the 2006 institute of medicine reports from the committee on the future of emergency care in the U.S. health system. Acad Emerg Med 2006;13:1345–51.

24. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006;184:213–6.

25. McMullan JT, Veser FH. Emergency department volume and acuity as factors in patients leaving without treatment. South Med J 2004;97:729–33.

26. Snooks HA, Dale J, Hartley-Sharpe C, et al. On-scene alternatives for emergency ambulance crews attending patients who do not need to travel to the accident and emergency department: a review of the literature. Emerg Med J 2004;21:212–5.

27. Patterson PD, Moore CG, Brice JH, et al. Use of ED diagnosis to determine medical necessity of EMS transports. Prehosp Emerg Care 2006;10:488–93.

28. Arts DL, Voncken AG, Medlock S, et al. Reasons for intentional guideline non-adherence: a systematic review. Int J Med Inform 2016;89:55–62.

29. van de Glind I, Berben S, Zeegers F, et al. A national research agenda for pre-hospital emergency medical services in the Netherlands: a Delphi-study. Scand J Trauma Resusc Emerg Med 2016;24:2.

30. Ebben RH, Vloet LC, Schalk DM, et al. An exploration of factors influencing ambulance and emergency nurses' protocol adherence in the Netherlands. J Emerg Nurs 2014;40:124–30.

31. Mikolaizak AS, Simpson PM, Tiedemann A, et al. Systematic review of non-transportation rates and outcomes for older people who have fallen after ambulance service call-out. Australas J Ageing 2013;32:147–57.

32. Brown LH, Hubble MW, Cone DC, et al. Paramedic determinations of medical necessity: a meta-analysis. Prehosp Emerg Care 2009;13:516–27.

33. Miles J, O’Keeffe C, Jacques R, et al. 17 Exploring ambulance conveyances to the emergency department: a descriptive analysis of non-urgent transports. Emergency Medicine Journal 2017;34:A872–A873.

34. Snooks H, Cheung WY, Close J, et al. Support and Assessment for Fall Emergency Referrals (SAFER 1) trial protocol. Computerised on-scene decision support for emergency ambulance staff to assess and plan care for older people who have fallen: evaluation of costs and benefits using a pragmatic cluster randomised trial. BMC Emerg Med 2010;10:2.

35. Snooks H, Anthony R, Chatters R, et al. Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care. BMJ Open 2012;2:e002169.

36. Selden BS, Schnitzer PG, Nolan FX, et al. The “No-Patient” Run: 2,698 Patients Evaluated but Not Transported by Paramedics. Prehosp Disaster Med 1991;6:135–42.

37. Snooks HA. Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs. Quality and Safety in Health Care 2005;14:251–7.

38. Dwyer R, Gabbe B, Stoelwinder JU, et al. A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities. Age Ageing 2014;43:759–66.

39. Pluye P, Hong QN, Vedel I. Toolkit for mixed studies reviews (V3). Montreal, Canada: Department of Family Medicine, McGill University, and Quebec-SPOR SUPPORT Unit, 2016.

40. Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu Rev Public Health 2014;35:29–45.



jopen.bmj.com

/B

MJ O


ugust 2018. Dow

nloaded from

http://creativecommons.org/licenses/by-nc/4.0/

http://dx.doi.org/10.1071/AH09866

http://www.ncbi.nlm.nih.gov/pubmed/21644869

http://dx.doi.org/10.3109/10903127.2011.561403

http://dx.doi.org/10.1136/emj.2004.016741

http://dx.doi.org/10.1017/S1049023X00027540

http://dx.doi.org/10.1017/S1049023X00027540

http://dx.doi.org/10.1016/S0735-6757(00)90002-0

http://dx.doi.org/10.1016/j.annemergmed.2005.12.001

http://dx.doi.org/10.7748/ns.21.7.35.s47

http://dx.doi.org/10.1136/bmj.c2102


http://dx.doi.org/10.1136/qshc.2006.018697

http://dx.doi.org/10.1097/MEJ.0000000000000133


http://dx.doi.org/10.1097/MEJ.0b013e3280146508

http://dx.doi.org/10.1136/emj.16.3.174

http://dx.doi.org/10.1186/s13049-017-0409-6

http://dx.doi.org/10.1080/10903120600725918

http://dx.doi.org/10.1111/1753-6405.12037

http://dx.doi.org/10.1111/1753-6405.12037

http://dx.doi.org/10.1017/S1049023X00039777

http://dx.doi.org/10.1017/S1049023X00039777

http://dx.doi.org/10.7326/0003-4819-118-3-199302010-00011

http://dx.doi.org/10.7326/0003-4819-118-3-199302010-00011

http://dx.doi.org/10.1046/j.1532-5415.2003.51152.x


http://dx.doi.org/10.1197/j.aem.2006.09.050


http://dx.doi.org/10.1097/00007611-200408000-00006


http://dx.doi.org/10.1080/10903120600886918

http://dx.doi.org/10.1080/10903120600886918

http://dx.doi.org/10.1016/j.ijmedinf.2016.02.009

http://dx.doi.org/10.1186/s13049-015-0195-y

http://dx.doi.org/10.1016/j.jen.2012.09.008

http://dx.doi.org/10.1111/ajag.12023

http://dx.doi.org/10.1080/10903120903144809

http://dx.doi.org/10.1136/emermed-2017-207308.17

http://dx.doi.org/10.1186/1471-227X-10-2

http://dx.doi.org/10.1186/1471-227X-10-2


http://dx.doi.org/10.1017/S1049023X00028259



http://dx.doi.org/10.1093/ageing/afu117

http://dx.doi.org/10.1146/annurev-publhealth-032013-182440

http://dx.doi.org/10.1146/annurev-publhealth-032013-182440



Open access

41. The laboratory of research on software engineering (LaPES). computing department of the federal university of são carlos. 2017. http:// lapes. dc. ufscar. br/ resources- and- downloads/ tools

42. Pace R, Pluye P, Bartlett G, et al. Testing the reliability and efficiency of the pilot Mixed Methods Appraisal Tool (MMAT) for systematic mixed studies review. Int J Nurs Stud 2012;49:47–53.

43. Carroll C, Booth A, Leaviss J, et al. "Best fit" framework synthesis: refining the method. BMC Med Res Methodol 2013;13:37.

44. Gillespie M, Peterson BL. Helping novice nurses make effective clinical decisions: the situated clinical decision-making framework. Nurs Educ Perspect 2009;30:164–70.

45. Gillespie M. Using the situated clinical decision-making framework to guide analysis of nurses' clinical decision-making. Nurse Educ Pract 2010;10:333–40.

46. Steiner I. Group process and productivity. Academic Press 1972. 47. Hackman JR. The design of work teams. In: Lorsch J, ed. Handbook

of organizational behavior. Englewood Cliffs, NJ: Prentice-Hall, 1987:315–42.

48. Persse DE, Key CB, Baldwin JB. The effect of a quality improvement feedback loop on paramedic-initiated nontransport of elderly patients. Prehosp Emerg Care 2002;6:31–5.

49. Alicandro J, Hollander JE, Henry MC, et al. Impact of interventions for patients refusing emergency medical services transport. Acad Emerg Med 1995;2:480–5.

50. Vilke GM, Sardar W, Fisher R, et al. Follow-up of elderly patients who refuse transport after accessing 9-1-1. Prehosp Emerg Care 2002;6:391–5.

51. Aftyka A, Rudnicka-Drożak E, Rybojad B. A comparison of ambulance responses to incidents of Medical Emergency Teams led by nurses and paramedics–A retrospective single-center study. Int J Nurs Stud 2014;51:555–61.

52. Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emerg Med J 2013;30:236–40.

53. Cooper S, Barrett B, Black S, et al. The emerging role of the emergency care practitioner. Emerg Med J 2004;21:614–8.

54. Stuhlmiller DF, Cudnik MT, Sundheim SM, et al. Adequacy of online medical command communication and emergency medical services documentation of informed refusals. Acad Emerg Med 2005;12:970–7.

55. Snooks HA, Carter B, Dale J, et al. Support and assessment for fall emergency referrals (SAFER 1): cluster randomised trial of computerised clinical decision support for paramedics. PLoS One 2014;9:e106436.

56. Waldron R, Finalle C, Tsang J, et al. Effect of gender on prehospital refusal of medical aid. J Emerg Med 2012;43:283–90.

57. Waldrop DP, Clemency B, Lindstrom HA, et al. "We are strangers walking into their life-changing event": how prehospital providers manage emergency calls at the end of life. J Pain Symptom Manage 2015;50:328–34.

58. Waldrop DP, Clemency B, Maguin E, et al. Preparation for frontline end-of-life care: exploring the perspectives of paramedics and emergency medical technicians. J Palliat Med 2014;17:338–41.

59. Zorab O, Robinson M, Endacott R. Are prehospital treatment or conveyance decisions affected by an ambulance crew's ability to access a patient's health information? BMC Emerg Med 2015;15:26.

60. Burstein JL, Hollander JE, Delagi R, et al. Refusal of out-of-hospital medical care: effect of medical-control physician assertiveness on transport rate. Acad Emerg Med 1998;5:4–8.

61. Snooks HA, Kearsley N, Dale J, et al. Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs. Qual Saf Health Care 2005;14:251–7.

62. Ebrahimian A, Seyedin H, Jamshidi-Orak R, et al. Exploring factors affecting emergency medical services staffs' decision about

transporting medical patients to medical facilities. Emerg Med Int 2014;2014:1–8.

63. O'Hara R, Johnson M, Siriwardena AN, et al. A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety. J Health Serv Res Policy 2015;20(1 Suppl):45–53.

64. Porter A, Snooks H, Youren A, et al. Should I stay or should I go?’ Deciding whether to go to hospital after a 999 call. J Health Serv Res Policy 2007;12:32–8.

65. Langabeer JR, Gonzalez M, Alqusairi D, et al. Telehealth-Enabled emergency medical services program reduces ambulance transport to urban emergency departments. West J Emerg Med 2016;17:713–20.

66. Murphy-Jones G, Timmons S. Paramedics' experiences of end-of-life care decision making with regard to nursing home residents: an exploration of influential issues and factors. Emerg Med J 2016;33:722–6.

67. Williams JG, Bachman MW, Lyons MD, et al. Improving decisions about transport to the emergency department for assisted living residents who fall. Ann Intern Med 2018;168:179.

68. Schaefer RA, Rea TD, Plorde M, et al. An emergency medical services program of alternate destination of patient care. Prehosp Emerg Care 2002;6:309–14.

69. Halter M, Vernon S, Snooks H, et al. Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study. Emerg Med J 2011;28:44–50.

70. Déziel J. Effects of emergency medical services agency ownership status on patient transport. Prehosp Emerg Care 2017;21:729–33.

71. Larsson G, Holmén A, Ziegert K. Early prehospital assessment of non-urgent patients and outcomes at the appropriate level of care: A prospective exploratory study. Int Emerg Nurs 2017;32:45–9.

72. Noble AJ, Snape D, Goodacre S, et al. Qualitative study of paramedics' experiences of managing seizures: a national perspective from England. BMJ Open 2016;6:e014022.

73. Simpson P, Thomas R, Bendall J, et al. ‘Popping nana back into bed’ - a qualitative exploration of paramedic decision making when caring for older people who have fallen. BMC Health Serv Res 2017;17.

74. Snooks HA, Anthony R, Chatters R, et al. Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial. Ann Emerg Med 2017;70:495–505.

75. Snooks H, Kearsley N, Dale J, et al. Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews. Qual Saf Health Care 2004;13:435–43.

76. Villarreal M, Leach J, Ngianga-Bakwin K, et al. Can a partnership between general practitioners and ambulance services reduce conveyance to emergency care? Emerg Med J 2017;34:459–65.

77. Hwang U, Shah MN, Han JH, et al. Transforming emergency care for older adults. Health Aff 2013;32:2116–21.

78. van der Linden N, van der Linden MC, Richards JR, et al. Effects of emergency department crowding on the delivery of timely care in an inner-city hospital in the Netherlands. Eur J Emerg Med 2016;23:337–43.

79. Almeida SL. Nursing perspectives on the emergency department. Emerg Med Clin North Am 2004;22117–.

80. Robinson KS, Jagim MM, Ray CE. Nursing workforce issues and trends affecting emergency departments. Nurs Manage 2005;36:46–53.

81. Raup GH. The impact of ED nurse manager leadership style on staff nurse turnover and patient satisfaction in academic health center hospitals. J Emerg Nurs 2008;34:403–9.

82. Flinkman M, Leino-Kilpi H, Numminen O, et al. Nurse competence scale: a systematic and psychometric review. J Adv Nurs 2017;73:1035–50.



jopen.bmj.com

/B

MJ O


ugust 2018. Dow

nloaded from

http://lapes.dc.ufscar.br/resources-and-downloads/tools

http://dx.doi.org/10.1016/j.ijnurstu.2011.07.002

http://dx.doi.org/10.1186/1471-2288-13-37


http://dx.doi.org/10.1016/j.nepr.2010.02.003

http://dx.doi.org/10.1080/10903120290938742

http://dx.doi.org/10.1111/j.1553-2712.1995.tb03244.x


http://dx.doi.org/10.1080/10903120290938003



http://dx.doi.org/10.1136/emermed-2011-200388


http://dx.doi.org/10.1197/j.aem.2005.06.004

http://dx.doi.org/10.1371/journal.pone.0106436

http://dx.doi.org/10.1016/j.jemermed.2011.06.136

http://dx.doi.org/10.1016/j.jpainsymman.2015.03.001

http://dx.doi.org/10.1089/jpm.2013.0442

http://dx.doi.org/10.1186/s12873-015-0054-1



http://dx.doi.org/10.1155/2014/215329

http://dx.doi.org/10.1177/1355819614558472

http://dx.doi.org/10.1258/135581907780318392

http://dx.doi.org/10.1258/135581907780318392

http://dx.doi.org/10.5811/westjem.2016.8.30660


http://dx.doi.org/10.7326/M17-0969

http://dx.doi.org/10.1080/10903120290938355

http://dx.doi.org/10.1080/10903120290938355


http://dx.doi.org/10.1080/10903127.2017.1335817

http://dx.doi.org/10.1016/j.ienj.2017.02.003


http://dx.doi.org/10.1186/s12913-017-2243-y




http://dx.doi.org/10.1377/hlthaff.2013.0670

http://dx.doi.org/10.1097/MEJ.0000000000000268

http://dx.doi.org/10.1097/00006247-200509000-00011

http://dx.doi.org/10.1016/j.jen.2007.08.020

http://dx.doi.org/10.1111/jan.13183


Open access Research Factors influencing the decision to ...Johan Oosterwold,1,2 Dennis Sagel,3 Sivera Berben,4,5,6 Petrie Roodbol,1 Manda Broekhuis7 To cite: Oosterwold J, Sagel D,

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