Scoping review on alternative care options for patients calling the ambulance

Abstract

Background

The modern-day population with more chronic, complex medical and social comorbidities is increasing ambulance utilisation and conveyance to emergency departments (ED). This contributes to ambulance ramping, ED overcrowding and increased hospital bed utilisation. This scoping review aims to identify alternative care paths for patients calling for ambulance services.

Methods

A total of 4902 articles were identified through four databases and the gray literature. The terms ‘paramedic’, ‘ambulance’ and ‘non-conveyance’, ‘alternative’ and ‘community care’ were combined to yield the search terms. The population studied includes individuals calling the national emergency number while the intervention focuses on prehospital services designed to avoid ED conveyance. Independent researchers screened the titles, abstracts and full texts, yielding 59 relevant articles which were then meta-synthesised.

Results

Five themes of care were identified - hear and treat, hear and refer, see and treat, see and refer and see and convey to a non-ED facility. Low-acuity patients, older patients, palliative and psychiatric patients, as well as those facing exacerbation of chronic conditions, alcoholic and frequent attenders appear to benefit from these alternative care service pathways (ACSPs). Allied health professionals such as nurses, social workers, occupational therapists, and physiotherapists collaborate with paramedics to frontload the care of these patients in the prehospital setting. Alternative conveyance destinations include general practices, geriatric wards, toxicology units, sobering centres and community hospitals.

Conclusions

Implementing ACSPs and integrating healthcare approaches to enhance service efficiency and patient outcomes can alleviate pressure on emergency services by providing timely care and directing patients to appropriate services.

Background

Around the world, many emergency and prehospital services are strained by increasing patient loads. In Australia [1] and the United States of America (USA) [2], for example, there has been an increase in the number of calls received by ambulance services and patients being conveyed to the emergency department (ED). This has led to a downstream effect of overcrowding in the ED and overutilisation of hospital beds. As a result, there is also an increase in ambulance diversions, increased ambulance waiting time in the ED [3] and an increase in the number of patients on the ambulance waiting to be handed over to the ED, i.e., ramping [4]. Ramping has also shown to be associated with increased adverse events, mortality and poor morale and attrition of paramedics [3]. This phenomenon is further exacerbated by an increasing number of non-emergency calls to ambulance services which affects the timeliness and availability of ambulances for ‘real’ emergencies [2]. Overall, this is taking a toll on health systems, increasing demand for ambulances, ED space and hospital beds. This contributes to rising healthcare costs. This impacts the quality of care being delivered to patients [3].

The reasons for this increase in the use of emergency services are multifactorial, such as an ageing population [5–7] where patients are more complex, with multiple comorbidities or socioeconomic disparities manifesting as the utilisation of emergency services [1].

Alternative care service pathways (ACSPs) provide a possible solution to address the problems associated with increased ED utilisation. It allows for intervention at the stage of calling an ambulance to better right-site patients to a more appropriate disposition, while at the same time ensuring patient safety.

There is a need to re-think and re-design prehospital services to provide alternative care pathways for the populations utilising their services. However, there are challenges in identifying these groups of patients such that the right care is delivered safely. For each patient calling the ambulance, there are also challenges in identifying the appropriate alternative care services specific to their population needs without compromising the quality or safety of care.

Prehospital triage systems are crucial in enabling these alternative care pathways by identifying patients suitable for non-conveyance and referral to alternative destinations. The process of triaging occurs at various stages, such as primary triage at dispatch, secondary telephone triage and on scene clinical assessment using structured triage tools. However, triage systems are not perfectly accurate and can result in incorrect diversion from the emergency department. Studies of non-conveyed patients have reported re-contact rates of 6.3%, emergency department attendance of 4.2% and mortality of up to 1.3% [8].

Hence the main goal of this scoping review was to identify ACSPs implemented for patients utilising the ambulance services and its safety by addressing 3 questions: (1) “What type of alternative services are being provided?” (2) “Which group of patients are suitable and safe for these alternative services?” and (3) “Who provides these alternative services?”

It is hoped that this review can provide a broad understanding of alternative services that can be provided by the prehospital emergency care services, which will enable the right siting of patient care without compromising on patient safety.

Methods

This review followed the Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.

Inclusion and exclusion criteria

The Population, Intervention, Comparison, Outcome and Time (PICOT) framework was used. The population was defined as anyone calling the national emergency number for an ambulance while the intervention was defined as the service provided at the prehospital or emergency setting to avoid conveyance to the ED or admission to the hospital. The comparison is the current method of conveying patients to the ED. Papers describing qualitative or quantitative outcomes or narratives of the services provided over the past 5 years were included. Commentaries, non-English articles and articles describing non-conveyance of patients with respiratory symptoms during the COVID-19 pandemic were excluded.

Search strategy

The Cochrane Collaboration database, the Campbell Collaboration and PubMed were searched for existing complete systematic reviews addressing this topic. Although a similar paper exists [9], the review excluded articles targeting specific clinical conditions and looked at articles up to February 2020. Our hypothesis was that newer models of care and challenges have emerged during and after the COVID-19 pandemic and hence the relevance of an updated search from February 2020 to February 2024. Furthermore, we found it important to expand the search to include alternative care for specific conditions as this is in line with our objectives of searching for groups of patients whom these alternative care paths would benefit. Hence this scoping review includes these articles.

An initial pilot search was conducted in two databases by the senior reviewer (GN) and the librarian to define effective search terms. This iterative process ensured that the search strategy captured all relevant studies.

The search was eventually conducted across PubMed, Scopus, CINAHL and Embase together with a snowball search of systematic reviews and the gray literature. Keywords and MeSH terms were generated with the PICOT framework. The ‘who’ (paramedic, ambulance) and ‘what’ (non-conveyance, alternative, community care) terms were then combined using Boolean operators ‘OR’ and ‘AND’ across the PICOT elements. Three reviewers (BF, YL and J) screened the abstracts independently and conflicts were resolved by consensus with a fourth reviewer GN, who is a senior emergency doctor. Three reviewers (BF, LYL and JT) then independently performed the full-text review, conflicts were resolved by GN.

Data extraction and result synthesis

Three reviewers (BF, LYL and JT) completed the extraction of a smaller sample of 59 studies. The extraction methods were then refined through consensus of 2 senior reviewers (GN and MO). Data extraction and analysis were performed via Excel.

Results

A total of 4902 articles were found. After a title and abstract screen, 417 articles appeared relevant and the full texts were extracted. Among these, 59 articles were found to be relevant. (Fig. 1).

Fig. 1.

Search strategy

A meta-synthesis of the articles was performed to summarise the findings of this scoping review into a concept map. (Fig. 2) Fig. 2 shows alternative prehospital pathways, alternative conveyance locations and alternative prehospital service providers. Five major themes of alternative care pathways/processes were derived from the literature: [1] hear and treat [2, 10–16] hear and refer [4, 17–20] see and treat [3, 8, 21–36] see and refer [37–45] and [5] see and convey to non-ED facilities [33, 46, 47].

Fig. 2.

Concept map of alternative care paths from meta-synthesis of the scoping review

Alternative care paths / processes

Part A: Hear (telephone triage)

Hear and treat

This refers to advice given over the phone to the public. This can include general first aid advice, guidance on where to seek appropriate and timely treatment or specific advice for specific groups of patients such as poisoning cases [10] or nursing home patients [11, 12]. ‘Hear and treat’ services usually exist with ‘hear and refer’ services where the service provider refers the callers to an appropriate service. This model is found in a few settings such as in Melbourne, Copenhagen, Osaka and the United Kingdom (UK) [13–16].

Hear and refer

This refers to the service provider assessing the patient over the phone and referring them to the appropriate services, as seen in the Victorian ambulance service or the UK National Health Service (NHS) 111 service. The service provider taking the call is usually a health professional who performs secondary triage after primary triage is performed by a layperson dispatcher [17]. The services described in the model include crisis management teams, community mental health teams, community pharmacies [18], and dental services. In some instances, the telehealth service redirects the caller to alternative transport services if ambulance transport is deemed inappropriate [19].

Both ‘hear and treat’ and ‘hear and refer’ fall under a broader umbrella of telephone triage services [20].

Part B: See (on-site assessment)

An entry point into the system is when the paramedic reviews the patients at scene and decides that alternative care is more appropriate.

See and treat / non-conveyance

This refers to the prehospital team assessing and treating the patient in the community itself, without having to transport them to a healthcare facility. The prehospital team may consist of paramedics with advanced training [21] or ambulance nurses with prehospital care training [22]. The team can also consist of a nurse and general practitioner [23] or an emergency medical technician and emergency physician [24]. Non-conveyance was one of the most common alternative paths [25] described in the literature, with many studies focused on the safety and acceptability [8, 26–28] of non-conveyance. Overall, it was a safe and efficient [29] option, except when applied to older patients. Studies show that non-conveyance can be a risky option for older patients, who have a higher risk of death and hospitalisation following non-conveyance in the absence of appropriate follow-up care [30, 31]. In some qualitative studies, patients felt that communication [32] and mode of follow-up for non-conveyed patients is crucial [22, 33, 34]. Adherence to the guidelines by the paramedics helps ensure the safety of this alternative path [35]. Without a safety net or clear guidelines on the patients’ disposition, paramedics felt that it was challenging to only treat and discharge patients in the community [36].

See and refer

This refers to paramedics or a team with emergency doctors reviewing patients in the community, providing treatment as needed, and referring them to appropriate medical services, social services [37–39], or alternative transport services when ambulance transport was deemed inappropriate. The literature describes a range of services that paramedics can refer to, such as primary healthcare [40], physiotherapy, occupational therapy, nursing, care co-ordination, social services, urgent care centres [41] and total home services [42]. A common point of referral is to primary healthcare services [43], but this appears to have certain limitations including reduced operating hours and increasing patient loads faced by primary healthcare services. Standardised clinical decision tools assist paramedics with this alternative path [40, 44]. A unique model is Pathfinder in Ireland, where a team of Advanced Paramedics, Physiotherapists, and Occupational therapists attend to older patients deemed to have a low-acuity condition after an initial assessment either over the phone or at the scene by a first responder (either paramedic or firefighter) [45].

See and convey to non-ED facilities

This refers to the prehospital team reviewing the patients in the community and sending them to an alternative appropriate healthcare facility instead of the ED. In Stockholm, a successful randomised trial was described where patients aged 65 years and above who met the inclusion criteria were sent to a geriatric ward in the community hospital after the ambulance nurse discussed the case with the on-call geriatric consultant [46, 47]. In some settings, patients are directly conveyed to a primary healthcare facility [23]. Some other types of facilities that patients get transferred to include poisoning centres, mental health centres and sobering centres.

Groups of patients suitable for alternative care paths

Various triaging tools have been used in different settings to help direct callers to alternative care paths. The Manchester Triage System (MTS), the Emergency Severity Index (ESI), the Adaptive Process Triage (ADAPT), the National Early Warning Score (NEWS), the Taiwan Prehospital Triage System (TPTS) and the Rapid Emergency Triage and Treatment System (RETTS) were some of the systems described in the literature. The RETTS and NEWS appear to be commonly used in the prehospital setting.

Table 1 shows the patient segmentations for which the alternative services have been developed.

Table 1.

Patient segmentation

Patient segmentation	Country	Year and first author (Ref)	Paper title	Study design	Intervention	Outcomes
Acute presentations in older patients	UK	2014, Snooks	Support and Assessment for Fall Emergency Referrals (SAFER 1): Cluster Randomised Trial of Computerised Clinical Decision Support for Paramedics	Cluster Randomised Trial	Computerised Clinical Decision Support (CCDS) for paramedics	With CCDS, paramedics referred twice as many participants to falls services without compromising safety.
	Sweden	2014, Vicente	Randomized Controlled Trial of a Prehospital Decision System by Emergency Medical Services to Ensure Optimal Treatment for Older Adults in Sweden	Randomised control trial	A prehospital decision support system that allows the nurse to transport older adults to alternative destinations e.g. acute care centre or geriatric ward	The ambulance nurses were able to send older adults to alternative healthcare facilities.
	Sweden	2020, Varg	Healthcare pathways and resource use: mapping consequences of ambulance assessment for direct care with alternative healthcare providers	Descriptive, observational	Patients conveyed directly to the geriatric ward by the ambulance	Lower costs for patients conveyed directly to geriatric wards.
	Sweden	2021, Lederman	Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis	Retrospective cohort	Non-conveyance	Older patients have increased risk of adverse events following non-conveyance.
	Ireland	2021, Bernard	Is Pathfinder a safe alternative to the emergency department for older patients? An observational analysis	Retrospective cohort	Pathfinder ‘Rapid Response Team’ consisting of Occupational Therapist and Physiotherapist attending to the patient alongside the paramedic	This is a safe alternative as 64% remained at home, none of the patients re-presented to the ED within 24 h and 10% re-presented within 7 days.
	Ireland	2020, McNamara	Community frailty response service: the ED at your front door	Descriptive	Frailty response team which consists of an advanced paramedic, an emergency medicine registrar and a senior occupational therapist, working with geriatric consultant in the community	Out of 592 patient reviews, only 43 patients were transferred to hospital for further investigation or management.
	Australia	2020, Eastwood	Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study	Retrospective cohort	Secondary telephone triage	Secondary triage could safely identify patients who may have been suitable for referral to low-acuity transport or alternative referral options.
Non-conveyed patients	Sweden	2019, Lederman	Assessing non-conveyed patients in the ambulance service: a phenomenological interview study with Swedish ambulance clinicians	Qualitative	Non-conveyance	Ambulance clinicians experience uncertainty, frustration, loneliness in assessment of non-conveyed patients and fear conducting erroneous assessments that could harm patients.
	Sweden	2021, Malm	Time consumption for non-conveyed patients within EMS: a one-year prospective descriptive and comparative study in a region of Sweden	Prospective observational	Non-conveyance	The mean non-conveyance time for all ambulance assignments was 26 min and significantly faster during the day than at night.
	UK	2018, Knowles	Exploring variation in how ambulance services address non-conveyance: a qualitative interview study	Qualitative	Non-conveyance	Approaches to non-conveyance differ with 3 themes: senior management commitment to non-conveyance, the ambulance workforce and the health and social needs of the population being served.
	UK	2019, O’Hara	Variation in the delivery of telephone advice by emergency medical services: a qualitative study in 3 services	Qualitative	Telephone advice	Telephone advice services varied based on the selection of workforce, tasks clinicians were expected to do, access to non-ambulance responses, operational differences between services and access to alternative response options.
	New Zealand	2021, Todd	Factors Associated with Emergency Medical Service Reattendance in Low Acuity Patients Not Transported by Ambulance	Retrospective cohort	Non-conveyance	Low rate of EMS reattendance. Patient age, sex and self-reported pain level were associated with reattendance.
	Netherlands	2021, Van Doorn	The experience of non-conveyance following emergency medical service triage from the perspective of patients and their relatives: a qualitative study	Qualitative	Non-conveyance	Four main themes describe their experience: (1) fear as the leading emotion, (2) confidence in non-conveyance decision relies on dialogue, (3) consequences and coping differ between patients and relatives and (4) a need for evaluation.
	Sweden	2022, Hoglund	Outcomes in patients not conveyed by emergency medical services (EMS): a one-year prospective study	Prospective descriptive	Non-conveyance	No patient received intensive care, and 0.7% patients died within seven days after the non-conveyance decision. Older age was associated with a higher risk of hospitalisation and death within seven days after a non-conveyance decision.
	Sweden	2022, Johansson	Reasons for bias in ambulance clinicians’ assessments of non-conveyed patients: a mixed methods study	Qualitative	Non-conveyance	The low adherence to guidelines and the paramedics deviating from the protocol put patients at risk of being harmed during a ‘see and treat’ referral.
	Sweden	2022, Larsson	Satisfaction among non-conveyed patients and significant others when discharged at the scene by the ambulance service: an exploratory cross-sectional survey	Cross-sectional survey	Non-conveyance	Overall, satisfaction was high with no significant difference between patients and significant others, although 17–19% were dissatisfied with the discharge information.
	Sweden	2020, Hoglund	Characteristics of non-conveyed patients in emergency medical services (EMS): a one- year prospective descriptive and comparative study in a region of Sweden	Descriptive and comparative consecutive design	Non-conveyance	The non-conveyed adults presented with nonspecific symptoms/malaise, abdomen/flank/groin pain, and breathing difficulties. Half of the non-conveyed patients were referred to self-care.
	Finland	2022, Paulin	Using machine learning to predict subsequent events after EMS non-conveyance decisions	Prospective cohort	Non-conveyance	Machine learning predicted subsequent events after non-conveyance decision. The most frequent signs and symptoms as subsequent event predictors were musculoskeletal-related, infection-related and non-specific complaints.
	Finland	2020, Paulin	Changing role of EMS –analyses of non- conveyed and conveyed patients in Finland	Prospective cohort	Non-conveyance	The non-conveyance decision was more likely made by ALS units, in the evening or night and when the distance to the health care facility was 21–40 km. Younger patients, female gender, alcohol consumption, and a rural area were also related to the non-conveyance decision.
	Finland	2021, Paulin	EMS non-conveyance: A safe practice to decrease ED crowding or a threat to patient safety?	Prospective cohort	Non-conveyance	Of the non-conveyed EMS patients, 6.3% re-contacted the EMS, 8.3% attended a primary health care facility, 4.2% went to the ED, 1.6% were hospitalised, and 0.1% died 0–24 h after non-conveyance. 0.3% of patients were admitted to an intensive care unit within 24 h.
	Finland	2018, Salminen-Tuomaala	Emergency patients’ and family members’ experiences of encountering care providers and receiving care in non-conveyance situations	Cross sectional survey	Non-conveyance	Patients and family members found that emergency care providers act in a professional and friendly manner. They expected more psychological support and time given to the patient.
	Finland	2022, Heinonen	Ambulance crew-initiated non-conveyance in the Helsinki EMS system—A retrospective cohort study	Retrospective cohort	Non-conveyance	Thirty-day mortality was 1.3% following non-conveyance. Abnormalities in multiple respiratory-related vital signs were associated with an increased likelihood of death within 30 days.
Acute exacerbation of chronic illness	USA	2019, Abrashkin	Community paramedics treat high acuity conditions in the home: a prospective observational study	Prospective observational	Community paramedics	17.9% of all responses and 21.0% of high acuity responses resulted in ED transport. Within 48 h of the visit, only 5.7% of the high acuity responses not initially transported were transported to the ED. Patient/caregiver satisfaction rates were high.
	USA	2019, Lezzoni	Making Triage Decisions for the Acute Community Care Program: Paramedics Caring for Urgent Health Problems in Patients’ Homes	Descriptive observational Qualitative	Acute Community Care Program (ACCP) triage	Clinical vignettes were useful for staff training and quality control in such paramedic initiatives.
	Canada	Jensen, 2013	Transport outcomes and dispatch determinants in a paramedic long term care program: a pilot study	Pilot Cohort Study	Extended Care Paramedics treat and release at scene.	Fewer transports to the ED with relatively low relapse rate when seen by the extended care paramedics.
	Canada	Nolan, 2018	Community paramedicine is growing in impact and potential	Narrative	Community Paramedicine (CP) program in preventive health visits	Significant reduction in calling 911 or ED for patients who used the CP program.
	Germany	Holzinger, 2021	Diverting less urgent utilizers of emergency medical services to primary care: is it feasible? Patient and morbidity characteristics from a cross-sectional multicenter study of self-referring respiratory emergency department consulters	Retrospective Observational	Potential redirection to primary Care instead of ED by EMS	There is limited scope for EMS diversion to primary care.
	USA	Adio, 2020	Community Paramedics’ Perception of Frequent ED Users and the Community Paramedicine Program: A Mixed-Methods Study	Mixed Method Study	Community Paramedicine Program	Community paramedics believed there was a potential to reduce frequent ED usage.
Elderly in residential aged care	USA	2020, Carolan	Use of telemedicine for emergency triage in an independent senior living community	Mixed methods	Telemedicine - Emergency medical technician–trained staff could engage an emergency medicine physician via telemedicine to assist with management and triage	It did not result in fewer ED transfers. The key barrier to program use was resistance from frontline staff members, who perceived telemedicine triage as time-consuming and as undermining their independent judgment.
	Australia	2021, Hullick	Reducing Hospital Transfers from Aged Care Facilities: A Large-Scale Stepped Wedge Evaluation	Stepped wedge	Aged Care Emergency (ACE) program: Nurse led triage and clinical support within residential aged care facilities	Statistically significant reduction in ED visit rates, ED reattendance and hospital admissions.
	Australia	2022, Hullick	Video telehealth to support clinical assessment and management of acutely unwell older people in residential aged care: a pre-post interventional study	Controlled pre-post study	Telemedicine - Video telehealth	There were no significant differences in hospital admission or ED visits after the introduction of video-telehealth to a structured hospital avoidance program with nursing telephone support.
Low-acuity patients managed in the community	UK	2018, Nazar	Consensus methodology to determine minor ailments appropriate to be directed for management within community pharmacy	Consensus	Community pharmacy	Stakeholders reached consensus that 64 low-acuity conditions could be safely redirected to community pharmacy via NHS111. This represented approximately 11.5% of patients.
	UK	2022, Pope	The remarkable invisibility of NHS 111 online	Qualitative	Telephone triage and treatment - NHS 111	There was low awareness among our interviewees on NHS 111 online.
	UK	Ablard, 2020	What does the ideal urgent and emergency care system look like? a qualitative study of service user perspectives	Qualitative Focus Groups	NA	Patients wanted a simpler, integrated healthcare system with better continuation of care.
	UK	Blodgett, 2020	Piloting data linkage in a prospective cohort study of a General Practitioner (referral scheme to avoid unnecessary ED conveyance	Prospective cohort	GP Referral scheme	GP referral scheme may safely reduce ED load.
	UK	2020, Joy	Community emergency medicine: taking the ED to the patient: a 12-month observational analysis of activity and impact of a physician response unit	Retrospective descriptive analysis	Management in the community via referral to relevant services. (Operating model is a senior emergency medicine doctor and emergency ambulance crew clinician.	67% of the patients were managed in the community. The service was estimated to generate a net economic benefit of £530,107.
	Ireland	2021, Patton	The alternative pre-hospital pathway team: reducing conveyances to the ED through patient centred community emergency medicine	Retrospective descriptive	Team consists of a Specialist Registrar in Emergency Medicine and an Emergency Medical Technician	There was a 67.8% non-conveyance rate. The median age was 62 years.
	USA	2019, Caroll	Examination of EMS Decision Making in Determining Suitability of Patient Diversion to Urgent Care Centers	Retrospective review	Diversion to Urgent care centre	Results indicated a rate of inappropriate diversion of 11.6%. UCCs may be an alternative option for EMS transport.
	USA	2022, Gingold	Analysis of an Alternative Model of Definitive Care For Low-Acuity Emergency Calls: A Natural Experiment	Natural experiment study design	Emergency Triage, Treat, and Transport (ET3) model within the Mobile integrated health community paramedicine (MIH-CP) program	The program can achieve a positive return on investment by enrolling 2.9 patients/day.
	USA	2019, Sanko	Advanced Practice Providers in the Field: Implementation of the Los Angeles Fire Department Advanced Provider Response Unit	Retrospective descriptive review	See and refer	50.5% of the 911-patients were treated and released on scene or transported to an alternative site for specialty care. High utilisers of 911 were referred to a social work organisation, and 66.7% decreased their use of EMS.
	USA	2020, Somers	Innovative Use of Emergency Medicine Providers in an Urban Setting to Reduce Overutilization of 9-1-1	Descriptive observational	Minor Definitive Care Now (MDCN) to address low-acuity complaints & decrease ED visits	65% were treated on the scene, 26% were transported to an urgent care facility, 0.6% was transported to their primary care provider for a same-day appointment, and 8.4% were transported to the ED.
	USA	2019, Champagne-Langabeer	Telehealth Impact on Primary Care Related Ambulance Transports	Retrospective, descriptive	Telehealth	Ambulance transports represented 11.2% of all transports, while alternative taxi transportation was used in 75.6%, and the remainder were self- or no-transports.
	Japan	2022, Katayama	Telephone Triage for Emergency Patients Reduces Unnecessary Ambulance Use: A Propensity Score Analysis with Population-Based Data in Osaka City, Japan	Retrospective observational	Telephone triage	The use of a secondary telephone triage service was associated with a lower proportion of unnecessary ambulance use in a metropolitan area of Japan.
	Canada	2018, Verma	Paramedic-initiated home care referrals and use of home care and emergency services	Retrospective cohort	Diversion - CREMS (Community Referrals by EMS) program where paramedics can link patients who call them with the community services.	There was a 7% reduction in the number of ambulance transports to ED per person. Paramedic-initiated home care referrals in Toronto were associated with improved access and use of home care services.
	Denmark	2018, Jensen	Self-rated worry in acute care telephone triage: a mixed methods study	Mixed methods study	Urgent care helpline	Degree of worry was associated with female sex and symptom duration. A high degree of worry significantly increased the chance of being triaged to a face-to-face consultation.
	Germany	2022, Oslislo	Redirecting EMS patients with unmet primary care needs: the perspective of paramedics on feasibility and acceptance of an alternative care path in a qualitative investigation from Berlin, Germany	Qualitative	Diversion - referral to GP	Alternative transport options were assessed as preferable. Patients were open to redirection if it entailed benefits like shorter wait times and proper explanation.
	Finland	2019, Roivainen	Telephone triage performed by nurses reduces non-urgent ambulance missions: a prospective observational pilot study in Finland	Prospective observational	Secondary telephone triage	By providing telephone counselling and patient care guidance to other social and health services than, the telephone triage reduced non-urgent EMS missions by one-third.
	Finland	Hanninen, 2020	Patients seeking retreatment after community paramedic assessment and treatment: piloting a community paramedic unit program in Southwest Finland	Observational cohort	Treatment by community paramedics	Community paramedic programs can decrease ED attendance.
	Sweden	Magnusson, 2022	Suboptimal prehospital decision-making for referral to alternative levels of care - frequency, measurement, acceptance rate and room for improvement	Review	GP referral Scheme	A substantial number of patients are not conveyed.
Alcoholics	US	2020, Scheuter	Cost impact of sobering centers on national health care spending in the United States	Budget impact analysis	Sobering centres	Sobering centres as a treatment alternative for individuals with uncomplicated acute alcohol intoxication could yield substantial cost savings.
Mental health	USA	2020, Henderson	Post-discharge health services use for patients with serious mental illness treated at an ED versus a dedicated community mental health center	Observational cohort	Non-conveyance EMS mobile integrated services program for patients experiencing mental health crises	There were no differences in spending post-discharge, suggesting EMS-operated alternative destination programs may be cost-neutral for Medicaid programs.
	USA	2018, Mackey	Can Mobile Integrated Health Care Paramedics Safely Conduct Medical Clearance of Behavioral Health Patients in a Pilot Project? A Report of the First 1000 Consecutive Encounters	Prospective observational	Paramedics referring patients to psychiatric unit	Specially trained paramedics can effectively employ triage algorithms to select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities.
	Australia	2018, Roggenkamp	Descriptive Analysis of Mental Health-Related Presentations to Emergency Medical Services	Descriptive	Secondary telephone triage	For patients undergoing secondary triage, 52.5% were frequent callers or with anxiety presentations. 27.7% were referred to an alternative service.
	Australia	2019, Kealy-Bateman	Development of a joint mental- health and drug health assessment unit and short-stay unit	Descriptive	Diversion to a short-stay unit	This reduced the burden of presentations of mental health, drug and alcohol presentations to the ED.
Palliative patients	USA	2021, Breyre	Effect of a Mobile Integrated Hospice Healthcare Program on Emergency Medical Services Transport to the Emergency Department	Descriptive Evaluation	Non-conveyance and EMS See and Treat	Reduction in transportation of hospice patients to the ED over the first three years of implementation.
Patients with epilepsy	UK	2020, McKinlay	Patient views on use of emergency and alternative care services for adult epilepsy: a qualitative study	Qualitative	Non-conveyance of known epileptic patients	Half of the participants reported unnecessary ED attendance, mainly due to lack of access to individual patient history, a lack of a caregiver, or seizures occurring in a public place.
Poison cases	New Zealand	Nicholls, 2022	Staying at home: the potential cost savings related to triage advice provided by the New Zealand national poisons centre	Prospective survey	Telephone Triage advice	There is a potential cost saving of 1 million NZD a year.

Low-acuity patients

Firstly, there is heterogeneity in the terms used to describe the cases deemed inappropriate for prehospital services. Non-life-threatening emergency, non-emergency, non-urgent, low-acuity are some of the terms that have been used. For the purpose of this paper, the term ‘low-acuity’ will be used. Next is the stage at which ‘low-acuity’ is determined - at the dispatch level versus the paramedic level. With non-medical professional-driven dispatch, ‘low-acuity’ is established when paramedics arrive at the scene [48].

This term describes a varied group of patients, from young patients seeking treatment for anxiety or minor injuries, to older patients seeking assistance after a fall with no physical injuries. What is seen across the literature is a rise in the number of low-acuity calls to prehospital services and hence the need for these alternative paths for such patients.

Several studies have explored alternative care for low-acuity patients with minor injuries and minor symptoms, deemed to be more suited for primary care. Many of these are qualitative studies exploring the paramedics’ and/or patients’ perspectives [49]. Interestingly, when multiple factors are taken into account, especially patients’ perceptions of their symptoms, the health system and accessibility of the setting, patients appear to have a valid reason for utilising prehospital services [50]. Those with chronic illness perceive their acute attacks to be severe and hence utilise emergency services. Those with chest pain and shortness of breath perceive their symptoms as severe enough to call an ambulance. In addition, limited accessibility to primary healthcare after office hours or to other medical services appears to be a driver for their utilisation of emergency medical services. Some of these patients also have difficulty accessing acute medical care due to mobility issues. As a result, these patients would utilise the emergency number. The potential benefit of pursuing non-conveyance for patients labelled low-acuity appears limited, as there was a high rate of reattendance observed [34].

Six significant groups of people appear suitable for a range of alternative care path services as described below.

Older patients

Utilisation of prehospital services by older patients is increasing due to the ageing population in these countries. A common finding is a lack of centralised referral points for the paramedics to refer this group of patients. The ED may not be the ideal referral point for older patients, as the ED and subsequent hospital admission puts them at risk of hospital-acquired infections, delirium, deconditioning and disruption to their existing social infrastructure. Hence, many studies have described the impact of the alternative services on this group of patients. It was found that solely adopting the method of ‘see, treat and discharge’ was unsafe. Secondary triage and dispatch, along with appropriate referrals or options for follow-up care, were useful for these patients [14, 51]. Additionally, it was found that older patients can be appropriately and safely conveyed directly to geriatric wards in community hospitals, while minimising the risks mentioned above that may result from an ED admission. Other models include sending a team of specialists to assess and treat them within the community itself [45, 52]. However, there was little intervention by the paramedics at scene itself as there was a lack of specialised knowledge and skills among the paramedics when they were required to manage older patients.

Older individuals in residential aged care

Telemedicine support is commonly described as a modality used to enable nurses at residential aged care facilities to provide appropriate treatment to older patients on-site without having to convey them to the ED to avoid risks associated with hospitalisation such as nosocomial infection, deconditioning and delirium. The impact of this is mixed [11], where only some of these interventions significantly reduced ED visits [12]. Programs that did not reduce ED transfers showed that the long-term facility staff felt that utilising telemedicine support was too time-consuming and undermined their judgment [53].

Hospice patients

An initiative in California describes a mobile integrated hospice unit where a paramedic with special palliative care training can manage palliative patients known to the hospice program under the direction of the hospice nurse [54]. This model prevented the palliative patients from being brought to the ED.

Patients with acute alcohol intoxication or acute poisoning

Sobering centres have been described in the USA for patients with acute alcohol intoxication. These are short-term monitoring facilities staffed with nonphysician providers, such as registered nurses or emergency medical technicians who triage and monitor intoxicated individuals transported by the ambulance or the police, until sobriety is achieved [55]. In New Zealand, triage advice is provided by the New Zealand National Poisons Centre (NZNPC). NZNPC would offer the caller appropriate advice based on assessment over the phone [10]. Both of these services displayed reduction in costs, measured based on the utilisation of emergency medical services.

Patients with mental health conditions, drug addiction or chronic alcoholism

Studies have shown a reduction in the utilisation of emergency services by direct conveyance of patients by ambulances to dedicated centres that manage mental health conditions [56, 57]. This pathway appears feasible and safe [58]. However, its cost-effectiveness has yet to be evaluated [59].

Frequent attenders with psychiatric and social issues

Many of the alternative services described enable the prehospital team (either an advanced paramedic, prehospital nurse practitioner or secondary triage via telemedicine) to connect frequent utilisers of prehospital services to appropriate social services [13, 60, 61].

Service providers for alternative care

Providers of alternative services can be organised at 2 levels: those who assess patients in the prehospital setting, and those who provide alternative care or efferent services to patients.

Most of the on-scene assessments are performed by an advanced paramedic [62], even for low-acuity cases. In the USA, these providers come from the pool of community paramedics or Mobile Integrated Health (MIH) [63]. Clinical decision tools are widely used to help paramedics decide alternative care paths for their patients. In contexts where advanced paramedics were not deployed, there was either a nurse or a doctor in the prehospital setting to assess and manage the patients.

The scope of the paramedics described in these services has broadened to include the ability to perform point-of-care assessments and clinical decision-making skills to enable them to offer appropriate alternative care pathways to patients. There was also significant discussion and job scope variation around the term ‘community paramedicine’ [64]. The role of a community paramedic in various systems ranges from home visits for chronic disease management to on-site intervention for acute medical conditions. A common goal for community paramedicine appears to be the provision of equitable emergency care to their population.

There are unique models of services where allied healthcare is involved in providing care to patients within the prehospital setting itself [45]. The efferent services described are usually provided by primary healthcare physicians, geriatric teams, allied healthcare teams, community allied healthcare teams, community pharmacists or social health support services. Figure 3 summarises the findings in a ‘chain of care for unscheduled needs’.

Fig. 3.

Chain of care for unscheduled needs

Mistriage risk in alternative care pathways

One of the biggest concerns in alternative prehospital care pathways is mistriage. Some of the articles described the adverse outcome rates when these alternative pathways were used. For example, in the paper by Paulin et al. [8], 6.3% called for an ambulance again, 4.2% attended the Emergency Department, 1.6% was eventually hospitalised and 0.3% needed hospitalisation. The mortality following non-conveyance was reported as 0.1% within 24 h by Paulin et al. [8], 0.7% within 7 days by Hoglund et al. [31] and 1.3% within 30 days by Heinonen et al. [28]

Discussion

Based on the findings, a ‘chain of care for unscheduled needs’ was developed (Fig. 3) to illustrate the relationship between patient access, triage, prehospital assessment, and downstream care pathways. Patients may enter the system through emergency calls for either true emergencies or perceived urgent needs. Initial dispatch triage is followed by secondary triage, either via telephone or on-site clinical assessment, to further determine patient acuity and care needs. Based on this assessment, patients may be conveyed to the emergency department, managed at scene, referred to community or primary care services, or conveyed to alternative healthcare facilities. This chain highlights the central role of secondary triage in directing patients to appropriate care providers and enabling alternative care pathways. It also demonstrates the need for integration between emergency services, community care, and alternative providers to ensure safe disposition, appropriate follow-up and continuity of care. Such an integrated system supports a ‘no wrong door’ approach, where patients can be safely up-triaged or down-triaged based on evolving clinical needs. This framework also highlights the dependency of alternative care pathways on accurate triage and the importance of clear referral pathways and safety-net mechanisms to minimise mistriage and adverse outcomes.

This scoping review showed non-conveyance being practiced in various systems in different forms. However, its effectiveness is limited by the lack of alternative care paths and the resultant emotions of fear of unsafe non-conveyance, uncertainty of the accuracy of their assessment and frustration in the lack of alternative care for patients [36]. Paramedics feel safer when there are services to which they can refer patients. They also describe their patients needing social support and hence express the need to work more closely with social services for these non-conveyance patients [26]. At the same time, patients have a sense of abandonment and feel unsafe without a safety net or support system [22]. These findings support the need for the provision of alternative care pathways for these patients who are not conveyed and the need to widen the scope of training and practice for paramedics to include understanding the social context of the population they are serving. In addition, there is a need for effective communication to reduce this feeling of abandonment and helplessness in patients [22, 32, 33, 65].

Furthermore, there is an increased risk of reattendance and complications for non-conveyance of older patients and those with respiratory symptoms [8, 28, 31]. Mistriage and adverse outcomes were not described in all the articles but found mainly in articles solely describing non-conveyance. The scoping review highlights the need for a common framework to ensure quality and consistency in the measures of success and failure. Strengthening triage systems is essential to ensure patient safety when implementing these models of care. Mistriage may occur due to the limitations of prehospital assessment, diagnostic uncertainty, lack of access to investigations, time pressures, and the complexity of patients with multiple medical and social needs. Strategies such as structured triage tools, clinical decision support, secondary triage systems, and access to alternative care pathways with appropriate safety-netting may help reduce mistriage and improve patient safety.

This review highlights the heterogeneity and complexity of low-acuity patients. The low-acuity patients appear to benefit from entering the alternative care pathways via the ‘Hear’ route. However, some of these low-acuity patients have complex medical and social co-morbidities that are not reflected in the triage systems, and they may benefit from the ‘see’ route or a more robust secondary triage system. Different forms of alternative care paths have been designed for these patients, the most common being a secondary triage system via a telephone helpline. More studies need to be performed to better understand the low-acuity patients and triage them more appropriately such that their needs can be captured at triage itself. In some of the systems described in these reviews, more advanced paramedics are sent to manage these low-acuity patients. This differs from the traditional approach of sending more advanced paramedics to attend to high acuity cases. Understanding the health and social needs of these low-acuity patients can also help reinforce the additional skills that paramedics need to redirect them to appropriate alternative care paths.

This scoping review shows that in addition to low-acuity patients, other groups of patients can benefit from alternative care paths in the prehospital setting rather than being conveyed to the ED (such as older patients, palliative patients and those with chronic or mental illness). These patients should be seen to have a better assessment of their needs prior to directing them to the alternative care paths. These findings on patient segmentation can help prehospital systems prioritise and plan alternative care paths for different groups of patients who are utilisers of prehospital services. Knowledge of this patient segmentation can be used together with the Bridges to Health Model [66] to guide evaluation of the ACSPs through evaluation of patient outcomes.

Multiple alternative care paths have been described for older patients, reflecting the need to address alternative care models for the older population in the prehospital setting. Interestingly, there is a paucity of alternative care models for palliative patients in the prehospital setting, which is a potential area for future studies.

This review describes paramedics with extended skills to facilitate the provision of ACSPs. Paramedics are required to do more at the scene and develop skill sets similar to that of a nurse or a medical doctor. There is a need to broaden paramedic education and the scope of paramedic practice. For older patients, it was recognised that there were fewer interventions by paramedics [14]. This could be due to the complexity of the conditions presented in older patients. This could also indicate a lack of familiarity and comfort level of the paramedics in managing these groups of patients. Traditional paramedic training focuses on medical emergencies with little focus on geriatric or social emergencies. This presents a potential area for further development in paramedic education [67].

This review describes ACSPs involving other allied healthcare providers in the prehospital setting. The models described implies frontloading care in the prehospital setting and may be a potential future model of prehospital care. However, more studies need to be performed to evaluate its cost-effectiveness in such a labour-intensive model of care.

This review showed alternative care paths for frequent attenders. Broadly, there are 2 groups: those with a complex psychiatric history and those with frequent acute exacerbations of chronic diseases. While the community paramedic approach is being adopted by some countries to help manage acute-on-chronic exacerbation of diseases, alternative models can be considered where community nurses can work alongside paramedics to treat acute events and prevent ED conveyances.

The review also uncovers a potential model of a virtual ED where emergency doctors can provide telemedicine services as support to other healthcare providers (such as paramedics, GPs or community nurses) who are by the patient’s side and provide real-time assessment and management.

Finally, an underlying theme was the need for seamless integration between the emergency and community services [68], the need for policy to support the prehospital system to divert patients to more appropriate care services besides the ED, as well as the need to support the financing system to ensure that the system is sustainable without incurring additional costs to the patients.

Conclusion

In this review, we found that there are multiple alternative care pathways available for different groups of patients in the prehospital setting. To implement these pathways, there is a need for effective triaging of these patients, widening the scope of paramedic education and practice, involving other allied healthcare professionals in provision of prehospital care and providing medical oversight through a virtual ED model. Implementing ACSPs and integrating healthcare approaches to enhance service efficiency and patient outcomes can alleviate pressure on emergency services by providing timely care and directing patients to appropriate services.

Clinical impact

• Non-conveyance without alternative care paths is unsafe for patients.

• Older patients, nursing home and mental health patients, alcoholics, frequent attenders and palliative patients can potentially benefit from alternative prehospital care services.

• Paramedics need to widen their scope of practice.

• In-depth studies are needed to understand the unmet needs of low-acuity patients utilising the emergency services.

• Care frontloading can occur in the prehospital setting where paramedics work alongside allied healthcare providers and virtual EDs.

Abbreviations

AACP

Acute Community Care Program

ACE

Aged Care Emergency

ACSPs

Alternative care service pathways

ADAPT

Adaptive process triage

CCDS

Computerised Clinical Decision Support system

CREMS

Community Referrals by EMS program

EMS

Emergency Medical Services

ED

Emergency department

ESI

Emergency Severity Index

ET3

Emergency Triage, Treat, and Transport model

GP

General practitioner

MDCN

Minor Definitive Care Now team

MIH

Mobile Integrated Health

MTS

Manchester triage scale

NHS

National Health Service

NEWS

National Early Warning Score

NZNPC

New Zealand National Poisons Centre

PICOT

Population, Intervention, Comparison, Outcome and Time framework

PRISMA-ScR

Systematic reviews and Meta-Analyses extension for Scoping Reviews

RETTS

Rapid Emergency Triage and Treatment System

SAFER 1

Support and Assessment for Fall Emergency Referrals

TPTS

Taiwan Prehospital Triage System

USA

United States of America

Author contributions

GDN, MEHO and BL conceived and designed the study. GDN, FB, TJ and LYL collected, screened and extracted the data. All the authors interpreted the data. GDN wrote the first draft, incorporated the coauthors’ suggestions; and prepared the final version for submission. All the authors contributed to all the drafts and approved the final version for submission.

Funding

This study was not funded.

Data availability

The search terms used were “Paramedicine“[MeSH Terms] OR “Emergency Medical Services“[MeSH Terms] OR “Ambulatory Care“[MeSH Terms] or “emergency care“[Title/Abstract] OR “ems care“[Title/Abstract] OR “pre hospital care“[Title/Abstract] OR “prehospital care“[Title/Abstract] OR “paramedic*“[Title/Abstract] together with “Community Medicine“[MeSH Terms] OR “Community Health Services“[MeSH Terms] or “Community“[Title/Abstract] OR “alternative“[Title/Abstract] OR “non-conveyance“[Title/Abstract] over the last 5 years.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.