Table 1

Characteristics of included studies

Lead author (year), countryAimMethodStudy populationQuality appraisal MMAT score */****Short overall
SettingEMS staff (n)Professional
Patients (n)Age range or mean (SD) of patientsSpecific elderly population
Aftyka51 (2014), Poland
The regional Directorate of EMS in Lublin
To compare the actions and referral decisions of nurses and paramedics taken in the field.QUAN—retrospective observational study. Analysis of ambulance records.n=992Pmedics, n=555; RN, n=437.n=10820>90 years.No**Methodological and statistical inconsistencies, making the results and conclusions difficult to interpret. Lacks a statistical power analysis.
Alicandro49 (1995), USA
Four suburban volunteer EMS in Suffolk county, New York
To evaluate the effect of a documentation checklist and online medical control contact on EMS conveyance decisions in patients refusing medical assistance.QUAN—non-randomised controlled trial. Prospective sequential intervention study.NDVolunteer, ALS providers, BLS providers.n=361 Phase 1, 39 (22) years.
Phase 2, 39 (22) years.
Phase 3, 41 (20) years.
No*Small sample size and the absence of a power calculation; no data on patient enrolment, unclear if all eligible patients were enrolled; results obtained in volunteer EMS, with both BLS and ALS personnel. Generalisability in non-volunteer EMS unclear.
Burrell52 (2013), UK
Ambulance clinicians from South London
To examine the decision-making process of ambulance clinicians in situations of epilepsy.QUAL—phenomenological study. Face-to-face and topic-guided interviews.n=15Pmedic, n=5; EMT 2, n=1; EMT 3, n=4; EmCP, n=1; PTL, n=4.NANANo***Convenience sample may have led to selection bias. No information on saturation in order to determine the qualitative sample size. Awareness of the impact of doing interviews by a colleague.
Burstein60 (1998), USA
Suburban volunteer EMS in Suffolk county, New York
To measure the effect of physician assertiveness on EMS conveyance decisions of patients attempted refusal of medical assistance.QUAN—cohort study. Prospective analysis of different outcome variables.NDVolunteer, ALS providers, BLS providers.n=130NDNo***No table of patient characteristics included; instrument for measuring assertiveness not validated; the sample was aware of being studied which may cause bias. Generalisability in non-volunteer EMS unclear.
Cooper53 (2004), UK
Westcountry Ambulance NHS Trust
To evaluate the role of emergency care practitioners on the conveyance decision and compare that with the paramedics.MM—sequential explanatory design. Two stages of data collection: (1) retrospective data analysis, (2) individual and focus groups interviews with ECPs, Pmedics, managers and other staff members.n=15ECP, n=4; Pmedic, n=11; ECP and Pmedics mean work experience=8 years.n=692;
51% males,
49% females.
0–99No***No statistical comparison between ECPs and Pmedics in terms of years of experience. ECPs treated more patients under the age of 16 years compared with the Pmedics (p=0.001).
Ebrahimian62 (2014), Iran
EMS staff working in different districts of Tehran
To explore factors affecting EMS staff’s decision about conveyance to medical facilities.QUAL—phenomenological study. Content analysis with semistructured interviews.n=18 (males)Diploma medical emergency (2-year course) or nursing (4-year course). Age: 28–39 years (min–max). Mean work experience=6.61 years.NANANo***Brief description of demographic profile of the respondents. Lack of intercoder reliability which is a crucial component in content analysis. External validity may be impaired because of non-Western culture/country.
Halter69 (2011), UK
London Ambulance Service
To clarify the EMS conveyance decisions, after the use of a clinical assessment tool, in older people who have a fall.QUAL—phenomenological study. Semistructured interview.n=12 (7 females, 5 males)Pmedic, n=1; EMT, n=11. Mean work experience =3.5 years .NDNDYes, elderly fallers****Convenience sample with low experience level of EMS staff.
O’Hara63 (2015), UK
Three ambulance trusts in England
To explore systemic influences on decision-making by paramedics relating to care transitions to identify potential risk factors.QUAL—multimethod study including a ethnographic study. Two phases of data collection: (1) semistructured interviews, (2) observation, digital diaries, focus groups.n=88Pmedic, n=57; SP , n=13; EMT, n=18. Experience EMS staff, <1–20 years.NANANo***Selection on participants is unclear, no information on sampling.
Persse48(2002), USA
City of Houston Emergency Medical Service
To determine if providing follow-up information about non-conveyed elderly patients would change the future decision-making by paramedics.QUAN—prospective chart review (descriptive study)NAPmedic’sn=260≥65 years of ageYes, patients
aged ≥65
911 services.
**Demographic information comparing groups in phase 1, 2 and 3 is missing. Differences between groups may account for any differences in outcomes. Less than 60% being contacted after non-conveyance. No power calculation.
Murphy-Jones66 (2016), UK
English NHS ambulance trust
To explore how Pmedics make conveyance decisions in end-of-life care situations.QUAL—phenomenological study. Semistructured interviews.n=6 (3 females,3 males)Pmedics age, 24–42 years. Work experience range 2–8 years.NANDYes, nursing
***Small sample size (n=6). Unknown if data saturation is reached. Working experience of Pmedics ≤8 years.
Schaefer68 (2002), USA
King county EMS
To determine if EMS staff could decrease the rate of conveyance to the ED, in patients with no urgent concerns, by identifying and safely triaging them to alternate care destinations.QUAN—cohort study. Matched historical control group.NDEMT and BLS training. Pmedic and ALS training.n=3633;
45.9% versus 47.4% males.
Range, 0–104,
No****Study took place within BLS response teams. One physician determined the eligibility for alternate destination of care based on predefined criteria. No level of agreement between physicians was measured. The significant difference in destination of care should be interpreted with caution because of the non-randomised study design.
Snooks75 (2004), UK
Two ambulance services in West London
To evaluate the effectiveness of ‘treat and refer’ protocols.QUAN—controlled trial without randomisation. Run sheet analysis and analysis of ED and GP records. Follow-up questionnaire of non-conveyed patients.NDPmedics and EMTsINT, n=788 CON,
n=251 ,
52% vs 51%
males (p=0.69).
Mean age,
54 vs 47 years
No****Power calculation was conducted but was reduced because of lower recruitment to study groups than anticipated. No table of patient characteristics, data reported in text.
Snooks61 (2005), UK
Two ambulance stations in London
To report the views and attitudes of EMS staff in conveyance decision-making in and in a new triage intervention on for non-conveyance.QUAL—Phenomenological study focus groups.n=21 (20 males,1 female)Duration of service, mean (range in years): Focus group 1, 7 (4–16); Focus group 2, 12 (0.5–25); Focus group 3, 8 (4–16).NANANo***Brief description on qualitative data analysis/coding procedure.
Snooks55 (2014), UK
9 Ambulance stations across a mixed rural and urban area in the UK
To investigate the effectiveness of a computerised clinical decision support tool for emergency paramedics in conveyance decisions of older people who have fallen.QUAN—cluster randomised controlled trial.n=42Pmedic’s .INT, n=436 CON, 
≥65 years.
Mdn age INT 
83 years CON
82 years.
Yes, older people who have fallen.***Study is slightly underpowered.
Stuhlmiller54 (2005), USA
Cleveland EMS
To assess the ability of EMS to determine medical decision-making capacity and in obtaining an informed refusal of transport.QUAN—retrospective observational study. Analysis of run sheets, non-transport worksheets and associated recorded refusal calls.NDPmedics and online medical command physicians.n=13745.9 (22.6),
range 0–91
No***Calls randomly generated.
Vilke50 (2002), USA
San Diego Medical Services Enterprise
To obtain information and experiences of patients (≥65 years of age) who refused transport by EMS and determine the potential role of online physician–patient contact.QUAN—prospective observational study, telephone survey and ambulance records analysis.NAEMT-Ps, EMT-Ds.n=10072.2 (6.4)Yes, patients aged ≥65 and signed out against medical advice .**Telephone survey with possibility of reporting bias. Of the total sample population, 16% of the patients were reached by telephone and agreed (100/636). Data collection tool was not validated.
Waldron56 (2012), USA
Hospital-based ambulance service in New York
To determine if there is an association between EMT gender and the patients decision to refuse conveyance to the hospital by ambulance.QUAN—case–control study. Retrospective ambulance records analysis.n=322 Male/male=271 Male/female and female/female=51EMT-Bs, EMT-Ps.Refusing medical aid,
n= 161; 47.2%
male Non refusing
medical aid, 
n=161; 48.4% male
53.1 (2.6);
Refusal, 53.6 (1.5).
No***Data on association and refusal of medical aid rate retrieved after propensity score matching to control for variables.
Waldrop57 (2015), USA
EMS staff from an emergency medical service
To explore and describe how EMS staff assess and manage end-of-life emergency calls.QUAL—phenomenology in-depth interviews.n=43, 77% malesPmedic, n=33; EMTs, n=10; age, 21–65 years, mean 39 (SD11).NANANo***Rigour or the trustworthiness of qualitative data analysis is described. Researcher–participant relationship unclear.
Waldrop58 (2014), USA
EMS staff from an emergency medical service
To identify how EMS providers deal with end of life calls and determine their perceived confidence in managing these situations, and perspectives on improved preparation.QUAL—cross-sectional survey. Questionnaire.n=178, 79% males76 EMT-B, 102 Pmedic. Mean years of working experience 12 (SD 9.5).NANANo***Power analyses was not conducted. Participants were invited to be interviewed.
Zorab59 (2015), UK
South Western Ambulance Service NHS Foundation Trust
To identify how EMS staff assess health information; ascertain if a lack of information could lead to a suboptimal care pathway; explore whether increasing amount of information leads to a more appropriate pathway.QUAL—cross-sectional survey. Online questionnaire.n=302, 63% malesEmCP or CCP n=36 Pmedic, n=185 EmCA, student UP, n=58. Most respondents (85.6%) were aged between 26 and 55 years.NANANo***Response rate of 12%.
Déziel70 (2017), USA
Virginia Department of Health Office of EMS
To identify any differences in the transport decision among agency ownership types.QUAN— retrospective observational study.NAFire-based EMS. Non-fire based EMS. Private organisation non-profit. Private organisation for-profit.4.6 millionMean age
52 years.
No****Very large dataset.
Langabeer65 (2016), USA
Houston EMS
To compare the effectiveness of an alternative EMS telehealth delivery model relative to traditional EMS care.QUAN—observational case–control study.NANAn=287Mdn age, 
INT 44 years CON
45 years.
No***Case–control study, controls are matched afterwards. Control group not matched on inclusion criteria but on demographic data.
Larrson71 (2017), Sweden
Ambulance organisation of Sweden
To examine early prehospital assessment of non-urgent patients and its impact on the choice of the appropriate level of care.QUAN—exploratory study based on a consecutive and retrospective review of patient records.NDAmbulance nurses.INT, n=184 CON, n=210Aged ≥18 years.
Mean age, INT 75.4 years CON 74.1 years.
Range INT 23–96 years CON  18–98 years.
No****Comparison with retrospective control group.
Noble72 (2016), UK
NHS Ambulance Trusts
To explore the experiences of EMS staff managing patients with seizures.QUAL—semi structured interviews.n=19Pmedic, n=19.NANANo****Independent and experienced interviewer with already validated topic tool.
Porter64 (2007), UK
NHS Ambulance Service Trust
To examine EMS staff’s view on how decision-making about non-conveyance works in practice.QUAL—three focus-group interviews using a topic guide.n=25Pmedics, n=25.NANANo***Short and compromised method section. Degree of independence between researcher and group unclear.
Simpson73 (2017), Australia
State-based Australian ambulance service
To explore the decision-making process used by paramedics when caring for older fallers.QUAL—grounded theory methodology. Semistructured interviews and focus groups.n=33 (21 males, 12 females)QP=16, ICP=11, ECP=6
Years of working experience 12 (SD 6)
NANAYes, older people who have fallen.****Data analysis and coding were done by one single researcher (also paramedic), but subjectivity was regularly checked during the analysis and challenged by members of the research team.
Snooks74 (2017), UK
Three UK ambulance services
To determine clinical and cost-effectiveness of a paramedic protocol for the care of older people who fall.QUAN—cluster randomised trial.n=215Pmedics, n=215.INT, n=2391 
CON, 2264
INT 82.54 (7.97)
CON 82.14 (8.11)
Yes, aged≥65 years.****Self-reported outcome results should be interpreted with caution. Response rate was very low, with high risk of selection bias.
Villarreal76 (2017), UK
West Midlands Ambulance Service
To evaluate the impact of a service development involving a partnership between EMS crew and GPs on reducing conveyance rates to the ED.QUAN—one group post-test only design.NDPmedicsn=190363.1% of study population aged ≥61 years.No****No control group, no data on outcome.
Williams67 (2018), USA
Wake County Emergency Medical Services
To determine whether unnecessary transport can be avoided.QUAN—Prospective cohort study.NDPmedicsn=84085.5 (8.3) years.Yes****‘Time-sensitive’ outcome measures seem to be somewhat random chosen.
  • ALS, advanced life support; BLS, basic life support; ED, emergency department; EmCP, emergency medical care practitioner; EMS, emergency medical service; EMT 2, emergency medical technician (supervised patient assessment); EMT 3, emergency medical technician (unsupervised patient assessment); GP, general practitioner; MMAT, mixed-methods appraisal tool; NA, not applicable; ND, not described; NHS, National Health Service; Pmedics, paramedics; PTL, paramedic team leader; QUAL, qualitative research; QUAN, quantitative research; RN, registered nurse.