|First author year [ref]||Article type||Country||Description of alternate route of care||Article description and author recommendations||Level of Evidence +|
|Alpert 2005 ||Commentary and economic cost analysis||USA||Transport to a physician’s office or health centre||
– Between 12 and 16% of Medicare covered transport to ED were avoidable.|
– Federal government could save $283–560 million+ per year if EMS ambulances can refer to non-ED alternatives.
|Altoft 2003 ||Scheme overview||UK||Intermediate care scheme that provides nursing care, physiotherapy, occupational therapy and rehabilitation||
– Referrals to scheme from ambulance crews are rare.|
– Paramedics who have used the scheme have positive reports.
– Increased use of scheme can prevent hospital conveyance and admission and provide better patient care.
|Arendts 2011 ||
Note: study results were not published due to “unresolvable inconsistencies in data” 
|Australia||Referral to a rapid (w/i 4 h) response primary care service in the patient’s own residence||
– Protocol outlines:|
1. randomisation to:
i. intervention (rapid response service)
ii. control (direct ED conveyance)
2. assessed outcomes will be:
i. unplanned medical attention w/i first 48 h
ii. clinical hospital outcomes
iii. Cost benefit analysis.
|Asplin 2001 ||Editorial||UK||To discuss how and who should identify patients that can be triaged safely away from ED and how to reduce unnecessary ED visits||
– Several key issues are highlighted:|
i. paramedic’s ability to triage and make decisions
ii. patient safety of non-conveyance alternatives
iii. Cost effectiveness of non-conveyance alternatives
iv. access barriers experienced by EMS staff and patients.
|Blodgett 2017 ||Viewpoint||UK||
To discuss an ambulance trust’s|
GP referral policy as an alternate to direct conveyance
– Overview of a collaborative telephone referral policy between on-scene paramedic and GP is provided.|
– Early evidence suggests that 61% of patients referred to GP do not attend ED within 30 days.
– There are some positive results, but critical appraisal of patient safety and re-contact rates is necessary.
|Emergency Medical Services Committee 2001 ||Policy statement||USA||No specific alternate route of care described||
The American College of Emergency Physicians and the National Association of EMS Physicians identify the need for alternative routes of care and outline key elements that should be included:|
i. physician medical director oversight
ii. assurance of patient safety in development/intervention
iii. Training for ambulance personnel
iv. compliance with dispatch criteria
v. no circumvention of 999/911 system
vi. consistent with medical necessity
vii. Appropriate compensation for EMS systems.
|American College of Emergency Physicians 2008 ||The above policy was reaffirmed in 2008.||7|
|Hsiao 1994 ||Commentary||USA||To propose a regional community health monitoring and referral system||Authors overview a model in which a centralized monitoring agency could coordinate EMS use and link patients to required levels of care, support, education and interventions.||7|
|Morganti 2014 ||Commentary||USA||To propose changes in payment policy that allow and promote alternatives to direct ED conveyance||
– Current American payment policies discourage non-conveyance to ED.|
– There are theoretical benefits of alternate transport settings and on-scene treatment alternatives.
– Assessment of alternate pathways of care is a high priority.
|Munjal 2019 ||Viewpoint||USA||To discuss barriers and consequences of alternative payment model that allows EMS agencies to be reimbursed for non-conveyance to ED||
– Alternate care routes include:|
i. nurse triage
ii. treatment by health care practitioner on scene or via telephone
iii. Transportation to urgent care centre or primary care physician.
– Main barriers are:
i. patient safety
ii. quality measurement and assurance
iii. Feasibility of payment models in different jurisdictions.
– Emphasised that the alterative model is a major advancement for out of hospital care.
|Sawyer 2017 ||Editorial||USA||To highlight concerns of alternatives to ED conveyance (including transport to primary care, general medical clinics, urgent care centres, and other social or psychological services)||
– Several concerns about implementing alternative transport options:|
i. limited evidence to support ‘theoretical’ claims of benefit to ED use, cost saving and enhanced primary care access
ii. patient safety as a result of under triage by paramedic
iii. Alternative destinations will disproportionately affect critically ill and vulnerable patient populations.