Non-conveyed patients : a thesis on epidemiology, and patients' and ambulance clinicians' experiences

BACKGROUND: As a consequence of the increased overall number of ambulance assignments in combination with an increase in patients assessed as having non-urgent complaints, new demands are being placed on the ambulance service and the ambulance clinicians (ACs) regarding patient assessments and decisions. Alternative care pathways – excluding emergency departments (EDs) – such as non-conveyance, have increased over the last decade. However, knowledge regarding non-conveyance is limited. Increased knowledge from an epidemiological and qualitative research perspective is needed to enhance patient safety. AIM: The overall aim was to explore situations in which patients were non-conveyed. Furthermore, it was intended to describe ACs and patients’ lived experiences of non-conveyance. METHODS: Four sub-studies were performed. Study I was an observational population-based study with the aim of describing the prevalence of non-conveyance, investigating associations and comparing patients’ characteristics, drug administration, initial problems, and vital signs between non-conveyed and conveyed patients. Patient data were retrieved from ambulance medical records (CAK-net, Region Stockholm). Study II was a retrospective cohort study with the aim of increasing the understanding of elderly non-conveyed patients. The primary objective of this study was to present the prevalence of older adult non-conveyed patients and their characteristics – in comparison with younger non-conveyed patients – and identify and describe the risk factors associated with ED visits, hospitalisations, and mortality up to 7 days following non-conveyance. The secondary objective was to investigate the probable associations between abnormal vital signs and ED visits, hospitalisations, and mortality up to 7 days after non-conveyance among older adult non-conveyed patients. Patient data were retrieved from the ambulance medical records, and follow-up data were retrieved from The Regional Health Care Data Warehouse (VAL). Study III was an interview study of ACs conducted using a reflective lifeworld research (RLR) approach based on phenomenology. The aim was to describe ACs experiences of assessing non-conveyed patients. Study IV was also an interview study conducted using an RLR approach. The aim was to describe experiences of becoming acutely ill and not accompanying the ambulance to a hospital from a non-conveyed patient perspective. RESULTS: The results show that non-conveyance situations represent a non-negligible proportion of all ambulance assignments performed annually. Non-conveyance constitutes a complex caring encounter involving a great diversity of patients with variating characteristics and complaints. Ambulance assignments ending in non-conveyance were often dispatched as the highest priority – involving overall younger individuals – and patients’ medical complaints were often assessed as non-specific or related to psychiatric problems (Study I). Older non-conveyed adults represent a risk group for adverse events that need to be met with adequate measures to ensure patient safety. The observed increased risk of hospitalisation and mortality among older adult patients compared to younger adult non-conveyed patients raises questions pertinent to patient safety (Study II). Furthermore, insufficient organisational support, a lack of non-conveyance education, and an absence of clinical performance feedback complicate ACs ability to perform accurate and person-centred non-conveyance assessments (Study III). Patients’ experiences of non-conveyance showed it to be a complex and versatile phenomenon in which patients need to be met with an ethical mindset in the creation of a caring encounter. Patients that are non-conveyed experience an existential fear and loss of bodily control that need to be met with confirmation, listening, and the establishment of a partnership (Study IV). CONCLUSIONS: Several conclusions with clinical implications stem from this thesis, including increased awareness and knowledge regarding the large group of patients with varying characteristics, complaints, and symptoms that are non-conveyed annually. Older adults that are non-conveyed were identified as a risk group for adverse events that need to be met with adequate measures to ensure patient safety. Performing non-conveyance assessments is complicated by several paradoxes that need to be met with sufficient organisational support, educational efforts, and the introduction of clinical performance feedback in order to perform person-centred care, ensure patient safety, and enhance professional development among ACs. Non-conveyance encounters are complex care meetings in which several existential aspects deemed important for non-conveyed patients need to be met in order to establish caring encounters based on person-centred care