Decision-making processes when paramedics refer patients away from hospital: a scoping review.

Kelly Sheffield, Peter O'Meara, Glenda Verrinder




Title: Decision-making processes when paramedics refer patients away from hospital: a scoping review.

Background: Paramedic practice faces increasing service demand with decision-making and referral pathways needing to change.  Patients with low acuity clinical presentations do not necessarily require ambulance transport to an emergency department, and previous studies show alternative referral pathways can be effective, safe and efficient. Decision-making processes within the context of referring patients needs to be examined. 

Objectives: To examine the literature related to paramedic decision-making when referring patients to alternative care services, instead of transporting to hospital.

Methods: In this scoping review, the literature between 2005 and 2015 of service providers was examined.  Key search terms were developed to search five databases and Internet search engines.

Results: Four studies were specifically related to decision-making.   Research into the broader topic of paramedics referring patients to alternative medical services other than hospital emergency departments were located, and thirteen relevant studies were included in this review.

Conclusions:  Key factors including clinical experience, education, protocol use, referral processes, and holistic healthcare approaches all influence decision-making of paramedics when referring patients away from hospital.  Further research into these factors is required to better understand how they influence and interact with each other.


Paramedic, Emergency Medicine, Pre Hospital Care, Community Paramedicine,

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Lowthian JA, Cameron PA, Stoelwinder JU, Curtis A, Currell A, Cooke MW, et al. Increasing utilisation of emergency ambulances. Australian Health Review. 2011;35(1):63-9.

Cooper S, Grant J. New and emerging roles in out of hospital emergency care: A review of the international literature. International Emergency Nursing. 2009;17(2):90-8.

Bigham BL, Kennedy SM, Drennan I, Morrison LJ. Expanding Paramedic Scope of Practice in the Community: A Systematic Review of the Literature. Prehospital Emergency Care. 2013;17(3):361-72.

Joyce CM, Wainer J, Archer F, Wyatt A, Pitermann L. Trends in the paramedic workforce: a profession in transition. Australian Health Review. 2009;33(4):533-40.

Tiedemann A, Mikolaizak AS, Sherrington C, Segin K, Lord SR, Close JCT. Older fallers attended to by an ambulance but not transported to hospital: a vulnerable population at high risk of future falls. Australian and New Zealand Journal of Public Health. 2013;37(2):179-85.

Weaver MD, Moore CG, Patterson PD, Yealy DM. Medical Necessity in Emergency Medical Services Transports. American Journal of Medical Quality. 2012;27(3):250-5.

Logan PA, Coupland CAC, Gladman JRF, Sahota O, Stoner-Hobbs V, Robertson K, et al. Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial2010 2010-05-11 09:21:02.

Simpson PM, Bendall JC, Toson B, Tiedemann A, Lord SR, Close JCT. Predictors of nontransport of older fallers who receive ambulance care. Prehospital Emergency Care. 2014;18(3):342-9.

Burrell L, Noble A, Ridsdale L. Decision-making by ambulance clinicians in London when managing patients with epilepsy: a qualitative study. Emergency Medicine Journal. 2013;30(3):236-40.

Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehospital Emergency Care. 2011;15(3):320-4.

Brown LH, Hubble MW, Cone DC, Millin MG, Schwartz B, Patterson PD, et al. Paramedic determinations of medical necessity: A meta-analysis. Prehospital Emergency Care. 2009;13(4):516-27.

Silvestri S, Rothrock SG, Kennedy D, Ladde J, Bryant M, Pagane J. Can paramedics accurately identify patients who do not require emergency department care? Prehospital Emergency Care. 2002;6(4):387-90.

Gray JT, Wardrope J. Introduction of non-transport guidelines into an ambulance service: a retrospective review. Emergency Medicine Journal. 2007;24(10):727-9.

Kue R, Ramstrom E, Weisberg S, Restuccia M. Evaluation of an emergency medical services–based social services referral program for elderly patients. Prehospital Emergency Care. 2009;13(3):273-9.

Hoyle S, Swain AH, Fake P, Larsen PD. Introduction of an extended care paramedic model in New Zealand. Emergency Medicine Australasia. 2012;24(6):652-6.

Snooks H, Kearsley N, Dale J, Halter M, Redhead J, Foster J. Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs. Quality and Safety in Health Care. 2005;14(4):251-7.

Halter M, Vernon S, Snooks H, Porter A, Close J, Moore F, et al. Complexity of the decision-making process of ambulance staff for assessment and referral of older people who have fallen: a qualitative study. Emergency Medicine Journal. 2011;28(1):44-50.

Levine SD, Colwell CB, Pons PT, Gravitz C, Haukoos JS, McVaney KE. How well do paramedics predict admission to the hospital? A prospective study. The Journal of Emergency Medicine. 2006;31(1):1-5.

Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implementation Science : IS. 2010;5:69-.

O'Meara P. Community paramedics: a scoping review of their emergence and potential impact. International Paramedic Practice. 2014;4(1):5-12.

Cooper S, Barrett B, Black S, Evans C, Real C, Williams S, et al. The emerging role of the emergency care practitioner. Emergency Medicine Journal. 2004;21(5):614-8.

Cooper S, O’Carroll J, Jenkin A, Badger B. Emergency care practitioners (ECP): Practice and performance in the UK West country – A case study. International Emergency Nursing. 2008;16(3):180-4.

Arksey H, O'Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32.

Fry MM. A systematic review of the impact of afterhours care models on emergency departments, ambulance and general practice services. Australasian Emergency Nursing Journal. 2011;14(4):217-25.

Swain AH, Weaver A, Gray AJ, Bailey M, Palmer SG. Ambulance triage and treatment zones at major rugby events in Wellington, New Zealand: a sobering experience. The New Zealand Medical Journal (Online). 2013;126(1372):12-24.

Hill H, McMeekin P, Price C. A systematic review of the activity and impact of emergency care practioners in the NHS. Emergency Medicine Journal. 2014;31(10):853-60.

Mason S, Knowles E, Colwell B, Dixon S, Wardrope J, Gorringe R, et al. Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: Cluster randomised controlled trial. British Medical Journal. 2007;335(7626):919 - 22.

Eastwood K, Morgans A, Smith K, Stoelwinder J. Secondary triage in prehospital emergency ambulance services: a systematic review. Emergency Medicine Journal. 2015;32(6):486-92.

Snooks H, Carter B, Dale J, Foster T, Humphreys I, Logan PA, et al. Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics. PLoS ONE. 2014;9(9):e106436.

Dale J, Higgins J, Williams S, Foster T, Snooks H, Crouch R, et al. Computer assisted assessment and advice for “non-serious” 999 ambulance service callers: the potential impact on ambulance despatch. Emergency Medicine Journal. 2003;20(2):178-83.

Tohira H, Fatovich D, Williams TA, Bremner AP, Arendts G, Rogers IR, et al. Is it Appropriate for Patients to be Discharged at the Scene by Paramedics? Prehospital Emergency Care. 2016:1-11.

Haines CJ, Lutes RE, Blaser M, Christopher NC. Paramedic Initiated Non-Transport of Pediatric Patients. Prehospital Emergency Care. 2006;10(2):213-9.

Coates D, Rawstorne S, Benger J. Can emergency care practitioners differentiate between an avoided emergency department attendance and an avoided admission? Emergency Medicine Journal. 2012;29(10):838-41.

Cooper S, O’Carroll J, Jenkin A, Badger B. Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner—qualitative and summative findings. Emergency Medicine Journal. 2007;24(9):625-9.

Comans TA, Currin ML, Quinn J, Tippett V, Rogers A, Haines TP. Problems with a great idea: referral by prehospital emergency services to a community-based falls-prevention service. Injury Prevention. 2013;19(2):134-8.

Gray JT, Walker A. Avoiding admissions from the ambulance service: a review of elderly patients with falls and patients with breathing difficulties seen by emergency care practitioners in South Yorkshire. Emergency Medicine Journal. 2008;25(3):168-71.

Jensen JL, Travers AH, Marshall EG, Leadlay S, Carter AJE. Insights into the Implementation and Operation of a Novel Paramedic Long-term Care Program. Prehospital Emergency Care. 2014;18(1):86-91.

Reeve C, Pashen D, Mumme H, De La Rue S, Cheffins T. Expanding the role of paramedics in northern Queensland: An evaluation of population health training. Australian Journal of Rural Health. 2008;16(6):370-5.

Talbot LV, H. Turn a stack of papers into a literature review : useful tools for beginners. Focus on Health Professional Education. 2008;10(1):51-8.

Machen I, Dickinson A, Williams J, Widiatmoko D, Kendall S. Nurses and paramedics in partnership: Perceptions of a new response to low-priority ambulance calls. Accident and Emergency Nursing. 2007;15(4):185-92.



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