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Table 2 Summary of qualitative, evidence-based studies (n = 12)

From: Alternatives to direct emergency department conveyance of ambulance patients: a scoping review of the evidence

First author year (ref) Country & sample size Data collection Aim Description of alternate route of care Findings and concluding evidence (and level of support) Level of Evidence +
Blodgett 2017 [13] UK
n = 8
Semi-structured paramedic interviews and observation To investigate paramedic’s perspectives on barriers and motivations on GP referrals. Referral to GP via ambulance scheme Paramedics described:
 i. time, process and training as the major barriers
 ii. their open mindedness and positivity about utilising the scheme
 iii. Frustrations with GP decision making
 iv. gaps in awareness and understanding of scheme.
Brydges 2015 [43] Canada
n = 23
Semi-structured paramedic interviews To investigate paramedic’s perspectives on challenges and opportunities with referrals Referral to community services via Community Care Access Centres Paramedics reported:
 i. confusion in their role
 ii. inadequate knowledge on referral
 iii. no feedback on success of referral
 iv. lack of accountability on use of scheme
 v. desire to provide best care for patient.
Bury 2005 [44] Ireland
n = 11 (surveys)
n = 5 (interviews)
Questionnaire surveys from GP cooperatives
Semi-structured interviews with senior management/ GPs
To describe the preparedness and contribution of GP co-operatives to manage emergencies in the community Referral to GP co-operatives providing out-of-hours services – 3/11 GP co-operatives had formal liaisons with ambulance service.
– 4/8 GP co-operatives received referrals from ambulance services (3 unknown).
– GPs reported uncertainty and anxiety in dealing with 999 referrals due to lack of established structure compared to normal practice.
Hoglund 2019 [45] Sweden
n = 20
Semi-structured interview with ambulance nurses To explore ambulance nurses’ experiences of non- conveying patients to alternate levels of care Transportation or referral to primary healthcare or other healthcare facility (optional consultation with GP) Nurses reported:
 i. desire to find the best pathway of care
 ii. that non-conveyance is demanding and complex task and the main challenges were:
  • misconceptions by patients about ambulance need
  • resources shortages
 iii. Lack of training and mandates to convey to appropriate level of care.
Jones 2005 [46] USA
n = 1058
Cross-sectional surveys with ED patients To assess if patients were willing to accept non-conveyance alternatives including different destination and/or modes of transport Transport to urgent care centres or primary care physician offices or referral to telemedicine Patients were:
 i. willing to consider transport to non-ED alternatives (69%)
 ii. more likely to consider alternatives if they were: younger, non-white race, lower patient acuity and had lower self-perceived illness severity.
Knowles 2018 [47] UK
n = 49
Semi-structured interviews with managers, paramedics and lead healthcare commissioner from 10 ambulance services in England To explore variation in how ambulance services address non-conveyance for calls ending in telephone advice and discharge at scene Transport or referral to range of different facilities:
 i. walk-in centre
 ii. MIU
 iii. GP
Differences between regional ambulance trusts had a substantial effect on use of alternative options. Main differences included:
 i. senior management’s approach to non-conveyance options (e.g. opportunity vs risky endeavour)
 ii. paramedic skill and training to appropriately triage patients to alternative care routes
 iii. Availability of services and care pathways that facilitate non-conveyance.
Lederman 2019 [48] Sweden
n = 11
Semi-structured interviews with ambulance nurse To explore ambulance clinician’s experiences of assessing non-conveyed patients Alternate transport or referral to:
 i. primary healthcare unit
 ii. MIU
 iii. Community care practitioner
Ambulance nurses reported:
 i. high willingness and recognition of benefits of non-conveyance alternatives
 ii. lack of confidence in decision making
 iii. Lack of organisational support for decision-making
 iv. insufficient training and feedback on non-conveyance decisions (e.g. missed learning opportunities).
Miles 2019 [49] UK
n = 143
Surveys with paramedic using quantitative and qualitative assessment of 6 patient vignettes To:
 i. examine if paramedics can accurately identify the most clinically necessary destination
 ii. .understand what contributes to decision making.
 i. transport to MIU
 ii. referral to GP
 iii. Referral to pharmacist
– Paramedics decisions were made with 69% accuracy.
– Sensitivity of correctly choosing ED: 0.90.
– Specificity of correctly choosing non-ED routes: 0.49.
– Decision-making was influenced by:
 i. patient safety
 ii. risk aversion (e.g. fear of litigation/consequences)
 iii. Comparison of patient’s presentation to normal condition.
Power 2019 [50] Ireland
n = 375
Survey of stakeholder opinions including:
 i. emergency medicine consultants
 ii. paramedics
 iii. Advanced paramedics
To understand stakeholder views on implementing a Treat and Referral care pathway to minimise ED attendance Alternative routes not described, but cover all situations where an ambulance crew offers a disposition other than ambulance transport to an ED – Stakeholders expressed clear support to introduce program into ambulance service.
– There was a consensus that program would improve patient care and clinical judgement of practitioners.
– The following suggestions were made:
 i. clinical audit to demonstrate improved care
 ii. initially implement program for advanced paramedics
 iii. Safety and efficacy of different clinical conditions must be evidence-based before implementation across trust.
Rantala 2018 [51] Sweden
n = 111
Cross-sectional surveys with patients assessed as non-urgent (yellow or green by RETTS) To explore patient’s experiences of the person-centred climate (and construct validity of person-centeredness dimension) Referrals to other level of care (e.g. primary care, GP visit at home) Patients reported that:
 i. the environment was highly person-centred
 ii. their clinical complaints were taken seriously.
Snooks 2005 [52] UK
n = 15
Three focus groups with ambulance crews:
1x pre-intervention
1x post-intervention
1x control group.
The authors describe ambulance crew’s views about non-conveyance to hospital including decision making process, alternate route or care and use of triage protocols Referral to community based services (GP, district nurse, etc.) using Treat & Refer protocols as described in [38] Paramedics described:
 i. positivity about implementing referral scheme across the ambulance service
 ii. difficulties with the scheme including:
  •more training for paramedics
  •patients who were unreceptive to referral
 iii. Ensuring wider support of primary care and community services.
Vicente 2013 [53] Sweden
n = 11
Semi-structured interviews with older patients who were referred To describe the patient experience of being offered an alternative care pathway to ED conveyance Transportation to geriatric care or community emergency care centre as described in [41] Patients reported:
 i. a preference for an alternative to direct conveyance to ED
 ii. a desire to be involved in the decision making.
  1. Abbreviations: ED Emergency Department, EMS Emergency Medical Services, GP General Practitioner, MIU Minor Injury Unit; RETTS Rapid Emergency Triage and Treatment System, UK United Kingdom, USA United States of America