An increasing demand for emergency medical service (EMS) responses is noticeable in many developed countries.1–4 The demand is highest with people aged over 65, and exponentially grows with increasing age.4–7 These elderly people need to get appropriate care after ambulance attendance, and this may not always be referral to a hospital’s emergency department (ED).
If EMS staff decide that ED attendance is not necessary, the patient can be left at home or referred to another healthcare facility.
Key Factors That Influence the Buying Decisions of Consumers
The possibilities vary by country, and their use is influenced by protocols, protocol adherence and alternative pathways.8–12 Both the increase in numbers of older people and the demand for EMS set challenges for future patient safety and providing the best possible healthcare.13
Non-conveyance after an emergency ambulance response is an increasing trend in many West-European countries.14 15 Non-conveyance can partly be attributed to patient refusals, minor injuries that are easy to handle and the death of patients.
Incorrect decisions by EMS staff on not to convey patients to the ED can lead to health-threatening situations and even to death.16–19 Referral to the ED may result in overcrowding and, especially for the elderly population, is associated with higher mortality, delays in receiving critical therapy, patient dissatisfaction, iatrogenic illness, functional decline and adverse events during care.20–25 Correct conveyance decision-making by ambulance staff is therefore relevant, but also very complex due to the many influencing factors.26 27 Further, national protocols do not always provide adequate guidance to EMS staff in making conveyance decisions, and guidelines and protocols are not always followed.12 19 28 29 Reasons for non-adherence to protocols are attributed to the individual professional, the organisation, external factors and protocol characteristics (Grol, cited in Ebben et al).30 Due to the large variety in situations, EMS staff often have to rely on their own professional judgement.
Factors such as the use of guidelines and protocols, patient preferences, experience of EMS staff, time aspects and the presence of carers can influence ambulance staff when deciding whether to take a patient to the ED.31
Whether EMS staff can adequately determine the medical necessity for an ED evaluation is not easy to define and to measure.
A systematic review and meta-analysis showed that there is insufficient evidence to support paramedics determining the medical necessity for ambulance transport.32 A retrospective analysis of ED data showed that 7.1% of patients aged 75+ taken there by ambulance were considered as non-urgent, with the largest number of non-urgent conveyances following falls.33 Currently, researchers are focusing on adequate, community-based, alternative referrals by EMS staff for older people who have fallen.34 35
National protocols can guide EMS staff in making a decision over the conveyance or non-conveyance of an elderly person after an emergency ambulance call, but these protocols cannot cover the full scope of practice.
Other factors also influence the conveyance decision-making process in which negotiation or joint decision-making between EMS staff, the patient and sometimes their family in deciding what is best for the patient can also play a pivotal role.19 36 37 In the future, the growing ageing population will have major consequences for the utilisation of EMS and so the conveyance decision, to the ED or elsewhere, after emergency ambulance attendance is of growing importance.
Insight into factors that influence this conveyance decision-making is especially important for the population of elderly because avoidable admissions may result in functional decline, iatrogenic illness, adverse events, ED overcrowding, excessive interventions and high healthcare costs.38 To increase knowledge about factors that may influence the conveyance decision for the specific group of elderly vulnerable people, after EMS attendance, there is a need for a full overview of these factors and the impact of the decision.
The aim of this study is to provide an overview of those factors that influence the decision whether or not to convey an elderly person to the ED after ambulance attendance and the outcomes of such decisions.
The findings will be summarised in a conceptual framework and are intended to inform practice, policy-makers and future researchers.
They can also serve as a basis for developing future EMS conveyance decision-making guidelines for vulnerable elderly people, where special attention is paid to minimising the risk of inappropriate conveyance and use of EMS and ED resources, adverse outcomes and medical legal consequences.