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University of Groningen
Factors influencing the decision to convey or not to convey elderly people to the emergencydepartment after emergency ambulance attendanceOosterwold, Johan; Sagel, Dennis; Berben, Sivera; Roodbol, Petrie; Broekhuis, Manda
Published in:BMJ Open
DOI:10.1136/bmjopen-2018-021732
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Citation for published version (APA):Oosterwold, J., Sagel, D., Berben, S., Roodbol, P., & Broekhuis, M. (2018). Factors influencing the decisionto convey or not to convey elderly people to the emergency department after emergency ambulanceattendance: a systematic mixed studies review. BMJ Open, 8(8), [e021732].https://doi.org/10.1136/bmjopen-2018-021732
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1Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review
Johan Oosterwold,1,2 Dennis Sagel,3 Sivera Berben,4,5,6 Petrie Roodbol,1 Manda Broekhuis7
To cite: Oosterwold J, Sagel D, Berben S, et al. Factors influencing the decision to convey or not to convey elderly people to the emergency department after emergency ambulance attendance: a systematic mixed studies review. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
► Prepublication history and additional material for this paper are available online. To view these files, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjopen- 2018- 021732).
Received 16 January 2018Revised 16 July 2018Accepted 18 July 2018
For numbered affiliations see end of article.
Correspondence toMr. Johan Oosterwold; j. oosterwold@ umcg. nl
Research
© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
AbstrACtbackground The decision over whether to convey after emergency ambulance attendance plays a vital role in preventing avoidable admissions to a hospital’s emergency department (ED). This is especially important with the elderly, for whom the likelihood and frequency of adverse events are greatest.Objective To provide a structured overview of factors influencing the conveyance decision of elderly people to the ED after emergency ambulance attendance, and the outcomes of these decisions.Data sources A mixed studies review of empirical studies was performed based on systematic searches, without date restrictions, in PubMed, CINAHL and Embase (April 2018). Twenty-nine studies were included.study eligibility criteria Only studies with evidence gathered after an emergency medical service (EMS) response in a prehospital setting that focused on factors that influence the decision whether to convey an elderly patient were included.setting Prehospital, EMS setting; participants to include EMS staff and/or elderly patients after emergency ambulance attendance.study appraisal and synthesis methods The Mixed Methods Appraisal Tool was used in appraising the included articles. Data were assessed using a ‘best fit’ framework synthesis approach.results ED referral by EMS staff is determined by many factors, and not only the acuteness of the medical emergency. Factors that increase the likelihood of non-conveyance are: non-conveyance guidelines, use of feedback loop, the experience, confidence, educational background and composition (male–female) of the EMS staff attending and consulting a physician, EMS colleague or other healthcare provider. Factors that boost the likelihood of conveyance are: being held liable, a lack of organisational support, of confidence and/or of baseline health information, and situational circumstances. Findings are presented in an overarching framework that includes the impact of these factors on the decision’s outcomes.Conclusion Many non-medical factors influence the ED conveyance decision after emergency ambulance attendance, and this makes it a complex issue to manage.
IntrODuCtIOn rationaleAn 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 expo-nentially 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. 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
strengths and limitations of this study
► The broad and empirical nature of the study has made it possible to identify multiple factors that influence the referral decision by emergency med-ical service staff after ambulance emergency atten-dance, and the outcomes of this decision.
► Building on existing general decision-making frame-works, an overarching framework was developed that proved helpful in structuring the influential fac-tors identified.
► A weakness is that not all of the factors identified can be definitely related to the elderly population because, in many studies, the elderly formed part of a broader study population, and the results were not specified by age group.
► The low methodological quality in some of the stud-ies and the considerable age of some of them are limitations of the study.
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Open access
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-threat-ening 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 guid-ance 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 para-medics 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 deci-sion 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 utilisa-tion 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 admis-sions 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.
ObjectivesThe 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 find-ings 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.
MethODA systematic mixed-studies review (MSR) was chosen to synthesise primary qualitative, quantitative and mixed-methods research studies.39 The integrated design selected is appropriate for complex and context-sensitive interventions, and can provide a deep and highly practical understanding of phenomena in the health sciences.40 This MSR follows recognised guidelines for systematic mixed-studies reviews.39
eligibility criteriaStudies were included if they contained empirical evidence on one or more factors that influenced the conveyance or non-conveyance decision to an ED for an elderly person after being attended by ambulance personnel. In more detail, studies were incorporated if they specifically addressed elderly patients, elderly people were part of a broader age group (eg, all adults), the factors considered could be linked to elderly patients (eg, end-of-life situations, falls) or when general factors were identified that affected all age groups (eg, EMS staff-re-lated factors). Searches were not restricted by publication date or by country, although only publications written in English, Dutch or German were eligible for inclusion. Detailed inclusion and exclusion criteria are provided in online supplementary appendix 1.
Information sourcesThree database searches (PubMed, Embase and CINAHL) were executed in October 2016, and these were updated in April 2018 to identify any relevant research published since the initial search. The search terms covered three areas: (1) ambulance or emergency medical services, (2) ‘conveyance or non-conveyance of patients’ or ‘treat and release’ or ‘referral and consultation’, and (3) ‘deci-sion-making’. The research team performed a broad search in order to include all the potentially relevant articles, meaning that a high percentage of the initial list would not be relevant. Only peer-reviewed articles were included in order to ensure a generally accepted level
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Open access
of quality. The full electronic search strategy is shown in online supplementary appendix 2.
study selectionIn this systematic MSR, the support tool ‘StArt’—State of the Art through systematic review—was used in the process of screening for relevant articles.41 All the articles retrieved (n=2412) were checked by one researcher for duplicates and irrelevant studies, and these were removed; the latter phase employed the exclusion criteria shown in table 1. A second reviewer (MB) independently screened a small random sample (5%), and there was full agree-ment on the accepted and rejected studies. Two reviewers (JO and DS) independently assessed the full texts of the remaining subset of 108 articles. Cohen’s kappa was calculated to determine if there was agreement between the two reviewers. The strength of agreement was consid-ered to be ‘good’, κ=0.786 (95% CI 0.652 to 0.919), and differences were resolved by discussion. Finally, 29 articles were accepted for inclusion in the systematic literature review (figure 1).
Data collection processOne researcher (JO) extracted data from the included studies. Characteristics extracted included setting, aim of the study, study design and study population (table 1). Data were also extracted describing factors that influenced the conveyance decision after ambulance attendance. A brief summary of these factors and the subjective/objec-tive outcomes of the decision are shown in table 2.
AppraisalOne author (JO) assessed all the included articles and four authors (PR, DS, SB and MB) each assessed some of them using a multimethod appraisal tool (MMAT, version 2011).39 42 The MMAT has been tested for validity and been used in various systematic MSRs to evaluate the methodological quality by answering four questions regarding recruitment, randomisation (if applicable), appropriateness of outcome measures and attrition rate/completeness of data. The final score reflects the number of criteria satisfied, varying from one criterion met (reported as *) to all criteria met (****). Any disagree-ments in ratings between reviewers were discussed until a consensus was reached.
synthesis of resultsIn this systematic review, a ‘best fit’ framework was used as a starting point for data synthesis.43 Since no suitable framework existed for the topic studied, a ‘best fit’ frame-work was constructed based on two existing models, one describing the process of clinical decision-making by Gillespie and Peterson and the other, the Input-Process-Output (IPO) model of Steiner and Hackman.44–47
The Situated Clinical Decision-Making framework by Gillespie and Peterson is a tool that is often used to assist educators in analysing nursing students, or novice nurses, in their complex and multidimensional clinical decision-making process.44 45 It can also be applied within
EMS practice since these decisions are also made within a dynamic context, knowledge is used from multiple sources, is influenced by all that the profession brings to knowledge and experience and is supported by a range of thinking processes.44 The themes covered by the Situated Clinical Decision-Making framework were incorporated within an IPO model (figure 2).
Finally, the objective and subjective outcomes are added to the framework. The process of data extraction, coding and analysis in this MSR leads to a conceptual framework that describes the factors that actually influence the deci-sion of conveyance, and the subjective and/or objective outcomes of such decisions.
Patient and public involvementThere was no involvement of patients and or public in this study.
resultsstudy selection and characteristicsThis systematic literature review covers 29 articles all published between 1995 and 2018 with the majority (n=19) published after 2010. The studies were mostly carried out in the UK (n=13) and the USA (n=12). The four remaining studies were from Sweden, Poland, Australia and Iran. Sixteen of the studies used quantita-tive research designs, 12 were qualitative and only 1 study used mixed methods. There were eight studies which focused exclusively on elderly people (aged ≥65), and in 10 studies, elderly people were part of a broader age group. In the remaining 11 studies, factors were identi-fied that affected all age groups.
Quality of the studiesUsing the quality criteria discussed earlier, four studies were classed as of low quality (* or **),48–51 15 as average (***)52–66 and 10 as good (****).67–76 Nevertheless, we included all the studies in our analysis but ranked them according to their quality score within the conceptual framework. Ranking was done by taking the average of the MMAT score of the related articles per theme and categorising them as A (≥3 asterisks), B (≥2 and <3 aster-isks) or C (<2 asterisks).
summarising and synthesisThe analysis resulted in a table presenting a priori themes within the ‘best fit’ framework with the relevant specific factors and a short summary of these factors (table 1). If described in the reviewed papers, the subjective and/or objective outcomes were also presented alongside the specific factors.
Macro-level themesGovernmental, societal and professional themes were identified in the literature that influenced the convey-ance decision-making process. One study by Déziel concluded that private EMS services were more likely to convey a patient to the hospital than public EMS services
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Open access
Tab
le 1
C
hara
cter
istic
s of
incl
uded
stu
die
sLe
ad a
utho
r (y
ear)
, co
untr
y
Aim
Met
hod
Stu
dy
po
pul
atio
n
Qua
lity
app
rais
al
MM
AT
sco
re *
/***
*
Sho
rt o
vera
llcr
itic
al c
ons
ider
atio
nsS
etti
ng
EM
S s
taff
(n)
Pro
fess
iona
lb
ackg
roun
dP
atie
nts
(n)
Ag
e ra
nge
or
mea
n (S
D)
of
pat
ient
sS
pec
ific
eld
erly
po
pul
atio
n
Aft
yka51
(201
4), P
olan
dTh
e re
gion
al D
irect
orat
e of
EM
S in
Lub
lin
To c
omp
are
the
actio
ns a
nd
refe
rral
dec
isio
ns o
f nur
ses
and
par
amed
ics
take
n in
th
e fie
ld.
QU
AN
—re
tros
pec
tive
obse
rvat
iona
l stu
dy.
A
naly
sis
of a
mb
ulan
ce
reco
rds.
n=99
2P
med
ics,
n=
555;
RN
, n=
437.
n=10
820>
90 y
ears
.N
o**
Met
hod
olog
ical
and
sta
tistic
al
inco
nsis
tenc
ies,
mak
ing
the
resu
lts a
nd c
oncl
usio
ns
diffi
cult
to in
terp
ret.
Lac
ks a
st
atis
tical
pow
er a
naly
sis.
Alic
and
ro49
(199
5), U
SA
Four
sub
urb
an
volu
ntee
r E
MS
in
Suf
folk
cou
nty,
New
Yo
rk
To e
valu
ate
the
effe
ct o
f a
doc
umen
tatio
n ch
eckl
ist
and
onl
ine
med
ical
co
ntro
l con
tact
on
EM
S
conv
eyan
ce d
ecis
ions
in
pat
ient
s re
fusi
ng m
edic
al
assi
stan
ce.
QU
AN
—no
n-ra
ndom
ised
co
ntro
lled
tria
l. P
rosp
ectiv
e se
que
ntia
l in
terv
entio
n st
udy.
ND
Volu
ntee
r, A
LS p
rovi
der
s,
BLS
pro
vid
ers.
n=36
1P
hase
1, 3
9 (2
2) y
ears
. P
hase
2, 3
9 (2
2) y
ears
. P
hase
3, 4
1 (2
0) y
ears
.
No
*S
mal
l sam
ple
siz
e an
d
the
abse
nce
of a
pow
er
calc
ulat
ion;
no
dat
a on
pat
ient
en
rolm
ent,
unc
lear
if a
ll el
igib
le p
atie
nts
wer
e en
rolle
d;
resu
lts o
bta
ined
in v
olun
teer
E
MS
, with
bot
h B
LS a
nd A
LS
per
sonn
el. G
ener
alis
abili
ty in
no
n-vo
lunt
eer
EM
S u
ncle
ar.
Bur
rell52
(201
3), U
KA
mb
ulan
ce c
linic
ians
fr
om S
outh
Lon
don
To e
xam
ine
the
dec
isio
n-m
akin
g p
roce
ss o
f am
bul
ance
clin
icia
ns in
si
tuat
ions
of e
pile
psy
.
QU
AL—
phe
nom
enol
ogic
al s
tud
y.
Face
-to-
face
and
top
ic-
guid
ed in
terv
iew
s.
n=15
Pm
edic
, n=
5; E
MT
2,
n=1;
EM
T 3,
n=
4; E
mC
P,
n=1;
PTL
, n=
4.
NA
NA
No
***
Con
veni
ence
sam
ple
may
ha
ve le
d t
o se
lect
ion
bia
s.
No
info
rmat
ion
on s
atur
atio
n in
ord
er t
o d
eter
min
e th
e q
ualit
ativ
e sa
mp
le s
ize.
A
war
enes
s of
the
imp
act
of d
oing
inte
rvie
ws
by
a co
lleag
ue.
Bur
stei
n60 (1
998)
, US
AS
ubur
ban
vol
unte
er
EM
S in
Suf
folk
cou
nty,
N
ew Y
ork
To m
easu
re t
he e
ffect
of
phy
sici
an a
sser
tiven
ess
on
EM
S c
onve
yanc
e d
ecis
ions
of
pat
ient
s at
tem
pte
d r
efus
al
of m
edic
al a
ssis
tanc
e.
QU
AN
—co
hort
stu
dy.
P
rosp
ectiv
e an
alys
is
of d
iffer
ent
outc
ome
varia
ble
s.
ND
Volu
ntee
r, A
LS p
rovi
der
s,
BLS
pro
vid
ers.
n=13
0N
DN
o**
*N
o ta
ble
of p
atie
nt
char
acte
ristic
s in
clud
ed;
inst
rum
ent
for
mea
surin
g as
sert
iven
ess
not
valid
ated
; th
e sa
mp
le w
as a
war
e of
b
eing
stu
die
d w
hich
may
ca
use
bia
s. G
ener
alis
abili
ty in
no
n-vo
lunt
eer
EM
S u
ncle
ar.
Coo
per
53 (2
004)
, UK
Wes
tcou
ntry
Am
bul
ance
N
HS
Tru
st
To e
valu
ate
the
role
of
em
erge
ncy
care
p
ract
ition
ers
on t
he
conv
eyan
ce d
ecis
ion
and
co
mp
are
that
with
the
p
aram
edic
s.
MM
—se
que
ntia
l ex
pla
nato
ry d
esig
n. T
wo
stag
es o
f dat
a co
llect
ion:
(1
) ret
rosp
ectiv
e d
ata
anal
ysis
, (2)
ind
ivid
ual
and
focu
s gr
oup
s in
terv
iew
s w
ith E
CP
s,
Pm
edic
s, m
anag
ers
and
ot
her
staf
f mem
ber
s.
n=15
EC
P, n
=4;
Pm
edic
, n=
11; E
CP
and
P
med
ics
mea
n w
ork
exp
erie
nce=
8 ye
ars.
n=69
2;
51%
mal
es,
49%
fem
ales
.
0–99
No
***
No
stat
istic
al c
omp
aris
on
bet
wee
n E
CP
s an
d
Pm
edic
s in
ter
ms
of y
ears
of
exp
erie
nce.
EC
Ps
trea
ted
m
ore
pat
ient
s un
der
the
age
of
16
year
s co
mp
ared
with
the
P
med
ics
(p=
0.00
1).
Eb
rahi
mia
n62 (2
014)
, Ir
anE
MS
sta
ff w
orki
ng in
d
iffer
ent
dis
tric
ts o
f Te
hran
To e
xplo
re fa
ctor
s af
fect
ing
EM
S s
taff
’s d
ecis
ion
abou
t co
nvey
ance
to
med
ical
fa
cilit
ies.
QU
AL—
phe
nom
enol
ogic
al
stud
y. C
onte
nt a
naly
sis
with
sem
istr
uctu
red
in
terv
iew
s.
n=18
(mal
es)
Dip
lom
a m
edic
al
emer
genc
y (2
-yea
r co
urse
) or
nurs
ing
(4-y
ear
cour
se).
Age
: 28–
39 y
ears
(m
in–m
ax).
Mea
n w
ork
exp
erie
nce=
6.61
yea
rs.
NA
NA
No
***
Brie
f des
crip
tion
of
dem
ogra
phi
c p
rofil
e of
th
e re
spon
den
ts. L
ack
of
inte
rcod
er r
elia
bili
ty w
hich
is a
cr
ucia
l com
pon
ent
in c
onte
nt
anal
ysis
. Ext
erna
l val
idity
may
b
e im
pai
red
bec
ause
of n
on-
Wes
tern
cul
ture
/cou
ntry
.
Hal
ter69
(201
1), U
KLo
ndon
Am
bul
ance
S
ervi
ce
To c
larif
y th
e E
MS
co
nvey
ance
dec
isio
ns,
afte
r th
e us
e of
a c
linic
al
asse
ssm
ent
tool
, in
old
er
peo
ple
who
hav
e a
fall.
QU
AL—
phe
nom
enol
ogic
al s
tud
y.
Sem
istr
uctu
red
inte
rvie
w.
n=12
(7 fe
mal
es, 5
m
ales
)P
med
ic, n
=1;
EM
T,
n=11
. Mea
n w
ork
exp
erie
nce
=3.
5 ye
ars
.
ND
ND
Yes,
eld
erly
falle
rs**
**C
onve
nien
ce s
amp
le w
ith lo
w
exp
erie
nce
leve
l of E
MS
sta
ff.
Con
tinue
d
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BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
5Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Lead
aut
hor
(yea
r),
coun
try
Aim
Met
hod
Stu
dy
po
pul
atio
n
Qua
lity
app
rais
al
MM
AT
sco
re *
/***
*
Sho
rt o
vera
llcr
itic
al c
ons
ider
atio
nsS
etti
ng
EM
S s
taff
(n)
Pro
fess
iona
lb
ackg
roun
dP
atie
nts
(n)
Ag
e ra
nge
or
mea
n (S
D)
of
pat
ient
sS
pec
ific
eld
erly
po
pul
atio
n
O’H
ara63
(201
5), U
KTh
ree
amb
ulan
ce t
rust
s in
Eng
land
To e
xplo
re s
yste
mic
in
fluen
ces
on d
ecis
ion-
mak
ing
by
par
amed
ics
rela
ting
to c
are
tran
sitio
ns
to id
entif
y p
oten
tial r
isk
fact
ors.
QU
AL—
mul
timet
hod
st
udy
incl
udin
g a
ethn
ogra
phi
c st
udy.
Tw
o p
hase
s of
dat
a co
llect
ion:
(1
) sem
istr
uctu
red
in
terv
iew
s, (2
) ob
serv
atio
n, d
igita
l d
iarie
s, fo
cus
grou
ps.
n=88
Pm
edic
, n=
57; S
P
, n=
13; E
MT,
n=
18. E
xper
ienc
e E
MS
st
aff,
<1–
20 y
ears
.
NA
NA
No
***
Sel
ectio
n on
par
ticip
ants
is
uncl
ear,
no in
form
atio
n on
sa
mp
ling.
Per
sse48
(200
2), U
SA
City
of H
oust
on
Em
erge
ncy
Med
ical
S
ervi
ce
To d
eter
min
e if
pro
vid
ing
follo
w-u
p in
form
atio
n ab
out
non-
conv
eyed
eld
erly
p
atie
nts
wou
ld c
hang
e th
e fu
ture
dec
isio
n-m
akin
g b
y p
aram
edic
s.
QU
AN
—p
rosp
ectiv
e ch
art
revi
ew (d
escr
iptiv
e st
udy)
NA
Pm
edic
’sn=
260
≥65
year
s of
age
Yes,
pat
ient
sag
ed ≥
65 re
que
sted
911
serv
ices
.
**D
emog
rap
hic
info
rmat
ion
com
par
ing
grou
ps
in p
hase
1,
2 an
d 3
is m
issi
ng. D
iffer
ence
s b
etw
een
grou
ps
may
ac
coun
t fo
r an
y d
iffer
ence
s in
out
com
es. L
ess
than
60
% b
eing
con
tact
ed a
fter
no
n-co
nvey
ance
. No
pow
er
calc
ulat
ion.
Mur
phy
-Jon
es66
(201
6),
UK
Eng
lish
NH
S a
mb
ulan
ce
trus
t
To e
xplo
re h
ow P
med
ics
mak
e co
nvey
ance
dec
isio
ns
in e
nd-o
f-lif
e ca
re s
ituat
ions
.
QU
AL—
phe
nom
enol
ogic
al
stud
y. S
emis
truc
ture
d
inte
rvie
ws.
n=6
(3 fe
mal
es,3
m
ales
)P
med
ics
age,
24–
42
year
s. W
ork
exp
erie
nce
rang
e 2–
8 ye
ars.
NA
ND
Yes,
nur
sing
hom
ere
sid
ents
.
***
Sm
all s
amp
le s
ize
(n=
6).
Unk
now
n if
dat
a sa
tura
tion
is
reac
hed
. Wor
king
exp
erie
nce
of P
med
ics
≤8 y
ears
.
Sch
aefe
r68 (2
002)
, US
AK
ing
coun
ty E
MS
To d
eter
min
e if
EM
S s
taff
coul
d d
ecre
ase
the
rate
of
con
veya
nce
to t
he E
D,
in p
atie
nts
with
no
urge
nt
conc
erns
, by
iden
tifyi
ng
and
saf
ely
tria
ging
the
m t
o al
tern
ate
care
des
tinat
ions
.
QU
AN
—co
hort
stu
dy.
M
atch
ed h
isto
rical
co
ntro
l gro
up.
ND
EM
T an
d B
LS t
rain
ing.
P
med
ic a
nd A
LS t
rain
ing.
n=36
33;
45.9
% v
ersu
s 47
.4%
m
ales
.
Ran
ge, 0
–104
, M
dn=
33.
No
****
Stu
dy
took
pla
ce w
ithin
B
LS r
esp
onse
tea
ms.
O
ne p
hysi
cian
det
erm
ined
th
e el
igib
ility
for
alte
rnat
e d
estin
atio
n of
car
e b
ased
on
pre
defi
ned
crit
eria
. No
leve
l of a
gree
men
t b
etw
een
phy
sici
ans
was
mea
sure
d.
The
sign
ifica
nt d
iffer
ence
in
des
tinat
ion
of c
are
shou
ld b
e in
terp
rete
d w
ith
caut
ion
bec
ause
of t
he n
on-
rand
omis
ed s
tud
y d
esig
n.
Sno
oks75
(200
4), U
KTw
o am
bul
ance
se
rvic
es in
Wes
t Lon
don
To e
valu
ate
the
effe
ctiv
enes
s of
‘tre
at a
nd
refe
r’ p
roto
cols
.
QU
AN
—co
ntro
lled
tria
l w
ithou
t ra
ndom
isat
ion.
R
un s
heet
ana
lysi
s an
d
anal
ysis
of E
D a
nd G
P
reco
rds.
Fol
low
-up
q
uest
ionn
aire
of n
on-
conv
eyed
pat
ient
s.
ND
Pm
edic
s an
d E
MTs
INT,
n=
788
CO
N,
n=25
1 ,
52%
vs
51%
mal
es (p
=0.
69).
Mea
n ag
e,54
vs
47 y
ears
(p=
0.08
).
No
****
Pow
er c
alcu
latio
n w
as
cond
ucte
d b
ut w
as r
educ
ed
bec
ause
of l
ower
rec
ruitm
ent
to s
tud
y gr
oup
s th
an
antic
ipat
ed. N
o ta
ble
of
pat
ient
cha
ract
eris
tics,
dat
a re
por
ted
in t
ext.
Sno
oks61
(200
5), U
KTw
o am
bul
ance
sta
tions
in
Lon
don
To r
epor
t th
e vi
ews
and
at
titud
es o
f EM
S s
taff
in
conv
eyan
ce d
ecis
ion-
mak
ing
in a
nd in
a n
ew
tria
ge in
terv
entio
n on
for
non-
conv
eyan
ce.
QU
AL—
Phe
nom
enol
ogic
al s
tud
y fo
cus
grou
ps.
n=21
(20
mal
es,1
fe
mal
e)D
urat
ion
of s
ervi
ce,
mea
n (r
ange
in y
ears
): Fo
cus
grou
p 1
, 7
(4–1
6); F
ocus
gro
up 2
, 12
(0.5
–25)
; Foc
us g
roup
3,
8 (4
–16)
.
NA
NA
No
***
Brie
f des
crip
tion
on
qua
litat
ive
dat
a an
alys
is/
cod
ing
pro
ced
ure.
Sno
oks55
(201
4), U
K9
Am
bul
ance
sta
tions
ac
ross
a m
ixed
rur
al
and
urb
an a
rea
in
the
UK
To in
vest
igat
e th
e ef
fect
iven
ess
of a
co
mp
uter
ised
clin
ical
d
ecis
ion
sup
por
t to
ol fo
r em
erge
ncy
par
amed
ics
in c
onve
yanc
e d
ecis
ions
of
old
er p
eop
le w
ho h
ave
falle
n.
QU
AN
—cl
uste
r ra
ndom
ised
con
trol
led
tr
ial.
n=42
Pm
edic
's .
INT,
n=
436
CO
N,
n=34
3≥6
5 ye
ars.
Md
n ag
e IN
T 83
yea
rs C
ON
82 y
ears
.
Yes,
old
er p
eop
le w
ho h
ave
falle
n.**
*S
tud
y is
slig
htly
un
der
pow
ered
.
Tab
le 1
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
6 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Lead
aut
hor
(yea
r),
coun
try
Aim
Met
hod
Stu
dy
po
pul
atio
n
Qua
lity
app
rais
al
MM
AT
sco
re *
/***
*
Sho
rt o
vera
llcr
itic
al c
ons
ider
atio
nsS
etti
ng
EM
S s
taff
(n)
Pro
fess
iona
lb
ackg
roun
dP
atie
nts
(n)
Ag
e ra
nge
or
mea
n (S
D)
of
pat
ient
sS
pec
ific
eld
erly
po
pul
atio
n
Stu
hlm
iller
54 (2
005)
, U
SA
Cle
vela
nd E
MS
To a
sses
s th
e ab
ility
of
EM
S t
o d
eter
min
e m
edic
al
dec
isio
n-m
akin
g ca
pac
ity
and
in o
bta
inin
g an
info
rmed
re
fusa
l of t
rans
por
t.
QU
AN
—re
tros
pec
tive
obse
rvat
iona
l stu
dy.
A
naly
sis
of r
un
shee
ts, n
on-t
rans
por
t w
orks
heet
s an
d
asso
ciat
ed r
ecor
ded
re
fusa
l cal
ls.
ND
Pm
edic
s an
d o
nlin
e m
edic
al c
omm
and
p
hysi
cian
s.
n=13
745
.9 (2
2.6)
,ra
nge
0–91
No
***
Cal
ls r
and
omly
gen
erat
ed.
Vilk
e50 (2
002)
, US
AS
an D
iego
Med
ical
S
ervi
ces
Ent
erp
rise
To o
bta
in in
form
atio
n an
d
exp
erie
nces
of p
atie
nts
(≥65
yea
rs o
f age
) who
r e
fuse
d t
rans
por
t b
y E
MS
an
d d
eter
min
e th
e p
oten
tial
role
of o
nlin
e p
hysi
cian
–p
atie
nt c
onta
ct.
QU
AN
—p
rosp
ectiv
e ob
serv
atio
nal s
tud
y,
tele
pho
ne s
urve
y an
d
amb
ulan
ce r
ecor
ds
anal
ysis
.
NA
EM
T-P
s, E
MT-
Ds.
n=10
072
.2 (6
.4)
Yes,
pat
ient
s ag
ed ≥
65 a
nd
sign
ed o
ut a
gain
st m
edic
al
advi
ce .
**T e
lep
hone
sur
vey
with
p
ossi
bili
ty o
f rep
ortin
g b
ias.
Of
the
tota
l sam
ple
pop
ulat
ion,
16
% o
f the
pat
ient
s w
ere
reac
hed
by
tele
pho
ne a
nd
agre
ed (1
00/6
36).
Dat
a co
llect
ion
tool
was
not
va
lidat
ed.
Wal
dro
n56 (2
012)
, US
AH
osp
ital-
bas
ed
amb
ulan
ce s
ervi
ce in
N
ew Y
ork
To d
eter
min
e if
ther
e is
an
ass
ocia
tion
bet
wee
n E
MT
gend
er a
nd t
he
pat
ient
s d
ecis
ion
to r
efus
e co
nvey
ance
to
the
hosp
ital
by
amb
ulan
ce.
QU
AN
—ca
se–c
ontr
ol
stud
y. R
etro
spec
tive
amb
ulan
ce r
ecor
ds
anal
ysis
.
n=32
2 M
ale/
mal
e=27
1 M
ale/
fem
ale
and
fem
ale/
fem
ale=
51
EM
T-B
s, E
MT-
Ps.
Ref
usin
g m
edic
al a
id,
n= 1
61; 4
7.2%
m
ale
Non
ref
usin
g m
edic
al a
id,
n=16
1; 4
8.4%
mal
e
Non
-ref
usal
,53
.1 (2
.6);
Ref
usal
, 53.
6 (1
.5).
No
***
Dat
a on
ass
ocia
tion
and
re
fusa
l of m
edic
al a
id r
ate
retr
ieve
d a
fter
pro
pen
sity
sc
ore
mat
chin
g to
con
trol
for
varia
ble
s.
Wal
dro
p57
(201
5), U
SA
EM
S s
taff
from
an
emer
genc
y m
edic
al
serv
ice
To e
xplo
re a
nd d
escr
ibe
how
EM
S s
taff
asse
ss
and
man
age
end
-of-
life
emer
genc
y ca
lls.
QU
AL—
phe
nom
enol
ogy
in-d
epth
inte
rvie
ws.
n=43
, 77%
mal
esP
med
ic, n
=33
; EM
Ts,
n=10
; age
, 21–
65 y
ears
, m
ean
39 (S
D11
).
NA
NA
No
***
Rig
our
or t
he t
rust
wor
thin
ess
of q
ualit
ativ
e d
ata
anal
ysis
is
des
crib
ed. R
esea
rche
r–p
artic
ipan
t re
latio
nshi
p
uncl
ear.
Wal
dro
p58
(201
4), U
SA
EM
S s
taff
from
an
emer
genc
y m
edic
al
serv
ice
To id
entif
y ho
w E
MS
p
rovi
der
s d
eal w
ith e
nd o
f lif
e ca
lls a
nd d
eter
min
e th
eir
per
ceiv
ed c
onfid
ence
in
man
agin
g th
ese
situ
atio
ns,
and
per
spec
tives
on
imp
rove
d p
rep
arat
ion.
QU
AL—
cros
s-se
ctio
nal
surv
ey. Q
uest
ionn
aire
.n=
178,
79%
mal
es76
EM
T-B
, 102
Pm
edic
. M
ean
year
s of
wor
king
ex
per
ienc
e 12
(SD
9.5
).
NA
NA
No
***
Pow
er a
naly
ses
was
not
co
nduc
ted
. Par
ticip
ants
wer
e in
vite
d t
o b
e in
terv
iew
ed.
Zor
ab59
(201
5), U
KS
outh
Wes
tern
A
mb
ulan
ce S
ervi
ce
NH
S F
ound
atio
n Tr
ust
To id
entif
y ho
w E
MS
sta
ff as
sess
hea
lth in
form
atio
n;
asce
rtai
n if
a la
ck o
f in
form
atio
n co
uld
lead
to
a su
bop
timal
car
e p
athw
ay;
exp
lore
whe
ther
incr
easi
ng
amou
nt o
f inf
orm
atio
n le
ads
to a
mor
e ap
pro
pria
te
pat
hway
.
QU
AL—
cros
s-se
ctio
nal s
urve
y. O
nlin
e q
uest
ionn
aire
.
n=30
2, 6
3% m
ales
Em
CP
or
CC
P
n=36
Pm
edic
, n=
185
Em
CA
, stu
den
t U
P,
n=58
. Mos
t re
spon
den
ts
(85.
6%) w
ere
aged
b
etw
een
26 a
nd 5
5 ye
ars.
NA
NA
No
***
Res
pon
se r
ate
of 1
2%.
Déz
iel70
(201
7), U
SA
Virg
inia
Dep
artm
ent
of
Hea
lth O
ffice
of E
MS
To id
entif
y an
y d
iffer
ence
s in
the
tra
nsp
ort
dec
isio
n am
ong
agen
cy o
wne
rshi
p
typ
es.
QU
AN
— r
etro
spec
tive
obse
rvat
iona
l stu
dy.
NA
Fire
-bas
ed E
MS
. Non
-fir
e b
ased
EM
S. P
rivat
e or
gani
satio
n no
n-p
rofit
. P
rivat
e or
gani
satio
n fo
r-p
rofit
.
4.6
mill
ion
Mea
n ag
e52
yea
rs.
No
****
Very
larg
e d
atas
et.
Lang
abee
r65 (2
016)
, U
SA
Hou
ston
EM
S
To c
omp
are
the
effe
ctiv
enes
s of
an
alte
rnat
ive
EM
S t
eleh
ealth
d
eliv
ery
mod
el r
elat
ive
to
trad
ition
al E
MS
car
e.
QU
AN
—ob
serv
atio
nal
case
–con
trol
stu
dy.
NA
NA
n=28
7M
dn
age,
IN
T 44
yea
rs C
ON
45 y
ears
.
No
***
Cas
e–co
ntro
l stu
dy,
con
trol
s ar
e m
atch
ed a
fter
war
ds.
C
ontr
ol g
roup
not
mat
ched
on
incl
usio
n cr
iteria
but
on
dem
ogra
phi
c d
ata.
Larr
son71
(201
7),
Sw
eden
Am
bul
ance
org
anis
atio
n of
Sw
eden
To e
xam
ine
early
pre
hosp
ital
asse
ssm
ent
of n
on-u
rgen
t p
atie
nts
and
its
imp
act
on t
he c
hoic
e of
the
ap
pro
pria
te le
vel o
f car
e.
QU
AN
—ex
plo
rato
ry
stud
y b
ased
on
a co
nsec
utiv
e an
d
retr
osp
ectiv
e re
view
of
pat
ient
rec
ord
s.
ND
Am
bul
ance
nur
ses.
INT,
n=
184
CO
N, n
=21
0 A
ged
≥18
yea
rs.
Mea
n ag
e, IN
T 75
.4 y
ears
C
ON
74.
1 ye
ars.
Ran
ge IN
T 23
–96
year
s C
ON
18–
98 y
ears
.
No
****
Com
par
ison
with
retr
osp
ectiv
e co
ntro
l gro
up.
Tab
le 1
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
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Open access
Lead
aut
hor
(yea
r),
coun
try
Aim
Met
hod
Stu
dy
po
pul
atio
n
Qua
lity
app
rais
al
MM
AT
sco
re *
/***
*
Sho
rt o
vera
llcr
itic
al c
ons
ider
atio
nsS
etti
ng
EM
S s
taff
(n)
Pro
fess
iona
lb
ackg
roun
dP
atie
nts
(n)
Ag
e ra
nge
or
mea
n (S
D)
of
pat
ient
sS
pec
ific
eld
erly
po
pul
atio
n
Nob
le72
(201
6), U
KN
HS
Am
bul
ance
Tru
sts
To e
xplo
re t
he e
xper
ienc
es
of E
MS
sta
ff m
anag
ing
pat
ient
s w
ith s
eizu
res.
QU
AL—
sem
i str
uctu
red
in
terv
iew
s.n=
19P
med
ic, n
=19
.N
AN
AN
o**
**In
dep
end
ent
and
exp
erie
nced
in
terv
iew
er w
ith a
lread
y va
lidat
ed t
opic
too
l.
Por
ter64
(200
7), U
KN
HS
Am
bul
ance
S
ervi
ce T
rust
To e
xam
ine
EM
S s
taff
’s v
iew
on
how
dec
isio
n-m
akin
g ab
out
non-
conv
eyan
ce
wor
ks in
pra
ctic
e.
QU
AL—
thre
e fo
cus-
grou
p in
terv
iew
s us
ing
a to
pic
gui
de.
n=25
Pm
edic
s, n
=25
.N
AN
AN
o**
*S
hort
and
com
pro
mis
ed
met
hod
sec
tion.
Deg
ree
of in
dep
end
ence
bet
wee
n re
sear
cher
and
gro
up u
ncle
ar.
Sim
pso
n73 (2
017)
, A
ustr
alia
Sta
te-b
ased
Aus
tral
ian
amb
ulan
ce s
ervi
ce
To e
xplo
re t
he d
ecis
ion-
mak
ing
pro
cess
use
d b
y p
aram
edic
s w
hen
carin
g fo
r ol
der
falle
rs.
QU
AL—
grou
nded
th
eory
met
hod
olog
y.
Sem
istr
uctu
red
in
terv
iew
s an
d fo
cus
grou
ps.
n=33
(21
mal
es, 1
2 fe
mal
es)
QP
=16
, IC
P=
11, E
CP
=6
Year
s of
wor
king
ex
per
ienc
e 12
(SD
6)
NA
NA
Yes,
old
er p
eop
le w
ho h
ave
falle
n.**
**D
ata
anal
ysis
and
cod
ing
wer
e d
one
by
one
sing
le
rese
arch
er (a
lso
par
amed
ic),
but
sub
ject
ivity
was
reg
ular
ly
chec
ked
dur
ing
the
anal
ysis
an
d c
halle
nged
by
mem
ber
s of
the
res
earc
h te
am.
Sno
oks74
(201
7), U
KTh
ree
UK
am
bul
ance
se
rvic
es
To d
eter
min
e cl
inic
al a
nd
cost
-effe
ctiv
enes
s of
a
par
amed
ic p
roto
col f
or
the
care
of o
lder
peo
ple
w
ho fa
ll.
QU
AN
—cl
uste
r ra
ndom
ised
tria
l.n=
215
Pm
edic
s, n
=21
5.IN
T, n
=23
91
CO
N, 2
264
INT
82.5
4 (7
.97)
CO
N 8
2.14
(8.1
1)
Yes,
age
d≥6
5 ye
ars.
****
Sel
f-re
por
ted
out
com
e re
sults
sh
ould
be
inte
rpre
ted
with
ca
utio
n. R
esp
onse
rat
e w
as
very
low
, with
hig
h ris
k of
se
lect
ion
bia
s.
Vill
arre
al76
(201
7), U
KW
est
Mid
land
s A
mb
ulan
ce S
ervi
ce
To e
valu
ate
the
imp
act
of a
ser
vice
dev
elop
men
t in
volv
ing
a p
artn
ersh
ip
bet
wee
n E
MS
cre
w a
nd G
Ps
on r
educ
ing
conv
eyan
ce
rate
s to
the
ED
.
QU
AN
—on
e gr
oup
pos
t-te
st o
nly
des
ign.
ND
Pm
edic
sn=
1903
63.1
% o
f stu
dy
pop
ulat
ion
aged
≥6
1 ye
ars.
No
****
No
cont
rol g
roup
, no
dat
a on
ou
tcom
e.
Will
iam
s67 (2
018)
, US
AW
ake
Cou
nty
Em
erge
ncy
Med
ical
S
ervi
ces
To d
eter
min
e w
heth
er
unne
cess
ary
tran
spor
t ca
n b
e av
oid
ed.
QU
AN
—P
rosp
ectiv
e co
hort
stu
dy.
ND
Pm
edic
sn=
840
85.5
(8.3
) yea
rs.
Yes
****
‘Tim
e-se
nsiti
ve’ o
utco
me
mea
sure
s se
em t
o b
e so
mew
hat
rand
om c
hose
n.
ALS
, ad
vanc
ed li
fe s
upp
ort;
BLS
, bas
ic li
fe s
upp
ort;
ED
, em
erge
ncy
dep
artm
ent;
Em
CP,
em
erge
ncy
med
ical
car
e p
ract
ition
er; E
MS
, em
erge
ncy
med
ical
ser
vice
; EM
T 2,
em
erge
ncy
med
ical
tec
hnic
ian
(sup
ervi
sed
pat
ient
ass
essm
ent);
EM
T 3,
em
erge
ncy
med
ical
te
chni
cian
(uns
uper
vise
d p
atie
nt a
sses
smen
t); G
P, g
ener
al p
ract
ition
er; M
MAT
, mix
ed-m
etho
ds
app
rais
al t
ool;
NA
, not
ap
plic
able
; ND
, not
des
crib
ed; N
HS
, Nat
iona
l Hea
lth S
ervi
ce; P
med
ics,
par
amed
ics;
PTL
, par
amed
ic t
eam
lead
er; Q
UA
L, q
ualit
ativ
e re
sear
ch; Q
UA
N,
qua
ntita
tive
rese
arch
; RN
, reg
iste
red
nur
se.
Tab
le 1
C
ontin
ued
on 24 Septem
ber 2018 by guest. Protected by copyright.
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j.com/
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J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
8 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
(likelihood of conveyance by private EMS service is 4.5 times greater than with a public service).70
Within the society theme, the factor ‘Presence or absence of alternative care destinations for low-acuity diagnoses’ was mentioned as an important reason for conveyance to the ED.52 63 68 72 Where there were alter-native destinations (other than referral to the hospital), Schaefer et al found a decrease in the proportion of non-acuity patients who were referred to the ED relative to a historical control group (51.8% vs 44.6%, p=0.001). No increase in medical morbidity resulted from this reduction in hospital referrals, and the patients with alternative care destinations were satisfied with their care.68
Within the profession theme, ‘being held liable’ was found to be an important factor leading to possibly unnecessary conveyance to the ED.52 62–64 66 EMS staff feared being held responsible for a patient’s welfare, and opted for the safe option of referral to the ED rather than ‘treat and release’.
Meso-level themesThree themes on the meso level had been identified as influencing the conveyance decision after an emer-gency ambulance call: ‘EMS organisational structure’, ‘availability of appropriate resources and/or persons’ and ‘workload’. Most of the factors identified were within the ‘EMS organisational structure’ theme. Four studies52 63 64 73 reported that low confidence in the organisational support led to decisions reflecting mini-mising risk and thus conveyance to the ED. Opera-tional demands, such as minimising on-scene time and reducing the number of conveyance rates, were factors in the decision-making process, but were counter-produc-tive. Non-conveyance decisions are often more complex and time consuming and therefore increasing on-scene time.61 62 72 73
An important factor within the ‘availability of appro-priate resources and/or persons’ theme is the presence of clear directives or protocols. EMS staff indicated that conveyance protocols could give legitimacy to informal
Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the selection process. EMS, emergency medical service.
on 24 Septem
ber 2018 by guest. Protected by copyright.
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j.com/
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J Open: first published as 10.1136/bm
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ownloaded from
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Open access
Tab
le 2
D
ata
extr
actio
n ta
ble
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
Gov
ernm
ent
Typ
e of
org
anis
atio
n, p
ublic
or
priv
ate.
Priv
ate
EM
S s
ervi
ces
are
mor
e lik
ely
to c
onve
y a
pat
ient
to
the
hosp
ital t
han
pub
lic E
MS
se
rvic
es (l
ikel
ihoo
d o
f con
veya
nce
by
priv
ate
EM
S s
ervi
ce is
4.5
tim
es g
reat
er t
han
with
a
pub
lic s
ervi
ce).
70A
1
Soc
iety
Pre
senc
e or
ab
senc
e of
al
tern
ativ
e ca
re d
estin
atio
ns
(for
low
-acu
ity d
iagn
oses
).
Com
par
ed w
ith t
he p
rein
terv
entio
n gr
oup
:
►S
mal
ler
pro
por
tion
of p
atie
nts
in t
he
inte
rven
tion
grou
p r
ecei
ved
car
e in
the
ED
(p
=0.
001)
.
►G
reat
er p
rop
ortio
ns o
f pat
ient
s in
the
in
terv
entio
n gr
oup
rec
eive
d c
linic
car
e (p
=0.
001)
or
hom
e ca
re (p
=0.
043)
.Fa
ctor
s in
crea
sing
con
veya
nce:
►N
o sa
fe e
nviro
nmen
t fo
r re
cove
ry o
r ab
senc
e of
inve
stig
atio
n an
d t
reat
men
t op
tions
, if
req
uire
d.
►
Lack
of a
cces
s to
alte
rnat
ive
serv
ice
and
co
mm
unity
res
ourc
es.
►
Lim
ited
aw
aren
ess
of a
ltern
ativ
e ca
re o
ptio
ns
by
EM
S s
taff.
5 ou
t of
81
pat
ient
s w
ere
initi
ally
re
ferr
ed t
o an
alte
rnat
ive
care
d
estin
atio
n b
efor
e p
roce
edin
g on
to
the
ED
. No
med
ical
mor
bid
ity r
esul
ted
from
th
is d
elay
.P
atie
nts
who
wer
e re
ferr
ed t
o an
al
tern
ativ
e ca
re d
estin
atio
n w
ere
satis
fied
with
the
ir ca
re.
68A
4
►
Con
veya
nce
dec
isio
ns a
fter
a p
rimar
y ca
re
or p
sych
osoc
ial r
esp
onse
are
com
ple
x an
d
time-
cons
umin
g, m
akin
g co
nvey
ance
mor
e lik
ely.
52 6
3 72
Shi
ft o
f em
erge
ncy
call
pro
file
(from
prim
arily
em
erge
ncy
care
d
ecis
ions
to
prim
ary
care
and
p
sych
osoc
ial c
are)
.
63A
1
Pro
fess
ion
52 6
1 63
64
66 6
9
Bei
ng h
eld
liab
le.
Pot
entia
lly in
crea
ses
conv
eyan
ce r
ate
due
to:
►
Fear
of E
MS
pro
vid
ers
of b
eing
hel
d
resp
onsi
ble
and
liab
le fo
r a
pat
ient
’s w
elfa
re.
►
Anx
iety
ass
ocia
ted
with
dec
isio
ns a
nd
pot
entia
l rep
ercu
ssio
ns w
hen
dec
idin
g no
t to
con
vey—
conv
eyan
ce t
o th
e E
D w
as
cons
ider
ed t
he ‘d
efau
lt sa
fety
net
’.
52 6
1 63
64
66 6
9A
6 Con
tinue
d
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ber 2018 by guest. Protected by copyright.
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j.com/
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Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
EM
S
orga
nisa
tiona
l st
ruct
ure
52 6
3 64
Lack
of p
erce
ived
or
gani
satio
nal s
upp
ort/
cove
rage
.
►
Less
per
ceiv
ed s
upp
ort
lead
s to
low
-ris
k d
ecis
ions
, tha
t is
, con
veya
nce
to t
he E
D.
►
Lack
of c
onfid
ence
in o
rgan
isat
iona
l sup
por
t af
ter
an in
cid
ent.
52 6
3 64
A4
Op
erat
iona
l dem
and
s.
►P
ress
ure
exp
erie
nced
by
EM
S s
taff
to
min
imis
e on
-sce
ne t
ime
and
to
red
uce
conv
eyan
ce r
ates
(cou
nter
-pro
duc
tive
per
form
ance
ind
icat
ors)
.
►N
on-c
onve
yanc
e d
ecis
ions
: oft
en m
ore
com
ple
x an
d t
ime
cons
umin
g (in
crea
sed
on-
scen
e tim
e).
►
Hos
pita
l del
ays
imp
act
heav
ily o
n E
MS
sta
ff d
ecis
ion-
mak
ing.
►
Non
-con
veya
nce
rate
s go
up
in s
ituat
ions
of
exte
nsiv
e ho
spita
l del
ays.
63 6
4 72
73
A5
Eq
uip
men
t.
►N
o ac
cess
to,
or
def
ectiv
e, e
ssen
tial
equi
pm
ent
lead
ing
to c
onve
yanc
e.62
A1
Wor
kloa
d
61 6
2
Influ
ence
of s
ervi
ce s
truc
ture
.
►O
per
atio
nal c
ircum
stan
ces
such
as
a d
ifficu
lt sh
ift, a
bus
y sh
ift o
r b
eing
at
the
end
of a
sh
ift le
adin
g to
the
eas
iest
op
tion,
tha
t is
, co
nvey
ance
.
61 6
2A
2
Ava
ilab
ility
of
app
rop
riate
re
sour
ces/
per
sons
58
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
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j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
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Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
Ava
ilab
ility
of c
lear
dire
ctiv
es
or p
roto
cols
.
►Fi
eld
-bas
ed d
ecis
ion-
mak
ing
with
out
clea
r d
irect
ives
in e
nd-o
f-lif
e ca
re is
con
sid
ered
p
rob
lem
atic
and
driv
es u
p c
onve
yanc
e ra
tes.
►
Intr
oduc
tion
of T
&R
pro
toco
ls d
id n
ot c
hang
e th
e p
rop
ortio
n of
pat
ient
s le
ft a
t th
e sc
ene
(inte
rven
tion
grou
p 9
3/25
1 vs
con
trol
gro
up
195/
537,
(p=
0.9)
).
58A
3
1. P
atie
nt s
atis
fact
ion
scor
es w
ere
sign
ifica
ntly
hig
her
afte
r in
trod
ucin
g T&
R g
uid
elin
es: r
ight
am
ount
of
advi
ce (p
=0.
04);
reas
sure
d b
y th
e ad
vice
(p=
0.02
); cl
arity
whe
n as
king
fo
r m
ore
help
(p=
0.03
).2.
Pat
ient
s’ s
atis
fact
ion
with
EM
S c
rew
in
crea
sed
(p=
0.02
).3.
Med
ian
job
cyc
le t
ime
was
8 m
in
long
er fo
r no
n-co
nvey
ed p
atie
nts
(p<
0.00
01).
4. 3
/93
pat
ient
s in
the
inte
rven
tion
grou
p a
nd 3
/195
pat
ient
s in
the
co
ntro
l gro
up w
ere
left
at
hom
e b
ut
shou
ld h
ave
bee
n ta
ken
to t
he E
D.
75
►
EM
S s
taff
rep
orte
d in
crea
sed
con
fiden
ce,
job
sat
isfa
ctio
n an
d c
onsi
sten
cy in
the
ir as
sess
men
t an
d d
ecis
ion-
mak
ing
afte
r th
e in
trod
uctio
n of
pro
toco
ls.
61
Pro
visi
on o
f ob
ject
ive
feed
bac
k in
form
atio
n.
►C
hang
es in
the
pra
ctic
e of
par
amed
ics
whe
n p
rovi
ded
with
ob
ject
ive
outc
ome
dat
a. P
aram
edic
s b
ecam
e se
lf-m
otiv
ated
to
imp
rove
car
e.
1. N
o si
gnifi
cant
diff
eren
ce b
efor
e an
d a
fter
the
inte
rven
tion
in r
elat
ion
to p
atie
nts
who
sou
ght
med
ical
he
lp a
nd r
equi
red
ad
mis
sion
with
in
24 h
ours
of E
MS
con
tact
and
pat
ient
r e
fusa
ls.
2. P
atie
nt s
atis
fact
ion
incr
ease
d a
fter
th
e in
terv
entio
n to
100
% (p
=0.
03).
48B
3
►
Lack
of f
eed
bac
k on
ref
erra
l out
com
e w
as
exp
erie
nced
as
frus
trat
ing.
69
►
Lim
ited
acc
ess
to fe
edb
ack
on r
efer
ral
dec
isio
ns w
as b
arrie
r to
ind
ivid
ual a
nd
orga
nisa
tiona
l lea
rnin
g an
d im
pro
vem
ent.
63
Per
sona
l and
rol
e-re
late
d fa
ctor
s 51
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
12 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
Kno
win
g th
e p
rofe
ssio
nE
duc
atio
nal b
ackg
roun
d,
com
pet
enci
es a
nd s
kills
.
►P
aram
edic
s on
the
ir ow
n p
rovi
ded
si
gnifi
cant
ly m
ore
aid
and
less
freq
uent
ly
conv
eyed
tha
n nu
rses
in a
sim
ilar
pos
ition
(p
=0.
000)
.
51B
5
►
Par
ticul
ar E
CP
s us
e a
hyp
othe
tico-
ded
uctiv
e ap
pro
ach
to d
ecis
ion-
mak
ing
com
par
ed
with
the
pat
tern
-bas
ed d
ecis
ion-
mak
ing
app
roac
h.
►E
CP
s w
ere
mor
e lik
ely
to t
reat
pat
ient
s at
the
sc
ene
than
par
amed
ics
(p=
0.00
7).
►
The
trai
ning
, com
pet
ence
and
con
fiden
ce
of t
he E
CP
s se
emed
to
imp
rove
the
ir d
ecis
ion-
mak
ing
pro
cess
, with
a s
igni
fican
t im
pac
t on
res
ourc
es (a
mb
ulan
ce u
se, E
D
pre
sent
atio
ns).
►
EC
Ps
wer
e m
ore
likel
y to
con
sid
er t
he la
test
ev
iden
ce in
det
erm
inin
g th
eir
pra
ctic
e.
Non
e of
the
EC
Ps’
or
par
amed
ics’
p
atie
nts
who
wer
e tr
eate
d a
t th
e sc
ene
wer
e su
bse
que
ntly
con
veye
d w
ithin
24
hou
rs (o
ne r
epea
t ca
ll to
an
EC
P-
trea
ted
pat
ient
who
had
falle
n fo
r a
seco
nd t
ime)
.E
duc
atio
n an
d e
xper
ienc
e in
min
or
inju
ry u
nit
gave
the
EC
Ps
the
com
pet
ence
and
con
fiden
ce t
o tr
eat
pat
ient
s at
the
sce
ne.
53 7
3
►
Lack
of t
rain
ing,
dev
elop
men
t an
d s
kill
use
inhi
bits
the
com
pet
ence
and
con
fiden
ce
of p
aram
edic
s in
dea
ling
with
sp
ecifi
c, a
nd
esp
ecia
lly lo
w a
cuity
, dec
isio
n-m
akin
g in
ca
ses
of n
on-c
onve
yanc
e.
63 7
2 73
Rol
e p
erce
ptio
n.
►In
div
idua
l par
amed
ic p
erce
ptio
n of
wha
t th
e ro
le o
f a p
aram
edic
is d
eter
min
es t
he n
atur
e th
e d
ecis
ion-
mak
ing
pro
cess
.
►P
aram
edic
s se
e th
emse
lves
as
high
ly t
rain
ed
to m
anag
e p
atie
nts
with
life
-thr
eate
ning
co
nditi
ons
and
do
not
see
‘low
-acu
ity’ w
ork
as t
heir
job
.
73A
1
Per
sona
l and
rol
e-re
late
d fa
ctor
s 52
61–
64 6
9 72
73
Kno
win
g th
e se
lfE
xper
ienc
e an
d c
onfid
ence
.
►P
rior
exp
erie
nce
or w
orki
ng e
xper
ienc
e af
fect
s co
nvey
ance
-rel
ated
dec
isio
ns.
52 6
1–64
69
72 7
3A
9
►
EM
S s
taff
mus
t ha
ve a
hig
h le
vel o
f co
nfid
ence
and
/or
exp
erie
nce
in d
ealin
g w
ith
do-
not-
resu
scita
te a
nd m
edic
al o
rder
s fo
r lif
e-su
stai
ning
tre
atm
ent
situ
atio
ns.
58
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
13Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
Gen
der
of E
MS
sta
ff.
►M
ale/
mal
e te
ams
wer
e 4.
75 t
imes
mor
e lik
ely
to g
ener
ate
an R
MA
tha
n te
ams
with
at
leas
t on
e fe
mal
e (O
R 4
.75,
95%
CI 1
.63
to 1
3.96
, p
<0.
0046
).
56A
1
Hea
lth s
tatu
s of
EM
S s
taf f.
►
EM
S s
taff
’s p
hysi
cal c
ond
ition
affe
cts
thei
r d
ecis
ion-
mak
ing
abili
ty. P
hysi
cal
pro
ble
ms
may
neg
ativ
ely
affe
ct E
MS
sta
ff’s
co
ncen
trat
ion,
res
ultin
g in
inad
equa
te
conv
eyan
ce d
ecis
ions
.
62A
1
Per
sona
l and
rol
e-re
late
d fa
ctor
s 56
62
69
Kno
win
g th
e ca
seA
deq
uate
kno
wle
dge
-rel
ated
to
pat
hop
hysi
olog
y.
►P
rese
nce
of a
ser
ious
dis
ease
, ob
viou
s ac
ute
sign
s an
d s
ymp
tom
s, a
nd p
erce
ived
un
pre
dic
tab
ility
of t
he d
isea
se r
esul
t in
tr
ansp
orta
tion
to t
he E
D.
56 6
2 69
A3
Kno
win
g th
e p
erso
n/p
atie
ntE
duc
atio
nal s
tatu
s of
pat
ient
(o
r fa
mily
).
►C
omm
unic
atin
g an
d in
tera
ctin
g w
ith p
atie
nt
and
fam
ily m
emb
ers
with
hig
her
or lo
wer
ed
ucat
iona
l sta
tus
can
affe
ct t
he c
onve
yanc
e d
ecis
ion
bot
h p
ositi
vely
and
neg
ativ
ely.
62A
1
Men
tal c
apac
ity o
f the
pat
ient
.
►P
olic
y an
d p
roto
cols
dic
tate
ED
con
veya
nce
in c
ases
wer
e E
MS
sta
ff fin
ds
the
pat
ient
s in
cap
able
of m
akin
g th
eir
own
dec
isio
ns (e
g,
drin
king
alc
ohol
).
64A
1
Per
sona
l and
rol
e-re
late
d fa
ctor
s 62
Kno
win
g th
e p
erso
n/p
atie
ntFi
nanc
ial s
tatu
s/in
sura
nce
cove
rage
.
►Th
ose
who
hav
e b
ette
r fin
anci
al s
tatu
s ca
n in
sist
, des
pite
the
ad
vice
of E
MS
, on
conv
eyan
ce t
o E
D. P
atie
nts
in fi
nanc
ial
pro
ble
ms
and
no
insu
ranc
e as
k to
man
age
thei
r p
rob
lem
s at
hom
e.
62B
2
►
Fina
ncia
l rea
sons
pla
y a
maj
or r
ole
in t
he
dec
isio
n-m
akin
g in
eld
erly
pat
ient
s af
ter
an
emer
genc
y ca
ll.
70%
of e
lder
ly p
atie
nts
who
ref
use
tran
spor
t to
the
hos
pita
l rec
eive
d
follo
w-u
p c
are,
of w
hom
32%
wer
e ad
mitt
ed t
o ho
spita
l. A
vera
ge r
atin
g of
p
aram
edic
car
e w
as 8
.1±
1.1.
50
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
14 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
Sp
ecia
l pat
ient
gro
ups.
Sp
ecia
l pat
ient
gro
ups,
suc
h as
:1.
Pat
ient
s w
ho h
old
str
ateg
ic m
anag
emen
t or
ad
min
istr
ativ
e p
ositi
ons.
2. E
lder
ly p
eop
le w
ho li
ve a
lone
. Stu
den
ts w
ho
dev
elop
pro
ble
ms
at s
choo
l.3.
Cul
prit
s an
d p
rison
ers.
4. F
orei
gner
s.Th
ese
pat
ient
s ha
ve t
o b
e co
nvey
ed
irres
pec
tive
of t
he s
ever
ity o
r th
e se
rious
ness
of
the
pro
ble
m.
62A
1
Lack
of a
cces
s to
bac
kgro
und
m
edic
al in
form
atio
n.
►La
ck o
f hea
lth in
form
atio
n in
crea
ses
likel
ihoo
d o
f bei
ng c
onve
yed
as
it is
see
n as
th
e ‘e
asy
optio
n’.
52 5
7 59
69
72A
5
PR
OC
ES
S
61 6
9
Cue
sIn
tuiti
on/in
stin
ct.
►
Inst
inct
and
intu
ition
, aft
er t
alki
ng t
o a
pat
ient
, wer
e na
med
as
fact
ors
that
in
fluen
ced
the
con
veya
nce
dec
isio
n.
61 6
9A
2
Use
of d
ecis
ion
sup
por
t to
ols
Use
of a
dec
isio
n to
ol.
►
In c
ases
of i
nitia
l ref
usal
, con
veya
nce
of
high
-ris
k p
atie
nts
to t
he E
D in
crea
sed
aft
er
usin
g a
high
-ris
k cr
iteria
che
cklis
t b
y E
MS
st
aff (
3% v
s 10
%).
Tran
spor
t of
pat
ient
s w
ithou
t hi
gh-r
isk
dec
reas
ed (1
8% v
s 5%
, si
gnifi
cant
find
ing)
.
Pat
ient
s w
ith h
igh-
risk
crite
ria w
ho
wer
e tr
ansp
orte
d t
o th
e E
D w
ere
mor
e lik
ely
to b
e ad
mitt
ed t
o th
e ho
spita
l th
an p
atie
nts
who
did
not
hav
e hi
gh-
risk
crite
ria (4
8% v
s 5%
, p=
0.03
).
50B
3
►
In c
ases
of f
alls
, pat
ient
s at
tend
ed b
y in
terv
entio
n p
aram
edic
s us
ing
com
put
eris
ed
clin
ical
sup
por
t to
ol w
ere
twic
e as
like
ly t
o b
e re
ferr
ed t
o a
fall
serv
ice
(42/
436,
9.6
%)
com
par
ed w
ith (1
7/34
3, 5
.0%
); O
R 2
.04,
95
% C
I 1.1
2 to
3.7
2). N
on-c
onve
yanc
e ra
te w
as h
ighe
r in
the
inte
rven
tion
grou
p
(non
-sig
nific
ant).
No
diff
eren
ce in
out
com
e b
etw
een
inte
rven
tion
and
con
trol
gro
ups.
55
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
15Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
►
In c
ases
of f
alls
, pat
ient
s at
tend
ed b
y in
terv
entio
n p
aram
edic
s us
ing
a cl
inic
al
dec
isio
n flo
w c
hart
wer
e m
ore
likel
y to
be
refe
rred
to
falls
ser
vice
s.
Ther
e w
as li
ttle
diff
eren
ce in
the
rat
e of
occ
urre
nce
of s
erio
us a
dve
rse
even
ts b
etw
een
grou
ps.
The
re w
as n
o d
iffer
ence
in o
vera
ll he
alth
care
cos
ts
at 1
or
6 m
onth
s. In
terv
entio
n p
atie
nts
rep
orte
d h
ighe
r sa
tisfa
ctio
n w
ith
inte
rper
sona
l asp
ects
of c
are.
74
PR
OC
ES
S
49 5
4
Inp
ut o
f sig
nific
ant
othe
rsC
onsu
lting
(EM
S) p
hysi
cian
.
►In
cas
es o
f ref
usal
, pho
ne c
onta
ct w
ith
phy
sici
an im
pro
ved
tra
nsp
orta
tion
to t
he E
D
of h
igh-
risk
pat
ient
s w
ithou
t in
crea
sing
the
on
-sce
ne t
ime
(from
3%
to
35%
, sig
nific
ant
find
ing)
.
►Tr
ansp
ort
of p
atie
nts
with
out
high
ris
k d
ecre
ased
(18%
vs
0%, s
igni
fican
t fin
din
g).
►
Sim
ilar
rese
arch
sho
wed
tha
t on
line
cont
act
with
phy
sici
an in
crea
sed
con
veya
nce
to t
he
ED
(32.
1% v
s 8.
3%, p
<0.
001)
.
Pat
ient
s w
ith h
igh-
ris
k cr
iteria
who
w
ere
tran
spor
ted
to
the
ED
wer
e m
ore
likel
y to
be
adm
itted
to
the
hosp
ital
than
pat
ient
s w
ho d
id n
ot m
eet
high
-ris
k cr
iteria
(48%
vs
5%, p
=0.
03).
49 5
4A
9
►
49%
of t
he p
atie
nts
who
ref
used
con
veya
nce
to t
he h
osp
ital s
tate
d t
hat
spea
king
to
a p
hysi
cian
wou
ld in
fluen
ce t
heir
dec
isio
n in
fa
vour
of t
rans
por
t to
the
hos
pita
l.
50
►
Diffi
culty
in m
akin
g co
ntac
t w
ith (o
ut o
f ho
urs)
GP
was
a v
aria
ble
tha
t le
ads
to
conv
eyan
ce t
o th
e E
D.
63
►
Con
sulti
ng a
nov
ice
emer
genc
y p
hysi
cian
us
ually
lead
s to
the
pat
ient
bei
ng c
onve
yed
, w
hile
exp
erie
nced
phy
sici
ans
pro
vid
ed
cons
truc
tive
advi
ce.
62
►
Con
sulti
ng a
n E
MS
phy
sici
an, a
fter
EM
S
asse
ssm
ent
com
bin
ed w
ith a
tria
ge
tool
, lea
ds
to 5
6% a
bso
lute
dec
reas
e in
co
nvey
ance
to
the
ED
(74%
con
trol
vs
18%
in
terv
entio
n, p
<0.
001)
.
65
Tab
le 2
C
ontin
ued
Con
tinue
d
on 24 Septem
ber 2018 by guest. Protected by copyright.
http://bmjopen.bm
j.com/
BM
J Open: first published as 10.1136/bm
jopen-2018-021732 on 30 August 2018. D
ownloaded from
16 Oosterwold J, et al. BMJ Open 2018;8:e021732. doi:10.1136/bmjopen-2018-021732
Open access
Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
►
Ear
ly d
ialo
gue
bet
wee
n am
bul
ance
nu
rse
and
a G
P, in
pat
ient
s w
ith n
on-
urge
nt m
edic
al c
ond
ition
s, in
fluen
ces
the
conv
eyan
ce d
ecis
ion
in fa
vour
of n
on-
conv
eyan
ce. G
P h
ad a
cces
s to
the
med
ical
hi
stor
y of
the
pat
ient
.
Num
ber
of n
on-c
onve
yanc
e w
as h
ighe
r in
the
inte
rven
tion
grou
p (7
3.9%
vs
36.5
%, p
<0.
001)
. Mea
n tim
e to
ret
urn
to s
ervi
ce w
as s
igni
fican
tly lo
wer
in t
he
inte
rven
tion
grou
p (8
6.88
vs
94.1
2 m
in,
p=
0.00
4).
71
►
Eld
erly
are
less
like
ly t
o b
e co
nvey
ed t
o th
e E
D a
fter
EM
S a
sses
smen
t co
mb
ined
with
a
tria
ge t
ool a
nd G
P c
onsu
ltatio
n (te
lep
hone
ad
vice
or
face
-to-
face
ass
essm
ent
by
GP
).
A t
ime-
sens
itive
con
diti
on o
ccur
red
in
2% o
f the
non
-con
veye
d p
atie
nts
afte
r a
grou
nd le
vel f
all,
des
pite
the
pro
toco
l us
ed (W
illia
ms,
201
8).
67 7
6
PR
OC
ES
S
63
Con
sulti
ng c
olle
ague
s or
oth
er
serv
ices
.
►P
aram
edic
s ha
d p
ositi
ve e
xper
ienc
es
and
rel
atio
nshi
ps
with
out
-of-
hour
s an
d
othe
r se
rvic
es s
uch
as fa
lls t
eam
s, t
here
by
pre
vent
ing
conv
eyan
ce t
o th
e E
D.
63A
1
Unf
amili
arity
with
enh
ance
d
skill
s an
d r
esp
onsi
bili
ties
by
othe
r he
alth
care
pro
fess
iona
ls.
►
Hea
lthca
re p
rofe
ssio
nals
wer
e un
awar
e of
th
e p
aram
edic
’s s
kills
and
res
pon
sib
ilitie
s m
akin
g co
mm
unic
atio
n an
d c
omm
unity
-b
ased
ref
erra
ls d
ifficu
lt.
63A
1
Fram
ing
crew
s ex
pec
tatio
ns
by
dis
pat
cher
.
►In
form
atio
n b
y d
isp
atch
er h
ad t
he p
oten
tial
to in
form
and
fram
e cr
ew e
xpec
tatio
ns,
but
thi
s in
form
atio
n w
as o
ften
lim
ited
and
p
oten
tially
mis
lead
ing.
63 7
3A
2
Vie
ws
of t
he p
atie
nt.
►
EM
S s
taff
felt
that
ep
ilep
sy p
atie
nts
und
erst
ood
the
ir co
nditi
on w
ell a
nd w
ere
com
pet
ent
to m
ake
an a
pp
rop
riate
dec
isio
n on
ce r
ecov
ered
. In
case
s of
end
-of-
life
resp
onse
s, E
MS
sta
ff p
refe
rred
to
mee
t th
e w
ishe
s of
the
pat
ient
if t
hey
wer
e ca
pab
le o
f d
ecid
ing.
52 6
6A
2
Eva
luat
ion
No
fact
ors
foun
d.
PR
OC
ES
S
52 5
7 64
Jud
gem
ent
Con
sid
erin
g co
ntex
tual
fa
ctor
s.
►In
cas
es w
here
the
fam
ily w
ere
inte
nsel
y re
activ
e, c
onve
yanc
e w
as t
he e
asie
st a
nd
safe
st c
hoic
e. B
ysta
nder
exp
ecta
tions
le
adin
g to
con
veya
nce.
52 5
7 64
A5
Tab
le 2
C
ontin
ued
Con
tinue
d
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Ref
eren
ces
Cum
ulat
ive
sco
re*
Fact
ors
infl
uenc
ing
the
d
ecis
ion
for
conv
eyan
ceIm
pac
t an
d in
terp
lay
of
the
fact
ors
Sub
ject
ive/
ob
ject
ive
out
com
e
►
Diff
eren
ces
in p
ract
ice
amon
g p
aram
edic
s in
end
-of-
life
emer
genc
y re
spon
ses
lead
ing
to c
onve
yanc
e of
the
pat
ient
aga
inst
the
ir p
erce
ived
bes
t in
tere
st.
66
►
Hig
h re
spon
se t
imes
com
bin
ed w
ith
unfa
vour
able
em
otio
nal a
tmos
phe
re in
p
atie
nts
and
fam
ily le
adin
g to
tra
nsp
ort
to
alle
viat
e th
e si
tuat
ion.
62
Pre
senc
e or
ab
senc
e of
car
ers.
►
Pre
senc
e of
ad
equa
te c
are
or c
arer
s in
fluen
ced
the
dec
isio
n w
heth
er t
o co
nvey
or
not
.
69A
2
►
If th
e p
atie
nt h
ad s
ocia
l sup
por
t an
d a
cces
s to
a d
istr
ict
nurs
e or
GP
the
n cr
ews
wer
e m
ore
pre
par
ed n
ot t
o ta
ke t
he p
atie
nt t
o th
e ho
spita
l.
75
*Cum
ulat
ive
scor
e=(a
vera
ge o
f MM
AT s
core
of r
elat
ed a
rtic
les
and
cat
egor
ised
in A
(≥3
aste
risks
), B
(<3
to ≥
2 as
teris
ks),
C (<
2 as
teris
ks) C
OM
BIN
ED
with
tot
al n
umb
er o
f rel
ated
art
icle
s).
ALS
, Ad
vanc
ed li
fe s
upp
ort;
BLS
, Bas
ic li
fe s
upp
ort;
CC
P, c
ritic
al c
are
par
amed
ic; E
CP,
Em
erge
ncy
Car
e P
ract
ition
er; E
D, e
mer
genc
y d
epar
tmen
t; E
mC
A, E
mer
genc
y ca
re a
ssis
tant
s; E
mC
P,
Em
erge
ncy
care
pra
ctiti
oner
; EM
T 2,
em
erge
ncy
med
ical
tec
hnic
ian
(sup
ervi
sed
pat
ient
ass
essm
ent);
EM
T 3,
em
erge
ncy
med
ical
tec
hnic
ian
(uns
uper
vise
d p
atie
nt a
sses
smen
t); E
MT-
P:
Em
erge
ncy
Med
ical
Tec
hnic
ian
Par
amed
ic; E
MT-
D: E
mer
genc
y M
edic
al T
echn
icia
n D
efib
rilla
tion-
cap
able
; EM
T, e
mer
genc
y m
edic
al t
echn
icia
n; E
MT-
B, E
mer
genc
y M
edic
al T
echn
icia
n B
asic
; G
P, g
ener
al p
ract
ition
er; I
CP,
Inte
nsiv
e C
are
Par
amed
ic; M
dn,
med
ian;
MM
, Mix
ed m
etho
d r
esea
rch;
MM
AT, m
ixed
-met
hod
s ap
pra
isal
too
l; N
A, n
ot a
pp
licab
le; N
D, n
ot d
escr
ibed
; Pm
edic
s,
par
amed
ics;
PS
, par
amed
ic s
pec
ialis
t; P
TL, p
aram
edic
tea
m le
ader
; QP,
Qua
lified
Par
amed
ics;
QU
AL;
Qua
litat
ive
rese
arch
; QU
AN
, Qua
ntita
tive
rese
arch
; RN
, reg
iste
red
nur
se; T
&R
, tre
at a
nd
refe
r; U
P, u
nreg
iste
red
pra
ctiti
oner
.
Tab
le 2
C
ontin
ued
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practice, but did not necessarily influence conveyance rates.61 Effects that were reported after the introduction of new guidelines/protocols were: higher patient satisfac-tion rates,61 increased mean job-cycle time,55 better docu-mentation of clinical assessment,61 75 and increased job satisfaction and confidence of EMS staff.61 Another factor found within this theme was making use of a ‘feedback loop’. When EMS staff were provided with objective feed-back information on non-conveyance responses, their self-motivation to improve care increased,48 63 and this led to individual and organisational learning.63 Under the workload theme, two studies found that attending incidents during difficult or busy shifts, or at the end of a shift, led to taking the easy option of conveying the patient to hospital.61 62
Micro-level themes: dynamics in the decision-making processThe micro level consists of the knowledge that informs EMS staff on the scene, and can be subdivided into six themes: ‘personal and role-related factors’, ‘cues’, ‘judgement’, ‘input of significant others’, ‘thinking’ and ‘evaluation’.
Theme 1: personal and role-related factorsIn terms of personal and role-related factors, deci-sion-making is informed by four knowledge-related aspects: ‘knowing the self’, ‘knowing the profession’, ‘knowing the case’ and ‘knowing the person/patient’.
Most of the information uncovered from our review related to the ‘knowing the self’ aspect. Several factors
influence the conveyance decision: their experience and confidence (where experience was reported as more important than training),58 61 62 64 69 72 73, previous nega-tive experiences,52 63 gender56 and the health status of the EMS staff.62 One study that examined the influence of EMS staff gender on non-conveyance due to patient refusal found that all-male teams were 4.75 times more likely to be confronted with a refusal of medical aid and subsequent conveyance to the ED than all-female and mixed-gender teams.56
Educational background, labelled as the ‘knowing the profession’, also influenced the conveyance decision. It has been reported that paramedics less frequently convey patients to a hospital than nurses.51 Cooper et al and Simpson et al reported that patients seen by an emergency care practitioner (ECP), someone who combines extensive nursing and paramedic skills, were less likely to be conveyed to the ED than those seen by paramedics.53 73 None of the articles investigating this topic provided information on objective outcomes linked to the educational background of the EMS providers. However, Cooper et al did note that there was no differ-ence between paramedics and ECPs in terms of non-con-veyed patients requiring subsequent conveyance to the ED within 24 hours. Simpson et al also reported exten-sively on paramedic role perception as a factor that influ-enced decision-making. Many felt that engagement in fall risk assessment or injury prevention did not fall within the scope of their function.73
Figure 2 A priori theoretical framework of the decision-making process on conveyance by emergency medical service staff (based on Gillespie and Peterson, Steiner and Hackman).44 46 47
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Adequate pathophysiology knowledge was classified under the ‘knowing the case’ aspect. Here, recognition of the presence of a serious disease, obvious acute signs or perceived unpredictability of a disease resulted in direct conveyance to the ED.56 62 69
Finally, five factors were linked to the ‘knowing the person/patient’ aspect. Patients with a better financial status were more likely to be conveyed to the ED.50 62 The majority of the elderly (70%) who were denied convey-ance to the ED because of their poor financial status did receive follow-up care, of which 32% were later admitted to a hospital. Furthermore, the ‘educational status of the patient’ and being a ‘special case’, such as elderly patients who lived alone, prisoners or foreigners, someone who had become incapable of making his/her own decisions were reported as influencing the convey-ance decision.62 64 Lastly, having access to the medical history and/or baseline health information influenced the conveyance decision. In the absence of such informa-tion, conveyance to the ED may be seen as the easiest and safest option.52 58 59 69 72
Theme 2: cuesTwo studies described how intuition or ‘instinct’ influ-enced the conveyance decision.61 69 That is, a feeling based on previous work or clinical experience became a lesson that informed later decisions.
Theme 3: use of decision support toolsUse of a decision support tool increased the conveyance of patients to a specific service for those who had suffered falls rather than to the ED.61 74 No differences in eventual outcomes between the two referral options were found. The EMS staff indicated that experience and intuition had more influence on the conveyance decision than the standardised assessment tool, although high-risk patients who initially refused conveyance were more likely to agree if a checklist tool was used.49
Theme 4: input of significant othersConsulting a physician, either by the EMS staff or by the patient, influenced conveyance rates. When a patient initially refused transport to the hospital, contact with a physician could change the decision in favour of convey-ance to the ED.49 50 54 Telephone discussions between the paramedic, patient and an EMS physician led in one study to a major reduction in ED conveyance rate and in the median response time (from notification to ambulance back in service).71 Another study similarly found that when EMS staff were unable to consult a physician, the patient was more likely to be conveyed to the ED.63 Research investigating partnerships between general practitioners (GPs) and EMS staff showed that face-to-face contact between GP and patient led to lower conveyance rates than when the GP support was only by telephone.67 76
Consulting a colleague or other healthcare provider (members of teams specialising in falls) was also
mentioned as a factor that could prevent unnecessary conveyance to the ED.63
Two studies reported that confident EMS staff were steered by the views of a patient (known to suffer from epilepsy) and believed that the patient understood their situation sufficiently well to be able to make the decision for themselves.52 66
When responding to patients in end-of-life situations, EMS staff would prefer to meet the wishes of the patient if a patient had the capacity for decision-making or if the situation was correctly documented.66
Finally, there is the influence of the dispatcher. EMS crews reported that the information provided by the dispatcher could frame their expectations and influence the decision-making.63 73
Theme 5: judgementJudgement of contextual factors can be used to gather information to support decision-making. A decision to convey to the ED could be influenced by others. Strong reactions from family members, carers or bystanders were mentioned as a reason to prevent or stabilise a crisis and choose the safest option.52 58 64 In addition, any dissat-isfaction by the patient or their family due to a lengthy response time was mentioned as a factor leading to conveyance to alleviate the situation.62
Sometimes, paramedics can seek confirmation from their colleague, and one could be influenced by the other. There were also situations where the colleague had an alternative approach to theirs, including conveying patients against their perceived best interests.66
When non-conveyance is being considered as an option, the EMS staff take into account whether someone should and could be involved in taking further care of the patient. The presence of adequate care/carers was reported as having an influence on this decision.61 69
Conceptual frameworkThe process of data extraction and coding led to a small revision of the framework. The theme ‘Decisions’ was redefined as 'Input of significant others', in order to give a more accurate description of the factors found from the studies. ‘Use of decision support tools’ was added as a new theme. No factors were found related to the theme ‘eval-uation’ and is therefore removed from the conceptual framework. Factors linked to ‘outcomes’ were displayed as objective and subjective outcomes. The revised concep-tual framework is displayed in figure 3.
DIsCussIOnsummary of evidenceThe main aim of this MSR was to provide insight and a deeper understanding of factors that influence the deci-sion regarding conveyance of elderly patients to an ED after an emergency ambulance attendance. Further, we looked at both objective and subjective outcomes related to the conveyance decision such as the occurrence of
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undesirable outcomes and patient-reported outcomes. Findings are presented in an overarching framework that primarily reflects the relatively large influence of factors unrelated to a patient’s condition on the conveyance decision.
Decisions over whether to convey someone to an ED after an emergency ambulance attendance often concern elderly people. An incorrect decision over an elderly person can lead to an increased risk of adverse or health-threatening effects as a result of chronic or multiple diseases, frailty, disability, polypharmacy and social isola-tion.20 21 24 25 77 Consequently, we decided to focus on the elderly in this study. We found 8 of the 29 studies included in our review primarily focused on elderly patients. Most of the studies focused on elderly were related to convey-ance decisions after a fall. The presence or absence of informal carers was mentioned as factor influencing the conveyance decision. In the absence of informal carers, elderly patients are likely to be taken to an ED even if there is no underlying life-threatening condition. These avoidable referrals to the ED can be hazardous, especially for vulnerable elderly people, and puts an additional strain on those treating a large number of acute admis-sions to the ED, and its resources, and also leads to higher healthcare costs.38 78
When broadening our scope and including all age groups, our first relevant finding is that the majority of factors that influence the conveyance decision are not determined by the direct contact between patient and EMS staff. Mainly on the macro and meso levels, and in personal and role-related factors, a variety of non-medical factors are influential. Our review of the literature shows that EMS staff are more likely to decide to convey a patient to the ED if they perceive a lack of organisational support, lack access to, or have defective, equipment, have coun-teracting performance indicators or sense that they are being held responsible for a patient’s health. These find-ings indicate the relevance of patient-unrelated factors in conveyance decisions that might have a significant impact on patient safety, resource use and, ultimately, healthcare costs. Being held liable while, at the same time, experi-encing insufficient organisational support and a ‘shame and blame’ culture can obstruct organisational learning and patient safety, whereas boosting the competences and working conditions of healthcare staff and leader-ship are known to increase the quality of healthcare.79–81 When managers are aware that macro and meso factors can have a major impact on conveyance decisions, and act accordingly, EMS staff can make more effective and efficient decisions.
Figure 3 Conceptual framework of factors affecting the decision of ambulance service personnel regarding conveying adult patients to an emergency department. ED, emergency department; ECP, emergency care practitioner; EMS, emergency medical service; GP, general practitioner; MMAT, mixed-methods appraisal tool; Pmedic, paramedic.
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Several factors, from both the EMS staff and patient perspectives, have been identified as affecting the convey-ance decision-making process. Work experience, and its impact on the confidence of EMS professionals, was often cited as a factor that influenced the conveyance decision. Research on registered nurses in hospitals has similarly demonstrated a positive link between work expe-rience and competence, and showed this had an influ-ence on patient outcomes.82 Higher education levels, permanent employment and participation in educa-tional programmes also boosted employees’ feelings of competence.82 As such, investing in increasing the knowl-edge and skills needed to assess the elderly, and in the expanding options for non-emergency responses, would seem to pay off. Introducing EMS staff with additional specialised knowledge and competences regarding elderly care could improve on-scene care and avoid unnecessary ED admissions. Here, our MSR shows that EMS special-ists were more likely to treat patients at the scene than paramedics, although there was little evidence in terms of different outcomes during the follow-up period.53 73 Further exploring the effect of using EMS specialists in assessing, treating and referring elderly patients should be considered and linked to objective and subjective outcomes.
EMS staff can find it helpful if they can contact a physi-cian in questionable and doubtful situations since this may provide EMS staff with the necessary medical infor-mation to make a correct referral decision. On the micro level, we saw that enabling EMS staff to consult a physi-cian could increase the likelihood of conveying, possibly overlooked, high-risk patients and a decrease in unneces-sary referrals of non-emergency cases to the ED.49 There are also multiple studies that describe how contacting a physician (EMS physician or GP) has a positive influence in cases where a patient initially refuses transfer to the ED.49 50 54 Facilities such as telecare and telehealth can support this consultation process and could be further investigated in order to improve the decision-making process.
A recent systematic review provided us with consider-able data on the outcomes of a decision not to convey a patient to the ED.16 The researchers concluded that, after non-conveyance, 6.1% of the patients again contacted EMS within 24 hours, and up to 19% visited an ED within 48 hours of the initial interaction. In our MSR, we found evidence that being able to refer to alternative care facil-ities, using EMS specialists (ECPs), using referral tools, providing objective feedback to EMS staff and enabling EMS staff to contact a physician were all feasible and safe options to increase the likelihood that patients received the right care in the appropriate place.
However, we also found several factors leading to referrals to the ED when alternative care destinations or non-referral could be a better option. Despite there being a lack of research on the proportion of patients being conveyed while not strictly requiring hospital care, previous research shows that such a decision comes with
risks and disadvantages, such as increased pressure on the ED, longer and often overnight stays in the ED and hospital, which all add to costs.21 23–25 38 To improve the future quality of EMS responses, more data are needed on avoidable conveyance decisions, in terms of the actual numbers, and subsequent research on how to reduce this.
lIMItAtIOnsA possible weakness is that the factors identified cannot be assumed to relate to elderly people because, in many studies, the elderly were just part of a broader study popu-lation, and the results were not specified by age group. In addition, the low methodological quality in some of the studies and the considerable age of some of them are also limitations of the study.
COnClusIOnsMaking a decision to convey an elderly person to the hospital after an emergency ambulance response is not only determined by the assessment of medical conditions, but additional factors also influences this decision. These factors should be taken into account when new guidelines are being developed, or when new research is conducted into conveyance decisions, to ensure that greater insight will be developed on how multiple factors and their inter-play influence the conveyance decision. Given the rapidly increasing number of vulnerable elderly individuals, it is, from both social and medical perspectives, highly rele-vant that EMS responses avoid unnecessary hospitalisa-tion, and that evidence is provided to support future safe conveyance guidelines.
IMPlICAtIOns fOr future reseArChThe low methodological quality in some of the studies, the considerable age of some of them and the broader population covered in many of them mean that further research focused on exploring the factors found in this review within EMS practice and the population of elderly people is warranted. In addition, study could be carried out to quantify the occurrence of preventable admissions to EDs based on the factors identified in this review.
Author affiliations1Department of Health Sciences – Nursing Research, UMC Groningen, Groningen, The Netherlands2NHL Stenden, University of Applied Sciences, Leeuwarden, The Netherlands3Ambulance Department, University Medical Center Groningen, Roden, The Netherlands4Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands5Eastern Regional Emergency Healthcare Network, Radboud University Medical Centre, Nijmegen, The Netherlands6IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands7Operations Department, Faculty of Economics and Business, Groningen, The Netherlands
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Acknowledgements We would like to thank Giles Stacey for his detailed comments on the manuscript.
Contributors All the authors contributed to the study design. Data were collected and selected by JO, DS and MB. Critical appraisal of all the selected articles was divided among PR, DS and MB. JO independently reviewed all the articles and results were compared. Agreement on a definitive appraisal was obtained by discussion. The manuscript was drafted by JO in close collaboration with MB and SB. All the authors approved the final manuscript before submitting.
funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Additional documentation on the data-collection process and appraisal is available from the corresponding author on reasonable request.
Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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