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

BACKGROUND: 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.