Table 2.

Summary of qualitative, evidence-based studies (n = 12)

First author year (ref)	Country & sample size	Data collection	Aim	Description of alternate route of care	Findings and concluding evidence (and level of support)	Level of Evidence +
Blodgett 2017 [13]	UK n = 8	Semi-structured paramedic interviews and observation	To investigate paramedic’s perspectives on barriers and motivations on GP referrals.	Referral to GP via ambulance scheme	Paramedics described:  i. time, process and training as the major barriers  ii. their open mindedness and positivity about utilising the scheme  iii. Frustrations with GP decision making  iv. gaps in awareness and understanding of scheme.	6
Brydges 2015 [43]	Canada n = 23	Semi-structured paramedic interviews	To investigate paramedic’s perspectives on challenges and opportunities with referrals	Referral to community services via Community Care Access Centres	Paramedics reported:  i. confusion in their role  ii. inadequate knowledge on referral  iii. no feedback on success of referral  iv. lack of accountability on use of scheme  v. desire to provide best care for patient.	6
Bury 2005 [44]	Ireland n = 11 (surveys) n = 5 (interviews)	Questionnaire surveys from GP cooperatives Semi-structured interviews with senior management/ GPs	To describe the preparedness and contribution of GP co-operatives to manage emergencies in the community	Referral to GP co-operatives providing out-of-hours services	– 3/11 GP co-operatives had formal liaisons with ambulance service. – 4/8 GP co-operatives received referrals from ambulance services (3 unknown). – GPs reported uncertainty and anxiety in dealing with 999 referrals due to lack of established structure compared to normal practice.	6
Hoglund 2019 [45]	Sweden n = 20	Semi-structured interview with ambulance nurses	To explore ambulance nurses’ experiences of non- conveying patients to alternate levels of care	Transportation or referral to primary healthcare or other healthcare facility (optional consultation with GP)	Nurses reported:  i. desire to find the best pathway of care  ii. that non-conveyance is demanding and complex task and the main challenges were:   • misconceptions by patients about ambulance need   • resources shortages  iii. Lack of training and mandates to convey to appropriate level of care.	6
Jones 2005 [46]	USA n = 1058	Cross-sectional surveys with ED patients	To assess if patients were willing to accept non-conveyance alternatives including different destination and/or modes of transport	Transport to urgent care centres or primary care physician offices or referral to telemedicine	Patients were:  i. willing to consider transport to non-ED alternatives (69%)  ii. more likely to consider alternatives if they were: younger, non-white race, lower patient acuity and had lower self-perceived illness severity.	6
Knowles 2018 [47]	UK n = 49	Semi-structured interviews with managers, paramedics and lead healthcare commissioner from 10 ambulance services in England	To explore variation in how ambulance services address non-conveyance for calls ending in telephone advice and discharge at scene	Transport or referral to range of different facilities:  i. walk-in centre  ii. MIU  iii. GP	Differences between regional ambulance trusts had a substantial effect on use of alternative options. Main differences included:  i. senior management’s approach to non-conveyance options (e.g. opportunity vs risky endeavour)  ii. paramedic skill and training to appropriately triage patients to alternative care routes  iii. Availability of services and care pathways that facilitate non-conveyance.	6
Lederman 2019 [48]	Sweden n = 11	Semi-structured interviews with ambulance nurse	To explore ambulance clinician’s experiences of assessing non-conveyed patients	Alternate transport or referral to:  i. primary healthcare unit  ii. MIU  iii. Community care practitioner	Ambulance nurses reported:  i. high willingness and recognition of benefits of non-conveyance alternatives  ii. lack of confidence in decision making  iii. Lack of organisational support for decision-making  iv. insufficient training and feedback on non-conveyance decisions (e.g. missed learning opportunities).	6
Miles 2019 [49]	UK n = 143	Surveys with paramedic using quantitative and qualitative assessment of 6 patient vignettes	To:  i. examine if paramedics can accurately identify the most clinically necessary destination  ii. .understand what contributes to decision making.	Alternate:  i. transport to MIU  ii. referral to GP  iii. Referral to pharmacist	– Paramedics decisions were made with 69% accuracy. – Sensitivity of correctly choosing ED: 0.90. – Specificity of correctly choosing non-ED routes: 0.49. – Decision-making was influenced by:  i. patient safety  ii. risk aversion (e.g. fear of litigation/consequences)  iii. Comparison of patient’s presentation to normal condition.	6
Power 2019 [50]	Ireland n = 375	Survey of stakeholder opinions including:  i. emergency medicine consultants  ii. paramedics  iii. Advanced paramedics	To understand stakeholder views on implementing a Treat and Referral care pathway to minimise ED attendance	Alternative routes not described, but cover all situations where an ambulance crew offers a disposition other than ambulance transport to an ED	– Stakeholders expressed clear support to introduce program into ambulance service. – There was a consensus that program would improve patient care and clinical judgement of practitioners. – The following suggestions were made:  i. clinical audit to demonstrate improved care  ii. initially implement program for advanced paramedics  iii. Safety and efficacy of different clinical conditions must be evidence-based before implementation across trust.	6
Rantala 2018 [51]	Sweden n = 111	Cross-sectional surveys with patients assessed as non-urgent (yellow or green by RETTS)	To explore patient’s experiences of the person-centred climate (and construct validity of person-centeredness dimension)	Referrals to other level of care (e.g. primary care, GP visit at home)	Patients reported that:  i. the environment was highly person-centred  ii. their clinical complaints were taken seriously.	6
Snooks 2005 [52]	UK n = 15	Three focus groups with ambulance crews: 1x pre-intervention 1x post-intervention 1x control group.	The authors describe ambulance crew’s views about non-conveyance to hospital including decision making process, alternate route or care and use of triage protocols	Referral to community based services (GP, district nurse, etc.) using Treat & Refer protocols as described in [38]	Paramedics described:  i. positivity about implementing referral scheme across the ambulance service  ii. difficulties with the scheme including:   •more training for paramedics   •patients who were unreceptive to referral  iii. Ensuring wider support of primary care and community services.	6
Vicente 2013 [53]	Sweden n = 11	Semi-structured interviews with older patients who were referred	To describe the patient experience of being offered an alternative care pathway to ED conveyance	Transportation to geriatric care or community emergency care centre as described in [41]	Patients reported:  i. a preference for an alternative to direct conveyance to ED  ii. a desire to be involved in the decision making.	6

Abbreviations: ED Emergency Department, EMS Emergency Medical Services, GP General Practitioner, MIU Minor Injury Unit; RETTS Rapid Emergency Triage and Treatment System, UK United Kingdom, USA United States of America