Table 2

Data extraction table

				References	Cumulative score*
	Factors influencing the decision for conveyance	Impact and interplay of the factors	Subjective/objective outcome
Government
	Type of organisation, public or private.	Private EMS services are more likely to convey a patient to the hospital than public EMS services (likelihood of conveyance by private EMS service is 4.5 times greater than with a public service).		70	A1
Society
	Presence or absence of alternative care destinations (for low-acuity diagnoses).	Compared with the preintervention group: Smaller proportion of patients in the intervention group received care in the ED (p=0.001). Greater proportions of patients in the intervention group received clinic care (p=0.001) or home care (p=0.043). Factors increasing conveyance: No safe environment for recovery or absence of investigation and treatment options, if required. Lack of access to alternative service and community resources. Limited awareness of alternative care options by EMS staff.	5 out of 81 patients were initially referred to an alternative care destination before proceeding on to the ED. No medical morbidity resulted from this delay. Patients who were referred to an alternative care destination were satisfied with their care.	68	A4
		Conveyance decisions after a primary care or psychosocial response are complex and time-consuming, making conveyance more likely.		52 63 72
	Shift of emergency call profile (from primarily emergency care decisions to primary care and psychosocial care).			63	A1
Profession				52 61 63 64 66 69
	Being held liable.	Potentially increases conveyance rate due to: Fear of EMS providers of being held responsible and liable for a patient’s welfare. Anxiety associated with decisions and potential repercussions when deciding not to convey—conveyance to the ED was considered the ‘default safety net’.		52 61 63 64 66 69	A6
EMS organisational structure				52 63 64
	Lack of perceived organisational support/coverage.	Less perceived support leads to low-risk decisions, that is, conveyance to the ED. Lack of confidence in organisational support after an incident.		52 63 64	A4
	Operational demands.	Pressure experienced by EMS staff to minimise on-scene time and to reduce conveyance rates (counter-productive performance indicators). Non-conveyance decisions: often more complex and time consuming (increased on-scene time). Hospital delays impact heavily on EMS staff decision-making. Non-conveyance rates go up in situations of extensive hospital delays.		63 64 72 73	A5
	Equipment.	No access to, or defective, essential equipment leading to conveyance.		62	A1
Workload				61 62
	Influence of service structure.	Operational circumstances such as a difficult shift, a busy shift or being at the end of a shift leading to the easiest option, that is, conveyance.		61 62	A2
Availability of appropriate resources/persons				58
	Availability of clear directives or protocols.	Field-based decision-making without clear directives in end-of-life care is considered problematic and drives up conveyance rates. Introduction of T&R protocols did not change the proportion of patients left at the scene (intervention group 93/251 vs control group 195/537, (p=0.9)).		58	A3
			Patient satisfaction scores were significantly higher after introducing T&R guidelines: right amount of advice (p=0.04); reassured by the advice (p=0.02); clarity when asking for more help (p=0.03). Patients’ satisfaction with EMS crew increased (p=0.02). Median job cycle time was 8 min longer for non-conveyed patients (p<0.0001). 3/93 patients in the intervention group and 3/195 patients in the control group were left at home but should have been taken to the ED.	75
		EMS staff reported increased confidence, job satisfaction and consistency in their assessment and decision-making after the introduction of protocols.		61
	Provision of objective feedback information.	Changes in the practice of paramedics when provided with objective outcome data. Paramedics became self-motivated to improve care.	No significant difference before and after the intervention in relation to patients who sought medical help and required admission within 24 hours of EMS contact and patient refusals. Patient satisfaction increased after the intervention to 100% (p=0.03).	48	B3
		Lack of feedback on referral outcome was experienced as frustrating.		69
		Limited access to feedback on referral decisions was barrier to individual and organisational learning and improvement.		63
Personal and role-related factors				51
Knowing the profession	Educational background, competencies and skills.	Paramedics on their own provided significantly more aid and less frequently conveyed than nurses in a similar position (p=0.000).		51	B5
		Particular ECPs use a hypothetico-deductive approach to decision-making compared with the pattern-based decision-making approach. ECPs were more likely to treat patients at the scene than paramedics (p=0.007). The training, competence and confidence of the ECPs seemed to improve their decision-making process, with a significant impact on resources (ambulance use, ED presentations). ECPs were more likely to consider the latest evidence in determining their practice.	None of the ECPs’ or paramedics’ patients who were treated at the scene were subsequently conveyed within 24 hours (one repeat call to an ECP-treated patient who had fallen for a second time). Education and experience in minor injury unit gave the ECPs the competence and confidence to treat patients at the scene.	53 73
		Lack of training, development and skill use inhibits the competence and confidence of paramedics in dealing with specific, and especially low acuity, decision-making in cases of non-conveyance.		63 72 73
	Role perception.	Individual paramedic perception of what the role of a paramedic is determines the nature the decision-making process. Paramedics see themselves as highly trained to manage patients with life-threatening conditions and do not see ‘low-acuity’ work as their job.		73	A1
Personal and role-related factors				52 61–64 69 72 73
Knowing the self	Experience and confidence.	Prior experience or working experience affects conveyance-related decisions.		52 61–64 69 72 73	A9
		EMS staff must have a high level of confidence and/or experience in dealing with do-not-resuscitate and medical orders for life-sustaining treatment situations.		58
	Gender of EMS staff.	Male/male teams were 4.75 times more likely to generate an RMA than teams with at least one female (OR 4.75, 95% CI 1.63 to 13.96, p<0.0046).		56	A1
	Health status of EMS staff.	EMS staff’s physical condition affects their decision-making ability. Physical problems may negatively affect EMS staff’s concentration, resulting in inadequate conveyance decisions.		62	A1
Personal and role-related factors				56 62 69
Knowing the case	Adequate knowledge-related to pathophysiology.	Presence of a serious disease, obvious acute signs and symptoms, and perceived unpredictability of the disease result in transportation to the ED.		56 62 69	A3
Knowing the person/patient	Educational status of patient (or family).	Communicating and interacting with patient and family members with higher or lower educational status can affect the conveyance decision both positively and negatively.		62	A1
	Mental capacity of the patient.	Policy and protocols dictate ED conveyance in cases were EMS staff finds the patients incapable of making their own decisions (eg, drinking alcohol).		64	A1
Personal and role-related factors				62
Knowing the person/patient	Financial status/insurance coverage.	Those who have better financial status can insist, despite the advice of EMS, on conveyance to ED. Patients in financial problems and no insurance ask to manage their problems at home.		62	B2
		Financial reasons play a major role in the decision-making in elderly patients after an emergency call.	70% of elderly patients who refuse transport to the hospital received follow-up care, of whom 32% were admitted to hospital. Average rating of paramedic care was 8.1±1.1.	50
	Special patient groups.	Special patient groups, such as: Patients who hold strategic management or administrative positions. Elderly people who live alone. Students who develop problems at school. Culprits and prisoners. Foreigners. These patients have to be conveyed irrespective of the severity or the seriousness of the problem.		62	A1
	Lack of access to background medical information.	Lack of health information increases likelihood of being conveyed as it is seen as the ‘easy option’.		52 57 59 69 72	A5
PROCESS				61 69
Cues	Intuition/instinct.	Instinct and intuition, after talking to a patient, were named as factors that influenced the conveyance decision.		61 69	A2
Use of decision support tools	Use of a decision tool.	In cases of initial refusal, conveyance of high-risk patients to the ED increased after using a high-risk criteria checklist by EMS staff (3% vs 10%). Transport of patients without high-risk decreased (18% vs 5%, significant finding).	Patients with high-risk criteria who were transported to the ED were more likely to be admitted to the hospital than patients who did not have high-risk criteria (48% vs 5%, p=0.03).	50	B3
		In cases of falls, patients attended by intervention paramedics using computerised clinical support tool were twice as likely to be referred to a fall service (42/436, 9.6%) compared with (17/343, 5.0%); OR 2.04, 95% CI 1.12 to 3.72). Non-conveyance rate was higher in the intervention group (non-significant).	No difference in outcome between intervention and control groups.	55
		In cases of falls, patients attended by intervention paramedics using a clinical decision flow chart were more likely to be referred to falls services.	There was little difference in the rate of occurrence of serious adverse events between groups. There was no difference in overall healthcare costs at 1 or 6 months. Intervention patients reported higher satisfaction with interpersonal aspects of care.	74
PROCESS				49 54
Input of significant others	Consulting (EMS) physician.	In cases of refusal, phone contact with physician improved transportation to the ED of high-risk patients without increasing the on-scene time (from 3% to 35%, significant finding). Transport of patients without high risk decreased (18% vs 0%, significant finding). Similar research showed that online contact with physician increased conveyance to the ED (32.1% vs 8.3%, p<0.001).	Patients with high- risk criteria who were transported to the ED were more likely to be admitted to the hospital than patients who did not meet high-risk criteria (48% vs 5%, p=0.03).	49 54	A9
		49% of the patients who refused conveyance to the hospital stated that speaking to a physician would influence their decision in favour of transport to the hospital.		50
		Difficulty in making contact with (out of hours) GP was a variable that leads to conveyance to the ED.		63
		Consulting a novice emergency physician usually leads to the patient being conveyed, while experienced physicians provided constructive advice.		62
		Consulting an EMS physician, after EMS assessment combined with a triage tool, leads to 56% absolute decrease in conveyance to the ED (74% control vs 18% intervention, p<0.001).		65
		Early dialogue between ambulance nurse and a GP, in patients with non-urgent medical conditions, influences the conveyance decision in favour of non-conveyance. GP had access to the medical history of the patient.	Number of non-conveyance was higher in the intervention group (73.9% vs 36.5%, p<0.001). Mean time to return to service was significantly lower in the intervention group (86.88 vs 94.12 min, p=0.004).	71
		Elderly are less likely to be conveyed to the ED after EMS assessment combined with a triage tool and GP consultation (telephone advice or face-to-face assessment by GP).	A time-sensitive condition occurred in 2% of the non-conveyed patients after a ground level fall, despite the protocol used (Williams, 2018).	67 76
PROCESS				63
	Consulting colleagues or other services.	Paramedics had positive experiences and relationships with out-of-hours and other services such as falls teams, thereby preventing conveyance to the ED.		63	A1
	Unfamiliarity with enhanced skills and responsibilities by other healthcare professionals.	Healthcare professionals were unaware of the paramedic’s skills and responsibilities making communication and community-based referrals difficult.		63	A1
	Framing crews expectations by dispatcher.	Information by dispatcher had the potential to inform and frame crew expectations, but this information was often limited and potentially misleading.		63 73	A2
	Views of the patient.	EMS staff felt that epilepsy patients understood their condition well and were competent to make an appropriate decision once recovered. In cases of end-of-life responses, EMS staff preferred to meet the wishes of the patient if they were capable of deciding.		52 66	A2
Evaluation	No factors found.
PROCESS				52 57 64
Judgement	Considering contextual factors.	In cases where the family were intensely reactive, conveyance was the easiest and safest choice. Bystander expectations leading to conveyance.		52 57 64	A5
		Differences in practice among paramedics in end-of-life emergency responses leading to conveyance of the patient against their perceived best interest.		66
		High response times combined with unfavourable emotional atmosphere in patients and family leading to transport to alleviate the situation.		62
	Presence or absence of carers.	Presence of adequate care or carers influenced the decision whether to convey or not.		69	A2
		If the patient had social support and access to a district nurse or GP then crews were more prepared not to take the patient to the hospital.		75

*Cumulative score=(average of MMAT score of related articles and categorised in A (≥3 asterisks), B (<3 to ≥2 asterisks), C (<2 asterisks) COMBINED with total number of related articles).
ALS, Advanced life support; BLS, Basic life support; CCP, critical care paramedic; ECP, Emergency Care Practitioner; ED, emergency department; EmCA, Emergency care assistants; EmCP, Emergency care practitioner; EMT 2, emergency medical technician (supervised patient assessment); EMT 3, emergency medical technician (unsupervised patient assessment); EMT-P: Emergency Medical Technician Paramedic; EMT-D: Emergency Medical Technician Defibrillation-capable; EMT, emergency medical technician; EMT-B, Emergency Medical Technician Basic; GP, general practitioner; ICP, Intensive Care Paramedic; Mdn, median; MM, Mixed method research; MMAT, mixed-methods appraisal tool; NA, not applicable; ND, not described; Pmedics, paramedics; PS, paramedic specialist; PTL, paramedic team leader; QP, Qualified Paramedics; QUAL; Qualitative research; QUAN, Quantitative research; RN, registered nurse; T&R, treat and refer; UP, unregistered practitioner.