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

Background This systematic review aimed to describe non-conveyance in ambulance care from patient-safety and ambulance professional perspectives. The review specifically focussed at describing (1) ambulance non-conveyance rates, (2) characteristics of non-conveyed patients, (3) follow-up care after non-conveyance, (4) existing guidelines or protocols, and (5) influencing factors during the non-conveyance decision making process. Methods We systematically searched MEDLINE, PubMed, CINAHL, EMBASE, and reference lists of included articles, in June 2016. We included all types of peer-reviewed designs on the five topics. Couples of two independent reviewers performed the selection process, the quality assessment, and data extraction. Results We included 67 studies with low to moderate quality. Non-conveyance rates for general patient populations ranged from 3.7%–93.7%. Non-conveyed patients have a variety of initial complaints, common initial complaints are related to trauma and neurology. Furthermore, vulnerable patients groups as children and elderly are more represented in the non-conveyance population. Within 24 h–48 h after non-conveyance, 2.5%–6.1% of the patients have EMS representations, and 4.6–19.0% present themselves at the ED. Mortality rates vary from 0.2%–3.5% after 24 h, up to 0.3%–6.1% after 72 h. Criteria to guide non-conveyance decisions are vital signs, ingestion of drugs/alcohol, and level of consciousness. A limited amount of non-conveyance guidelines or protocols is available for general and specific patient populations. Factors influencing the non-conveyance decision are related to the professional (competencies, experience, intuition), the patient (health status, refusal, wishes and best interest), the healthcare system (access to general practitioner/other healthcare facilities/patient information), and supportive tools (online medical control, high risk card). Conclusions Non-conveyance rates for general and specific patient populations vary. Patients in the non-conveyance population present themselves with a variety of initial complaints and conditions, common initial complaints or conditions are related to trauma and neurology. After non-conveyance, a proportion of patients re-enters the emergency healthcare system within 2 days. For ambulance professionals the non-conveyance decision-making process is complex and multifactorial. Competencies needed to perform non-conveyance are marginally described, and there is a limited amount of supportive tools is available for general and specific non-conveyance populations. This may compromise patient-safety. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0409-6) contains supplementary material, which is available to authorized users.


Background
The past decades, ambulance care has evolved from a health care facility that conveys patients to the hospital, into emergency medical services (EMS) that provide advanced out-of-hospital care for (non-) life-threatening conditions [1,2]. At the same time, the utilization of ambulance care has increased throughout the developed world, with various underlying reasons such as ageing of the population, changes in social support, accessibility and costs [3]. Together, these developments put a growing demand on ambulance systems and ambulance capacity, the emergency departments (ED) and the wider healthcare system, and this may compromise patient safety, healthcare quality, and access [3]. In addition to this growing demand, frequent overcrowding of the ED occurs [4,5].
The ambulance process is situated within this context. This process often results in patient conveyance to an ED or other healthcare facility, but ambulance care can also result in patients not being conveyed. The NHS Litigation Authority (2012) defines conveyance as "the transfer of patients, medical and clinical personnel, equipment and associated records, as appropriate including from one healthcare facility to another as well as the initial journey from the scene." [6]. Non-conveyance is defined as "an ambulance deployment as appropriate, where the patient after examination and/or treatment on-scene does not require conveyance with medical personnel and equipment to the healthcare facility" [7]. Non-conveyed patients can be treated and 'discharged' on-scene, or may be referred to other (primary) healthcare facilities such as the general practitioner. According to the literature, non-conveyance can be divided in two categories: the patient-initiated refusal and the ambulance professional decision [8]. Often, non-conveyance is a combination of these two categories.
Non-conveyance rates of patients who received onscene emergency care from an ambulance emergency crew, have been reported up to 30% [9,10]. On the other hand, it has been estimated that 11%-61% of the conveyances is medically not necessary [11]. Factors influencing these non-conveyance rates are patients with low-acuity problems or primary care problems who call an ambulance [12,13], accuracy of triage systems at the EMS dispatch centre [14], and professional competencies [15].
The priority to conduct research on non-conveyance is reflected on the Dutch National Pre-hospital Research Agenda for EMS 2014-2018 [16]. From patient-safety and professional perspective, little is known about nonconveyance. Insight into characteristics and outcomes of the non-conveyance patients is lacking. Furthermore, it is unknown how often non-conveyance exactly occurs, which complaints non-conveyed patients have, what care is provided after non-conveyance, and how often these patients have adverse events. Conversely from the professional perspective, little is known about the on-scene nonconveyance decision-making process. As ambulance care has become a more complex environment, ambulance professionals are faced with decision-making over multiple care options as conveyance to an emergency department, or another non-emergency service, treat-and-release or referral to another healthcare professional [17]. Literature described that this decision-making process requires adequate competencies, skills and clinical reasoning of ambulance professionals [18], although ambulance professionals curricula include a little on conveyance decision making [19]. Also, few ambulance services developed non-conveyance protocols and policies [20]. However, the question is whether the literature describes guidelines, protocols or triage criteria to support the ambulance professionals in the decision making process for non-conveyance, how competent are they to decide and apply for non-conveyance, and how are they influenced during the decision making process for nonconveyance? These aspects of patient safety and ambulance professional perspectives related to non-conveyance in ambulance EMS have not yet been synthesized in an overview.

Aim
The aim of this systematic review is twofold. The first aim is safety orientated, as we want to describe nonconveyance rates, characteristics of patients, and followup care after non-conveyance. The second aim is formulated from the perspective of the ambulance professional, as we want to describe available guidelines or protocols and triage criteria, competencies needed by ambulance professionals to make appropriate (non-) conveyance decisions, and also to describe which factors influence ambulance professionals during the decisionmaking process.

Design
A systematic review of the literature was performed according to the steps of the Cochrane Handbook for Systematic Reviews of Interventions [21]. This review is reported in concordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (Additional file 1: PRISMA) statement [22].

Search strategy
Firstly, the Cochrane database for systematic reviews and the DARE database were checked for a similar review (protocol). No review was identified, therefore systematic searches were performed in MEDLINE (EBSCO), PubMed, CINAHL (EBSCO), and EMBASE (OVID) in June 2016. Search strategies were developed to represent 'terms for non-conveyance' AND 'terms for pre-hospital ambulance care'. Full search strategies per database are given in Additional file 2: Appendix 1.
Searches were not restricted by year of publication. In addition to the electronic searches, after full-text inclusion we hand-searched reference lists to identify relevant studies.

Study selection procedure
We included all types of peer-reviewed systematic reviews, and quantitative or qualitative designs in real clinical practice or simulation situations, on nonconveyance. We defined non-conveyance as 'the situation where an ambulance was dispatched and where the patient received on-scene diagnostics and/or treatment, followed by professional and/or patient initiated non-conveyance to the ED or another emergency care facility'. Studies were included when reporting on one or more of the following criteria: Non-conveyance rates; Characteristics of non-conveyed patients; Follow-up care after non-conveyance; Non-conveyance guidelines, protocols, or on-scene triage criteria; Professional competencies needed to initiate nonconveyance; Factors influencing the non-conveyance decisionmaking process.
Conference abstracts, narrative reviews, editorials, personal communications, or unpublished studies were excluded. All articles were screened on title and abstract by two independent reviewers (RE, SB, RS, NT, LV). In case of doubt, a third reviewer (SB, LV) was asked to make a final decision. The remaining articles were screened full text by two independent reviewers (RE, SB, RS, NT, JL, LV). In addition, reference lists of included articles were screened (RE, JL) and potentially relevant publications were screened in a similar way (RE, RS, NT, JL).

Quality assessment
To assess the risk of bias of (pre-, or quasi-) experimental studies we used the 'risk of bias assessment tool' [21]. This tool is a domain-based evaluation to assess selection bias, performance bias, attrition bias, detection bias and reporting bias. For non-randomized studies, the Cochrane collaboration recommends to add additional domains. Therefore, we added two domains to the tool: (1) randomization (yes/no), and (2) control group (yes/ no). To assess the quality of systematic reviews we used AMSTAR, as recommended by Cochrane [23]. To assess the quality of observational studies (retrospective, crosssectional, prospective) and qualitative studies we used tools developed for evaluating primary research papers in a variety of fields [24]. From the 14-criteria quantitative tool, we deleted three criteria (criteria five, six, and seven) on experimental research as we assessed quality of experimental studies with the tool described above. For qualitative studies we used the 10-criteria tool. The quality assessment was performed by couples of two independent researchers (RE, RS, NT, JL). In case of doubt, a third reviewer from these four researchers was asked to make a final decision.

Data extraction
Data were extracted by two independent researchers (RE, RS, NT, JL). Outcomes extracted were non-conveyance rates, characteristics of non-conveyed patients, existing guidelines, protocols or triage criteria for non-conveyance, follow-up care by patients after non-conveyance, ambulance professionals competencies needed to perform nonconveyance, and factors influencing ambulance professionals during the non-conveyance decision-making process.

Data synthesis and presentation
Due to heterogeneity of the studies with regard to patient populations, interventions and outcomes, a metaanalysis was not possible. Instead, we extensively analysed and synthesized the studies, by scrutinizing and categorizing data and formulating (sub)themes. To report non-conveyance rates, percentages were extracted or calculated. When patients died or left the scene before ambulance arrival, these were not taken into account for non-conveyance rates. To compare patients' initial complaints or conditions across studies, we classified these according to the ICD-10 classification [25]. The ICD-10 classification is an international standard to classify diseases or other health problems, and is widely accepted and used. For each ICD-10 category we described the proportions of the patients who had a certain classification.

Review statistics
The initial search identified 2989 unique records, after the selection procedure 67 studies were included (see Fig. 1). A list of excluded articles (n = 67) is provided in Additional file 3: Appendix 2.
The two systematic review were performed in Australia and the UK. The empiric studies were conducted in North America (n = 36), Europe (n = 17), Australia (n = 6), Asia (n = 5), and Africa (n = 1), and concerned general patient populations or specific patient populations, including patients with hypoglycaemia, patients who refused conveyance, paediatric and/or older patients, patients with supraventricular tachycardia, patient with acute opioid overdose, post-ictal patients, and patients who had fallen. The ambulance professionals in these studies were ambulance nurses, basic and advanced life support paramedics, emergency medical technicians, (specialized) physicians, general practitioners, and first responder fire fighters. For this review we will use the term 'ambulance professional' to cover all these types of professionals.
Three studies described the vital signs of nonconveyed patients [50,52,63]. One study on a general population reported that 14.9% of the non-conveyed patients had abnormal vital signs (blood pressure, O 2 -saturation, Glasgow Coma Scale, and body temperature) [52]. A second study in a non-conveyed general patient population reported that 70.0% had a blood pressure within normal limits, 72.2% had a heart rate within normal limits, and 63.2% had a respiratory rate within normal limits [63]. The last study on vital signs with injured people not conveyed reported a mean systolic blood pressure of 134.7 mmHg (±21.1), a mean pulse rate of 91.8 (±15.9), and a mean Glasgow Coma Scale of 15.0 (±0.3) [50].
Five studies described the patient's history by describing the medical history and/or current medication use [48,63,73,74,76]. Two studies [63,76] described the medical history, for general patient populations 68.7% had no medical history [63], for people aged ≥70 years who had fallen 43.8% had urinary incontinence and 39.0% had a central nervous system disorder.
Repeated access to walk-in clinic is measured in three studies for specific patient populations (children, people who had fallen, and patients aged >65 years) [26,65,78]. The follow-up periods used for this outcome ranged from <48 h up to 12 months, and repeated access percentages varied from 3.8% (<48 h) up to 12.0-49.0% (12 months).
Professionals competencies and other factors influencing the non-conveyance decision-making process (Table 4) Factors influencing the non-conveyance decision-making process are related to the professional, the patient and his relatives, the healthcare process/system, or supportive tools [26,29,49,51,57,64,65,74,77,78,80,[83][84][85][86][87][88][89] ( Table 4). These factors can be present at (a) pre-arrival, when the professional forms an early opinion based on information from the emergency call, during (b) initial patient contact where the ambulance professional gets a first impression of the patient, during (c) patient assessment of vital signs and other parameters, and (d) during the actual (non-) conveyance decision moment [84].
As for professional related factors, two studies described professional competencies needed to perform non-conveyance. These studies showed that additional training for ambulance professionals led to higher nonconveyance rates compared to ambulance professionals who received regular training [64,77]. Besides competencies, other professional related factors are weighing of patient risks and personal litigation risk in case of a wrong non-conveyance decision [87,88], experience and intuition of the ambulance professional [89], and pragmatism as conveyance being an easy option compared to non-conveyance [89]. For patient related factors, firstly the health status of the patient influenced the non-conveyance decision of the professional [26,49,65,74,78,83,85,88]. Only three studies specified these physical conditions: the sufficiency of on-scene treatment [26], if problems/injuries have resolved pre-arrival or were only minor [26,85], patient physiology [74], the absence of new pain or injury [74], and possible changes in usual level of functioning [74]. A second patient related factor is refusal. Refusal might be related to relatives thinking conveyance is not necessary [65], but also by patients concerns about costs of conveyance or ED care [65,78], or the refusal reasons were not further specified [26,85]. Thirdly, patient wishes and the patients' best interest are factors that influence a conveyance decision [86].
Influencing factors related to the healthcare system are access/referral to GP or alternative healthcare facility in case of non-conveyance [26,87]. To make appropriate conveyance or referral decisions, access to patient information is essential. One study [80] showed that 90.7% of the ambulance professionals felt that a lack of patient information leads to less appropriate care being selected. To make appropriate decisions, ambulance professionals gave high priority to previous medical history, patient's usual vital signs and resuscitation status as patient information.
Finally, three studies showed that implementing online medical control as supportive tool, where a physician can be contacted by the pre-hospital professional, solely or in combination with a high risk card, increased conveyance rates for patients with high risk criteria or patients who refused conveyance [29,51,57].

Discussion
This systematic review includes 67 articles that describe non-conveyance in ambulance care from patient safety and ambulance professional perspectives. Our results show that non-conveyance occurs in all types of EMS systems across the world, and that there is a wide variation in non-conveyance rates for general and specific patient populations. These variations might be caused by differences in patient populations (medical acuity and medical necessity to convey), and differences between EMS-systems in terms of triage systems, types of services, educational levels of ambulance professionals, and type of vehicles (conveying and non-conveying) [91][92][93]. Although non-conveyance in itself is a valid outcome of ambulance care [17], our results do not distinct between justified or unjustified non-conveyance. This can be a focus of future research.
Our review provides a first insight in characteristics of non-conveyed patients. Our results show that patients of all ages and both men and women are represented in the non-conveyance population. Non-conveyed patients most often had a neurological or trauma related complaint or condition. Vulnerable patients as children and elderly, and specific patient groups of people who had fallen or people with hypoglycaemia are relatively high represented in the non-conveyance population. Another subpopulation is patients who refuse care and/or conveyance. From our results it remains unknown what kinds of complaints or conditions these patients have from ICD-10 perspective, and what consequences their refusal has from patient-safety perspective.
Although the assessment of vital signs is an important aspect of the primary survey in ambulance care to make appropriate treatment and triage decisions [94], we found only three studies describing vital signs of nonconveyed patients. These studies show that roughly 15% of the non-conveyed patients have vital signs that deviate from limits. We do not know whether vital signs differ between conveyed and non-conveyed patients. Therefore future research should focus on a comparison of vital signs and follow-up outcomes between conveyed and non-conveyed patient groups. Furthermore, it remains unclear if abnormal vital signs were present in the medical history due to illness or medication use. Poor access to healthcare information systems by ambulance professionals is reported [80], this underlines the possible advantage of access to healthcare information systems in the chain of emergency care, and the accessibility of the general practitioner.
Results show that a significant amount of non-conveyed patient re-enters the (emergency) healthcare system. For instance, 6.1% of the patients re-enters the EMS-system <24 h after non-conveyance, and up to 19.0% of the patient visits an ED within 48 h after non-conveyance. From the patient-safety perspective it remains unclear whether these repeated EMS calls and ED visits are based on medical necessity, as it remained unclear in the data which complaints or conditions these patients had during this repeated access to emergency healthcare, and whether it was similar to the initial EMS contact. Furthermore, the studies did not describe whether the re-entry is based on professional referral or self-referral. Clinical practice could benefit from the development of valid quality indicators for patient safety in the chain of emergency care. These could measure systematically (un)justified re-entry of the emergency healthcare system and quality of care provided.
From the professional perspective, our results indicate that the non-conveyance decision-making process is multifactorial, with influences from the professional, the patient and his relatives, the healthcare system, and supportive tools. Our results do not give clear direction which additional competencies ambulance professionals need to make safe non-conveyance decisions, as only two studies describe positive effects of additional training. Studies not included in our review suggest that pre-hospital professionals with additional training on the conveyance decision, and on management of minor illness and injuries, are less likely to convey patients compared to regular ambulance staff [15,95]. Initiatives to implement new competencies of pre-hospital professionals in EMS or possibly new professionals with additional competencies in clinical reasoning and conveyance decision-making should be explored and tested regarding patient safety.
As for supportive tools, our results show that there is a limited number of flowcharts, checklists or protocols available to guide non-conveyance decisions for general and specific patient populations. However, it remains unclear how these tools were developed and to what degree they are evidence-based. This urges the need to develop evidence-based supportive tools to guide nonconveyance decision-making for different patient groups. In order to do so, future research should be aimed at identifying factors to guide accurate non-conveyance decision making, to predict non-conveyance in the EMS dispatch phase through tailored triage criteria, or to predict follow-up outcomes such as mortality and re-enters in the emergency healthcare system. This with the aim to support professionals in their decision making and to enhance quality and safety in pre-hospital care.

Limitations of included studies
As described in the result section, the quality of included studies varied. For the quantitative studies (Additional file 4: Appendix 3, Additional file 5: Appendix 4, Additional file 6: Appendix 5), the quality assessment criteria objective/aim, design, methods of subject/group selection, appropriateness of sample size, description analytical methods, and detailed reporting of results scored good quality. The moderate assessment criteria were description of subject characteristics, outcome definition, and the relationship between results and conclusion. The reporting of estimate of variance was poor, and due to design most studies could not be controlled for confounding. Within the qualitative studies (Additional file 7: Appendix 6) the quality assessment criteria objective/ aim, design, connection to theoretical framework, datacollection and data-analysis scored good quality. The moderate assessment criteria were description of context, sampling strategy, and conclusion supported by results. Use of verification procedures and reflexivity of account were the two poor assessment criteria. Another limitation concerned the studies describing initial complaints and conditions. These studies used different types of classification systems, or systems were lacking. Therefore, we recommend to use one classification system, such as the ICD-10, in future research to enhance generizability and comparability of results.

Study strengths and limitations
Despite the fact that this systematic review is the most complete and systematic analysis to date of nonconveyance in ambulance care, there are some limitations. A possible limitation is that our review did not cover the entire ambulance care process, as we focused on the phases after ambulance dispatch. Additional research should focus on the accuracy and predictive value of current EMS dispatch systems for non-conveyance decisions. Secondly, a meta-analyses was not feasible due to heterogeneity amongst studies. Another limitation concerns the quality assessment tools for quantitative and qualitative designs. A variety of these tools exist without a clear evidence-base. Strengths of our study concern the usage of Cochrane and PRISMA methods and tools to perform and report our research.