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Table 4 Competences and influencing factors (n = 18)

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

Authors (publication year) country [ref] Competences/influencing factors Type of factor
Alicandro (1995) USA [29] The implementation of a (1) high risk card (T1) and (2) online medical control (T2) for patients with high-risk criteria improved the transport rate: T0 2/60 (3.3%)- T1 7/70 (10.0%) - T2 12/34 (35.3%) p = .00003 1. Supportive tools
2. Healthcare process/system
Burstein (1998) USA [57] The implementation of medical control by telephone to convince patients who attempt refusal of medical care to be transported to the ED: 61/130 (47%) of the patients was convinced 1. Healthcare process/system
Ebrahimian (2014) Iran [83] Affecting factors of EMS staffs’ decision about transporting:
1. patient’s condition:
 a. Physical health status
 b. Socioeconomic status:
  i. Patient support system
  ii. Patient and his family’s educational status
  iii. Patient and his family’s financial status
c. Cultural background:
  i. Confidence
  ii. Believes and attitudes
2. The context of the EMS mission:
  a. Characteristics of the mission
  b. EMS staffs’ characteristics
1. Patient/relative
2. Healthcare process/system
Halter (2011) UK [84] Influencing factors:
 1. Pre-arrival: forming an early opinion from information from the emergency call
 2. Initial contact: assessing the need for any immediate action and establishing a report
 3. Continuing assessment: gathering and assimilating medical and social information
 4. Making a conveyance decision: negotiation, referral and professional defense using professional experience, instinct
1. Healthcare process/system
Jensen (2013) Canada [64] Extended care paramedics received additional specialized training in the following “extended care” roles:
 1. Geriatric assessments and management
 2. End-of-life care
 3. Primary wound closure techniques (suturing, tissue adhesive)
 4. Point-of-care testing.
LTC patients treated by ECPs remained at the LTC facility in 98 of 140 (70%) cases, compared to 21 of 98(21.4%) of emergency paramedic calls.
1. Professional
Kahalé (2006) Canada [65] Reasons for non-transport as cited in parent/patient interviews (n = 106):
 1. 31/106 (29.2%) EMS-personnel stated that transport was unnecessary
 2. 25/106 (23.6%) parents thought that going to the hospital was unnecessary
 3. 22/106 (20.8%) parents wanted to use another method of transportation to seek medical care
 4. 5/106 (4.7%) parents were concerned about costs related to ambulance transports
 5. 23/106 (21.7%) other
1. Professional
2. Patient/relative
Keene (2015) Australia [85] Reasons for not accepting transport (from fieldnotes):
 1. Just wanted reassurance, assistance, advice or support/ referral
 2. Symptoms had resolved prior to arrival or during assessment
 3. Concern over ED waiting time/ED workload
 4. Prior negative experience with a hospital
 5. Personal reasons: (e.g. ‘I just didn’t want to go’. ‘I was embarrassed by all the fuss’
1. Patient/relative
Mikolaizak (2013) Australia [26] Factors influencing transport decision:
 1. refusal to travel
 2. patient did not sustain an injury/only minor injuries
 3. sufficient on-scene treatment
 4.referral to GP
1. Patient/relative
Murphy-Jones (2016) UK [86] 3 main themes:
1. Patient wishes (insufficient care plans, nursing care staff insufficient knowledge of patients’ wishes, patients’ inability to express their wishes)
2. patients’ best interest (when patients were not considered to have the capacity for decision making, paramedics want to act in their best interest, factors used: diagnosis, comorbidities, quality of life, wishes and current condition, risks and benefits of hospitalization, concerns about care provision in some nursing homes
3. influence of others (nursing home staff, patients’ relatives and other paramedics)
1. Patient/relative
2. Healthcare process/system
O’Hara (2015) UK [87] 7 overarching system influences on decision making:
1. Increasing demand (of non-emergent cases)
2. Performance regime and priorities
3. Access to appropriate care options in case of non-conveyance to an ED
4. Disproportionate risk aversion: non-conveyance was perceived as a risk for both patient and paramedic
5. Beneficial impact of additional training on decision making competences
6. Communication and feedback to crews
7. Ambulance service resources
1. Healthcare process/system
Porter (2007) UK [88] Influencing factors:
1. Patient autonomy
2. Opinion family/carers
3. Clinical need as assessed by crew members
4. Protection of themselves for the risk of litigation by crew members
5. Mental capacity of the patient to make a transport decision
6. Lacking skills or status of the crew member to be judging the mental capacity of the patient
7. Back-up of other professionals
8. Fear of a possible comeback if the non-conveyance decision turned out to be wrong
1. Patient/relative
2. Professional
Simpson (2014a) Australia [74] 6-item predictive model for non-conveyance odds (goodness-of-fit test indicated good model fit (8 DF, χ2 = 7.43, p = 0.49), factors associated with increased odds of a non-conveyance outcome.
1. 65–74 year
2. Lower response priority (90 min response time)
3. The presence of personal alarm
4. The absence of new injury/pain
5. Normal physiology
6. Change in usual level of function post fall
1. Patient/relative
2. Healthcare process/system
Snooks (2005) UK [89] Influencing factors on ED conveyance:
1. Experience and intuition of the paramedic
2. Pragmatism: conveyance – the easy option
3. Patient/carer factors
1. Professional
2. Patient/relative
Stark (1990) USA [49] Predictors for left at Scene Against Medical Advice:
1. Family present (β = −1.87, p = .001)
2. Disorientation (β = −1.04, p = .04)
3. Abnormal speech (β = −1.92, p = .05)
4. Police hold (β = −2.04, p = .03)
5. Alcohol use (β = 1.48, p = .006)
6. Treated hypoglycemia (β = 1.63, p = .05)
1. Patient/relative
2. Healthcare process/system
Stuhlmiller (2005) USA [51] 28/137 (20.4%) patients with whom the online medical control (OLMC) physician spoke during the encounter: 9/28 (32.1%) agreed to be transported, compared with nine (8.3%) of the 109 patients who did not speak to the OLMC physician (p = .001) 1. Supportive tools
Van der Pols (2011) Netherlands [77] Motorcycle response vehicles with one ambulance nurse with additional training (n = 468) compared to regular ambulance (n = 1196): (1) treat and release 129/468 (27.6%) vs 149/1196 (12.5%) RR 2.21 (95%CI 1.80–2.73) 1. Professional
Vilke (2002) USA [78] Patient reasons (n = 100) for patients to refuse transport:
1. 37/100 (37.0%) did not want transport and ED care
2. 23/100 (23.0%) concerned about the cost/coverage of ED
3. 19/100 (19.0%) paramedics implied no transport was needed
4. 17/100 (17.0%) concerned about the cost of the ambulance
5. 4/100 (4.0%) language barrier
1. Patient/relative
Zorab (1999) UK [80] 274/302 (90.7%) paramedics felt that a lack of health information of the patient had led to a less appropriate carepathway being selected, information that could have helped according to paramedics:
1. Resuscitation status (n = 233, 77.2%)
2. Current medication (n = 184, 60.9%)
3. Allergy information (n = 103, 34.1%)
4. Previous medical history (n = 262, 86.8%)
5. Patient’s normal parameters (n = 235, 77.8%)
6. End of life care choices (n = 221, 73.2%)
7. Information about implanted devices, e.g. pacemakers (n = 106, 35.1%)
8.Other, e.g. ECG, mental health records, blood and other test results (n = 38, 1.3%)
1. Professional