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Table 3 Summary of consensus-based articles (n = 10)

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

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.
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.
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.
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.
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.
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.
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.
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.
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.
  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