Table 3 Summary of consensus-based articles (n = 10)
First author year [ref] | Article type | Country | Description of alternate route of care | Article description and author recommendations | Level of Evidence + |
|---|---|---|---|---|---|
Alpert 2005 [54] | 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. | 7 |
Altoft 2003 [55] | 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. | 7 |
Arendts 2011 [56] | Study protocol Note: study results were not published due to “unresolvable inconsistencies in data” [57] | 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. | 7 |
Asplin 2001 [58] | 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. | 7 |
Blodgett 2017 [16] | 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. | 7 |
Emergency Medical Services Committee 2001 [59] | 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. | 7 |
American College of Emergency Physicians 2008 [60] | The above policy was reaffirmed in 2008. | 7 | |||
Hsiao 1994 [61] | 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 [62] | 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. | 7 |
Munjal 2019 [63] | 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. | 7 |
Sawyer 2017 [64] | 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. | 7 |