The non-conveyance of trauma patients in Swedish emergency medical services: a retrospective observational study of the trauma population not transported to an emergency department.

INTRODUCTION: Due to a systemic modification in Swedish emergency medical services (EMS) staffing in recent years, the nature of the Swedish EMS has changed. Transport to an emergency department (ED) is no longer the only option. Referrals and non-conveyance form a growing part of EMS assignments. Trauma is one of the most common causes of death and accounts for 17% of Swedish EMS assignments. The aim of this study was to describe the characteristics and clinical outcomes of non-conveyed trauma patients who were assessed, treated and triaged by the EMS to gain a better understanding of, and to optimise, transport and treatment decisions. METHODS: The study had a descriptive, retrospective and epidemiologic design and was conducted by reviewing EMS and hospital records for 837 non-conveyed trauma patients in the southwest of Sweden in 2019. RESULTS: Three in four non-conveyed trauma patients did not seek further medical care within 72 h following EMS assessment. The patients who were admitted to hospital later were often older, had suffered a fall and had a medical history. Half of all the incidents occurred in a domestic environment, and head trauma was the major complaint. Less than 1% of the studied patients died. CONCLUSION: Most of the non-conveyed trauma patients did not seek further medical care after being discharged at the scene. Falling was the most common trauma event, and for the older population, this meant a higher risk of hospital admission. The reasons for falls should therefore be investigated thoroughly prior to non-conveyance decisions. Future studies should focus on the reasons for non-conveyance and measure the morbidity and invalidity outcomes rather than mortality.

Exploring factors influencing time from dispatch to unit availability according to the transport decision in the pre-hospital setting: an exploratory study.

BACKGROUND: Efficient resource distribution is important. Despite extensive research on response timings within ambulance services, nuances of time from unit dispatch to becoming available still need to be explored. This study aimed to identify the determinants of the duration between ambulance dispatch and readiness to respond to the next case according to the patients' transport decisions. METHODS: Time from ambulance dispatch to availability (TDA) analysis according to the patients' transport decision (Transport versus Non-Transport) was conducted using R-Studio™ for a data set of 93,712 emergency calls managed by a Middle Eastern ambulance service from January to May 2023. Log-transformed Hazard Ratios (HR) were examined across diverse parameters. A Cox regression model was utilised to determine the influence of variables on TDA. Kaplan-Meier curves discerned potential variances in the time elapsed for both cohorts based on demographics and clinical indicators. A competing risk analysis assessed the probabilities of distinct outcomes occurring. RESULTS: The median duration of elapsed TDA was 173 min for the transported patients and 73 min for those not transported. The HR unveiled Significant associations in various demographic variables. The Kaplan-Meier curves revealed variances in TDA across different nationalities and age categories. In the competing risk analysis, the 'Not Transported' group demonstrated a higher incidence of prolonged TDA than the 'Transported' group at specified time points. CONCLUSIONS: Exploring TDA offers a novel perspective on ambulance services' efficiency. Though promising, the findings necessitate further exploration across diverse settings, ensuring broader applicability. Future research should consider a comprehensive range of variables to fully harness the utility of this period as a metric for healthcare excellence.

Patient experience of non-conveyance in the EMS of Southwest Finland: a descriptive survey study.

BACKGROUND: Emergency Medical Services are dispatched more frequently than before. However, many non-urgent patients do not need ambulance transportation to a healthcare facility after evaluation and treatment on scene. This study explored the experiences of non-conveyed patients. Our research questions were: (1) How have non-conveyed patients experienced the service received from EMS? (2) Does a patient's age, gender, or time of the emergency call impact the patient's experience? METHODS: This descriptive survey study examined non-conveyed Emergency Medical Services patients in the Wellbeing Services County of Southwest Finland. The study period was from March 1, 2023, to March 31, 2023. The study population was 1017. They received a questionnaire that was sent by mail. The questionnaire was formed based on questions previously used in four different questionnaires. We received 247 answers (24.3% response rate). Percentages, medians with interquartile ranges, and non-parametric tests were used in the descriptive analyses. RESULTS: Non-conveyed patients were very satisfied with the paramedics' expertise and behavior, their ability to meet their individual needs, the sense of safety provided by the paramedics, and the instructions given to the patients. Time to receive help (19% rated 3 or less on a scale from 1 to 5), how paramedics introduced themselves (16.5%), and satisfaction with non-conveyance decisions (14.6%) were more frequently rated lower than other areas. Further, pain management stood out in the less favorable evaluations. Still, patients' experiences of the service were positive. The age group, gender, or time of the emergency call were not associated with patient experience. CONCLUSIONS: Patients were very satisfied with the paramedics' interpersonal skills. A more focused approach to pain management and developing EMS to ensure faster patient outreach and clearer explanations of non-conveyance decisions could further enhance the patient experience.

Factors influencing non-conveyance care encounters in the ambulance service, registered nurses experiences - a qualitative study.

BACKGROUND: There is a notable variation in the percentage of non-conveyed patients within the ambulance service. Discharging patients at the scene includes a risk of adverse events, and both patients and ambulance clinicians experience the complexity of non-conveyance. Therefore, this study aimed to describe factors influencing the care encounter when care in the ambulance service concludes with non-conveyance. METHOD: A qualitative study design employing the critical incident technique for data collection through individual interviews, and a qualitative analysis based on Fridlund et al. descriptions was utilized. The study conforms to the COREQ checklist for reporting qualitative research. RESULTS: Fourteen Registered Nurses (RN) described 30 incidents and various factors were identified as influencing the care encounter. The factors included communication, sharing information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and an overall understanding of the patient's entire situation. These factors were integrated into the RNs' decision-making process for non-conveyance. CONCLUSION: The decision-making process for non-conveyance by RNs is a multifaceted approach that incorporates several factors. Communication, sharing of information, maintaining a secure and confident approach, organizational aspects, applying person-centered care in collaboration with the patient, relatives, and other caregivers, and a comprehensive understanding of the patient's entire situation. These findings have the potential to contribute to the development of guidelines supporting the RNs working in the ambulance service in their decisions regarding non-conveyance. Further research is needed on the patient's and relatives' perspective on non-conveyance otherwise, patient participation and partnership in person-centered care are not possible to achieve.

Prehospital COVID-19 patients discharged at the scene - an observational study.

BACKGROUND: Emergency medical services (EMS) were the first point of contact for many COVID-19 patients during the pandemic. The aim of this study was to investigate whether the non-conveyance decision of a COVID-19 patient was more frequently associated with a new EMS call than direct ambulance transport to the hospital. METHODS: All confirmed COVID-19 patients with an EMS call within 14 days of symptom onset were included in the study. Patients were compared based on their prehospital transport decision (transport vs. non-conveyance). The primary endpoint was a new EMS call within 10 days leading to ambulance transport. RESULTS: A total of 1 286 patients met the study criteria; of these, 605 (47.0%) were male with a mean (standard deviation [SD]) age of 50.5 (SD 19.3) years. The most common dispatch codes were dyspnea in 656 (51.0%) and malaise in 364 (28.3%) calls. High-priority dispatch was used in 220 (17.1%) cases. After prehospital evaluation, 586 (45.6%) patients were discharged at the scene. Oxygen was given to 159 (12.4%) patients, of whom all but one were transported. A new EMS call leading to ambulance transport was observed in 133 (10.3%) cases; of these, 40 (30.1%) were in the group primarily transported and 93 (69.9%) were among the patients who were primarily discharged at the scene (p<.001). There were no significant differences in past medical history, presence of abnormal vital signs, or total NEWS score. Supplemental oxygen was given to 33 (24.8%) patients; 3 (2.3%) patients received other medications. CONCLUSION: Nearly half of all prehospital COVID-19 patients could be discharged at the scene. Approximately every sixth of these had a new EMS call and ambulance transport within the following 10 days. No significant deterioration was seen among patients primarily discharged at the scene. EMS was able to safely adjust its performance during the first pandemic wave to avoid ED overcrowding.

Decision on non-conveyance of patients suspected of COVID-19 in a novel arrangement with assessment visits by paramedics at home.

BACKGROUND: During the first weeks of the outbreak of the coronavirus disease 2019 (COVID-19), the North Denmark emergency medical services authorised paramedics to assess patients suspected of COVID-19 at home, and then decide if conveyance to a hospital was required. The aim of this study was to describe the cohort of patients who were assessed at home and their outcomes in terms of subsequent hospital visits and short-term mortality. METHODS: This was a historical cohort study in the North Denmark Region with consecutive inclusion of patients suspected of COVID-19 who were referred to a paramedic's assessment visit by their general practitioner or an out-of-hours general practitioner. The study was conducted from 16 March to 20 May 2020. The outcomes were the proportion of non-conveyed patients who subsequently visited a hospital within 72 hours of the paramedic's assessment visit and mortality at 3, 7 and 30 days. Mortality was estimated using a Poisson regression model with robust variance estimation. RESULTS: During the study period, 587 patients with a median age of 75 (IQR 59-84) years were referred to a paramedic's assessment visit. Three of four patients (76.5%, 95% CI 72.8;79.9) were non-conveyed, and 13.1% (95% CI 10.2;16.6) of the non-conveyed patients were subsequently referred to a hospital within 72 hours of the paramedic's assessment visit. Within 30 days from the paramedic's assessment visit, mortality was 11.1% [95% CI 6.9;17.9] among patients directly conveyed to a hospital and 5.8% [95% CI 4.0;8.5] among non-conveyed patients. Medical record review revealed that deaths in the non-conveyed group had happened among patients with 'do-not-resuscitate' orders, palliative care plans, severe comorbidities, age ≥ 90 years or nursing home residents. CONCLUSIONS: The majority (87%) of the non-conveyed patients did not visit a hospital for the following three days after a paramedic's assessment visit. The study implies that this newly established prehospital arrangement served as a kind of gatekeeper for the region's hospitals in regard to patients suspected of COVID-19. The study also demonstrates that implementation of non-conveyance protocols should be accompanied by careful and regular evaluation to ensure patient safety.

A phenomenological interview study with patients being non-conveyed in the ambulance service.

BACKGROUND: Non-conveyed patients (i.e. patients who are not transported to a hospital after being assessed by ambulance clinicians) represent a significantly increasing proportion of all patients seeking ambulance care. Scientific knowledge about patients' non-conveyance experiences is sparse. This study describes the lived experiences of non-conveyed patients in an ambulance care context. METHODS: A reflective lifeworld research (RLR) approach founded on phenomenology is used. Data is derived from nine in-depth interviews with patients not conveyed by the ambulance service in a major Swedish region. RESULTS: Patients' lived experiences of becoming acutely ill or injured and not conveyed by ambulance to a hospital are characterised by several dynamic movements: losing and regaining situational and bodily control, dependence and autonomy, external competence and inner knowledge, handing over and regaining responsibility, and fear and security. CONCLUSIONS: Patients' lived experiences of non-conveyance are complex and versatile. Although non-conveyed patients initially experience strong fear and the loss of situational and bodily control, they gradually feel more secure when experiencing confirmation and trust, which evolves into insecurity and uncertainty. The non-conveyance situation's complexity from a patient's perspective implies the need for ambulance organisations to take measures to prevent further suffering. Non-conveyed patients must be taken seriously in their unique situations, requiring ambulance clinicians to reflect and act with a conscious ethical perspective before, during and after their visit.

Ambulance crew-initiated non-conveyance in the Helsinki EMS system-A retrospective cohort study.

BACKGROUND: Ambulance patients are usually transported to the hospital in the emergency medical service (EMS) system. The aim of this study was to describe the non-conveyance practice in the Helsinki EMS system and to report mortality following non-conveyance decisions. METHODS: All prehospital patients ≥16 years attended by the EMS but not transported to a hospital during 2013-2017 were included in the study. EMS mission- and patient-related factors were collected and examined in relation to patient death within 30 days of the EMS non-conveyance decision. RESULTS: The EMS performed 324,207 missions with a patient during the study period. The patient was not transported in 95,909 (29.6%) missions; 72,233 missions met the study criteria. The patient mean age (standard deviation) was 59.5 (22.5) years; 55.5% of patients were female. The most common dispatch codes were malaise (15.0%), suspected decline in vital signs (14.0%), and falling over (12.9%). A total of 960 (1.3%) patients died within 30 days after the non-conveyance decision. Multivariate logistic regression analysis revealed that mortality was associated with the patient's inability to walk (odds ratio 3.19, 95% confidence interval 2.67-3.80), ambulance dispatch due to shortness of breath (2.73, 2.27-3.27), decreased level of consciousness (2.72, 1.75-4.10), decreased blood oxygen saturation (2.64, 2.27-3.06), and abnormal systolic blood pressure (2.48, 1.79-3.37). CONCLUSION: One-third of EMS missions did not result in patient transport to the hospital. Thirty-day mortality was 1.3%. Abnormalities in multiple respiratory-related vital signs were associated with an increased likelihood of death within 30 days.

Using machine learning to predict subsequent events after EMS non-conveyance decisions.

BACKGROUND: Predictors of subsequent events after Emergency Medical Services (EMS) non-conveyance decisions are still unclear, though patient safety is the priority in prehospital emergency care. The aim of this study was to find out whether machine learning can be used in this context and to identify the predictors of subsequent events based on narrative texts of electronic patient care records (ePCR). METHODS: This was a prospective cohort study of EMS patients in Finland. The data was collected from three different regions between June 1 and November 30, 2018. Machine learning, in form of text classification, and manual evaluation were used to predict subsequent events from the clinical notes after a non-conveyance mission. RESULTS: FastText-model (AUC 0.654) performed best in prediction of subsequent events after EMS non-conveyance missions (n = 11,846). The model and manual analyses showed that many of the subsequent events were planned before, EMS guided the patients to visit primary health care facilities or ED next or following days after non-conveyance. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-, infection-related and non-specific complaints. 1 in 5 the EMS documentation was inadequate and many of these led to a subsequent event. CONCLUSION: Machine learning can be used to predict subsequent events after EMS non-conveyance missions. From the patient safety perspective, it is notable that subsequent event does not necessarily mean that patient safety is compromised. There were a number of subsequent visits to primary health care or EDs, which were planned before by EMS. This demonstrates the appropriate use of limited resources to avoid unnecessary conveyance to the ED. However, further studies are needed without planned subsequent events to find out the harmful subsequent events, where EMS non-conveyance puts patient safety at risk.

Reasons for bias in ambulance clinicians' assessments of non-conveyed patients: a mixed-methods study.

BACKGROUND: The number of ambulance assignments and the influx of patients to the emergency departments (EDs) in Sweden have increased in recent years. This is one reason the protocol for prehospital emergency care was developed around referring patients for non-conveyance, either through the see-and-convey elsewhere approach or through the see-and-treat approach. However, this protocol has led to challenges in patient assessments. This study aimed to investigate the underlying causes of patient harm among those referred for the see-and-treat approach by the emergency medical services. METHODS: This three-phase study involved a mixed-methods design. Cases of injuries, internal investigations and incident analyses of referrals for the see-and-treat approach in two regions in south eastern Sweden from 2015 to 2020 were examined using qualitative content analysis. This qualitative analysis was the basis for the quantitative analysis of the ambulance records. After the qualitative analysis was completed, a review protocol was developed; 34 variables were used to review 240 randomly selected ambulance records logged in 2020, wherein patients were referred for the see-and-treat approach. Finally, the review results were synthesised. RESULTS: The qualitative analysis revealed three common themes: 'assessment of patients', 'guidelines' and 'environment and organisation'. These results were confirmed by a medical journal review. Shortcomings were found in the anamnesis and in the number of targeted examinations performed. The checklist for referring patients for the see-and-treat approach and the information sheet to be provided to the patients were not used. In 34% of the ambulance records examined, the EMS clinicians deviated from the current guidelines for a see-and-treat referral. CONCLUSIONS: The results indicated that the low adherence to guidelines and the patient assessment deviating from the protocol put patients at risk of being harmed during a see-and-treat referral. Measures are needed to guarantee a safe assessment of an increasing number of patients who are referred for the see-and-treat approach, especially the multi-sick elderly patients.

Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey.

BACKGROUND: The ambulance service is facing an increased number of calls and ambulance assignments. Between 12 and 42% of all assignments result in non-conveyance to the Accident and Emergency Department. However, there is limited knowledge regarding satisfaction among patients and significant others when patients are assessed as non-urgent and discharged at the scene. Therefore, the aim of the study was to explore and compare satisfaction with the ambulance service among patients and significant others when the patient was discharged at the scene. METHODS: The present study was designed as a cross-sectional exploratory survey with a consecutive sample employing the Consumer Emergency Care Satisfaction Scale questionnaire on patients and significant others. RESULTS: A total of 162 questionnaires were analysed, 87 patients and 75 significant others. Overall, satisfaction was high with no significant difference between patients and significant others, although 17-19% were dissatisfied with the discharge information. CONCLUSIONS: Generally, patients and significant others are satisfied with the care provided by the Ambulance Service when discharged at the scene and thus not conveyed the Accident and Emergency Department. The participants were especially satisfied with Specialist Ambulance Nurses' interpersonal skills, e.g., making time and providing thorough information. Guidelines for assignments involving non-conveyance, as well as information, instructions and what to expect when discharged at the scene can be improved.

Ultrashort-term responses of riparian vegetation restoration to adjacent cycles of ecological water conveyance scheduling in a hyperarid endorheic river basin.

The management of ecological water conveyance (EWC) can allow riparian vegetation communities to survive the threat of degradation in hyperarid inland areas and promote the health of groundwater-recharged riparian ecosystems. However, the ultrashort-term effects of periodic EWC scheduling on riparian vegetation remain unclear. This study explored the spatiotemporal differentiation in species structure (herbs, shrubs, and trees), diversity (measured by the Simpson, Shannon-Wiener, Pielou, and Margalef indices), stability (evaluated via Godron fitting distances and abundance-biomass comparison curves), and integrity (proxied by the vegetation-based index of biotic integrity) of vegetation communities in the downstream Heihe River Basin, China. Empirical orthogonal function, Pearson correlation, canonical correspondence analysis (CCA), and partial CCA methods were used to evaluate the effects of dominant habitat environmental factors from the hydrogeographic features, soil physicochemical properties, and anthropogenic impacts. The results showed that the riparian vegetation community diversity, stability, and integrity varied moderately to slightly with hierarchical distance from near wetlands (<200 m; containing mainly herbs) to far desert edges (>800 m; occupied by shrubs/subshrubs). The middle transition zone (200-800 m; occupied mostly by trees/subtrees) had the best diversity and integrity but relatively poor stability. The most significant influencing factors were EWC and soil moisture. The simple diversity, fair-level integrity, and disturbed but not irreversibly damaged stability of the vegetation community were generally improved by 14.82%, 20.33%, and 30.57%, respectively, in the pre-EWC period but worsened in the post-EWC period. The difference in spatially distributed EWC quantities caused more apparent vegetation restoration in high water-supplied subareas where certain biological community instability existed. Therefore, adequate EWC management can be considered a prerequisite for the maintenance of high richness and structural stability in local communities and requires a good balance between interregional vegetation abundance and enhanced environmental tolerance.

News coverage of drug development: implications for the conveyance of health information.

BACKGROUND: Technical information regarding health-related advances is sometimes esoteric for the general public. News media, therefore, plays a key role in public health promotion via health information conveyance. In this study, we use China as a sample country and analyze the claims and frames in news coverage of health-related advances, with special focus on news coverage of the development and performance of newly developed or tested drugs. METHODS: A keyword search was performed to retrieve news articles from four representative news agencies in China. In total, 3029 news reports were retrieved, of which 128 were selected for further analysis. RESULTS: Four aspects of news coverage of drug development were identified: (1) the characteristics of new drugs covered, (2) the sources of information, (3) the accuracy of health information in newspapers, and (4) textual features of news coverage. CONCLUSIONS: Our findings reveal that guidelines should be established to facilitate more systematic news reporting on health-related advances. Additionally, literacy among the general public and professionalism in health information conveyance should be promoted to negate the "illusion of knowing" about health-related advances.

Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis.

BACKGROUND: Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively. METHODS: This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18-64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses. RESULTS: Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients. CONCLUSIONS: Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

EMS non-conveyance: A safe practice to decrease ED crowding or a threat to patient safety?

BACKGROUND: The safety of the Emergency Medical Service's (EMS's) non-conveyance decision was evaluated by EMS re-contacts, primary health care or emergency department (ED) visits, and hospitalization within 48 h. The secondary outcome was 28-day mortality. METHODS: This cohort study used prospectively collected data on non-conveyed EMS patients from three different regions in Finland between June 1 and November 30, 2018. The Adjusted International Classification of Primary Care (ICPC2) as the reason for care was compared to hospital discharge diagnoses (ICD10). Multivariable logistic regressions were used to determine factors that were independently associated with adverse outcomes. Results are presented with adjusted odds ratios (aORs) together with 95% confidence intervals (CIs). Data regarding deceased patients were reviewed by the study group. RESULTS: Of the non-conveyed EMS patients (n = 11,861), 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalized, and 0.1% died 0-24 h after the EMS mission. The 0-24 h adverse event rate was higher than 24-48 h. After non-conveyance, 32 (0.3%) patients were admitted to an intensive care unit within 24 h. Primary non-urgent EMS mission (aOR 1.49; 95% CI 1.25 to 1.77), EMS arrival at night (aOR 1.82; 95% CI 1.58 to 2.09), ALS unit type vs BLS (aOR 1.43; 95% CI 1.16 to 1.77), rural area (aOR 1.74; 95% CI 1.51 to 1.99), and older patient age (aOR 1.41; 95% CI 1.20 to 1.66) were associated with subsequent primary health care visits (0-24 h). CONCLUSIONS: Four in five non-conveyed patients did not have any re-contact in follow-up period. EMS non-conveyance seems to be a relatively safe method of focusing ED resources and avoiding ED crowding.

The Alternative Pre-hospital Pathway team: reducing conveyances to the emergency department through patient centered Community Emergency Medicine.

BACKGROUND: Internationally increasing demand for emergency care is driving innovation within emergency services. The Alternative Pre-Hospital Pathway (APP) Team is one such Community Emergency Medicine (CEM) initiative developed in Cork, Ireland to target low acuity emergency calls. In this paper the inception of the APP Team is described, and an observational descriptive analysis of the APP Team's service data presented for the first 12 months of operation. The aim of this study is to describe and analyse the APP team service. METHODS: The APP Team, consisting of a Specialist Registrar (SpR) in Emergency Medicine (EM) and an Emergency Medical Technician (EMT) based in Cork, covers a mixed urban and rural population of approximately 300,000 people located within a 40-min drive time of Cork University Hospital. The team are dispatched to low acuity 112/999 calls, aiming to provide definitive care or referring patients to the appropriate community or specialist service. A retrospective analysis was performed of the team's first 12 months of operation using the prospectively maintained service database. RESULTS: Two thousand and one patients were attended to with a 67.8% non-conveyance rate. The median age was 62 years, with 33.0% of patients aged over 75 years. For patients over 75 years, the non-conveyance rate was 62.0%. The average number of patients treated per shift was 7. Medical complaints (319), falls (194), drug and alcohol related presentations (193), urological (131), and respiratory complaints (119) were the most common presentations. CONCLUSION: Increased demand for emergency care and an aging population is necessitating a re-design of traditional models of emergency care delivery. We describe the Alternative Pre-Hospital Pathway service, delivered by an EMT and an Emergency Medicine SpR responding to low acuity calls. This service achieved a 68% non-conveyance rate; our data demonstrates that a community emergency medicine outreach team in collaboration with the National Ambulance Service offering Alternative Pre-Hospital Pathways is an effective model for reducing conveyances to hospital.

Ecological water conveyance drives human-water system evolution in the Heihe watershed, China.

Watersheds are coupled with human-water systems where human, and water resources interact and coevolve with each other. Restoration management not only affects the ecosystem itself but also alters the mutual feedback relationship between humans and water, resulting in additional effects and impeding the ecological restoration process. Taking the lower reaches of the Heihe River as an example (Inner Mongolia, PR China), this study investigated the evolution of the human-water system after the implementation of ecological water conveyance using multiple data sources (e.g., remote sensing data, hydrological data, field data and socioeconomic data). We found that (1) after the implementation of ecological water conveyance, vegetation recovered in the last 15 years with an NDVI increasing from 0.10 to 0.13 across the region except some degraded areas near the river; (2) besides restoring the target ecosystem, ecological water conveyance also promoted socioeconomic development and affected the water resources utilization; (3) after 15 years' water conveyance, the coupled human-water system changed from the early ecological water deficit to the present ecological-socioeconomic water-use trade-off with negative impact resulted from agriculture expansion and water usage conflict between the middle and the lower reaches. These effects impeded the restoration of the ecological environment and aggravated the conflicts of water resources utilization within the whole Heihe watershed, consistent with of the hypothesized disturbance effect transmutation. Our results highlighted that analysis on the mutual feedback effect in the coupled human-water system, and dynamic adjustments for restoration measures are needed for sustainable watershed management.

Finding water scarcity amid abundance using human-natural system models.

Water scarcity afflicts societies worldwide. Anticipating water shortages is vital because of water's indispensable role in social-ecological systems. But the challenge is daunting due to heterogeneity, feedbacks, and water's spatial-temporal sequencing throughout such systems. Regional system models with sufficient detail can help address this challenge. In our study, a detailed coupled human-natural system model of one such region identifies how climate change and socioeconomic growth will alter the availability and use of water in coming decades. Results demonstrate how water scarcity varies greatly across small distances and brief time periods, even in basins where water may be relatively abundant overall. Some of these results were unexpected and may appear counterintuitive to some observers. Key determinants of water scarcity are found to be the cost of transporting and storing water, society's institutions that circumscribe human choices, and the opportunity cost of water when alternative uses compete.

Characteristics of non-conveyed patients in emergency medical services (EMS): a one-year prospective descriptive and comparative study in a region of Sweden.

BACKGROUND: There has been an increasing demand for emergency medical services (EMS), and a growing number of patients are not conveyed; i.e., they are referred to levels of care other than ambulance conveyance to the emergency department. Patient safety issues have been raised regarding the ability of EMS to decide not to convey patients. To improve non-conveyance guidelines, information is needed about patients who are not conveyed by EMS. Therefore, the purpose of this study was to describe and compare the proportion and characteristics of non-conveyed EMS patients, together with assignment data. METHODS: A descriptive and comparative consecutive cohort design was undertaken. The decision of whether to convey patients was made by EMS according to a region-specific non-conveyance guideline. Non-conveyed patients' medical record data were prospectively gathered from February 2016 to January 2017. Analyses was conducted using the chi-squared test, two-sample t test, proportion test and Mann-Whitneys U-test. RESULTS: Out of the 23,250 patients served during the study period, 2691 (12%) were not conveyed. For non-conveyed adults, the most commonly used Emergency Signs and Symptoms (ESS) codes were unspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. For non-conveyed children, the most common ESS codes were breathing difficulties and fever of unclear origin. Most of the non-conveyed patients had normal vital signs. Half of all patients with a designated non-conveyance level of care were referred to self-care. There were statistically significant differences between men and women. CONCLUSIONS: Fewer patients were non-conveyed in the studied region compared to national and international non-conveyance rates. The differences seen between men and women were not of clinical significance. Follow-up studies are needed to understand what effect patient outcome so that guidelines might improve.

Piloting data linkage in a prospective cohort study of a GP referral scheme to avoid unnecessary emergency department conveyance.

BACKGROUND: UK Ambulance services are under pressure to safely stream appropriate patients away from the Emergency Department (ED). Even so, there has been little evaluation of patient outcomes. We investigated differences between patients who are conveyed directly to ED after calling 999 and those referred by an ambulance crew to a novel GP referral scheme. METHODS: This was a prospective study comparing patients from two cohorts, one conveyed directly to the ED (n = 4219) and the other referred to a GP by the on-scene paramedic (n = 321). To compare differences in patient outcomes, we include follow-up data of a smaller subset of each cohort (up to n = 150 in each) including hospital admission, history of long-term illness, previous ED attendance, length of stay, hospital investigations, internal transfers, 30-day re-admission and 10-month mortality. RESULTS: Older individuals, females, and those with minor incidents were more likely to be referred to a GP than conveyed directly to ED. Of those patients referred to the GP, only 22.4% presented at ED within 30 days. These patients were more likely to be admitted then than were those initially conveyed directly to ED (59% vs 31%). Those conveyed to ED had a higher risk of death compared to those who were referred to the GP (HR: 2.59; 95% CI 1.14-5.89), however when analyses were restricted to those who presented at ED within 30 days, there was no difference in mortality risk (HR: 1.45; 95% CI 0.58-3.65). CONCLUSIONS: Despite limited data and a small sample size, there were differences between patients conveyed directly to ED and those who were referred into GP care. Initial evidence suggests that referring individuals to a GP may provide an appropriate and safe alternative path of care. This pilot study demonstrated a need for larger scale, methodologically rigorous study to demonstrate the benefits of alternative conveyance schemes and recommend changes to the current system of urgent and emergency care.