The results found that ambulance driving influenced both the patient’s medical condition and the EMS care of the patient by having a potential effect on prehospital time spent on the road, safety, and medical and comfort factors. Therefore, driving the ambulance itself needs to be considered an essential part of care within emergency medical services.
Prehospital times are important to reduce mortality, especially in time-critical conditions such as severe trauma [3]. However, all prehospital time is not the same. Studies have indicated that it may not be the total prehospital time, but time spent on the scene, that has the biggest impact on mortality [26]. Therefore, it seems reasonable to reflect on where time should be saved in the prehospital process to reduce total prehospital time. As reflected in many of the included studies, the actual transportation time must be weighed not only against increased safety risks but also against possible effects on the patient’s medical condition and the possibilities of providing adequate medical care during transportation. By reducing time spent on the scene, actual transport could be performed at a slower speed, thereby reducing risks and discomfort for all involved without a negative impact on the patient’s survival and wellbeing. Although this hypothesis cannot be concluded from this review, it is a potential research question.
The use of lights and sirens when transporting a time-critical patient has been debated for many years, mainly from a traffic safety or time-saving perspective. On one hand, using lights and sirens may reduce time spent on the road [27]. On the other hand, lights and sirens have also been found to increase stress among patients transported in an ambulance [28]. Therefore, the use of lights and siren must be a carefully considered intervention where the comfort and safety of the patient is balanced against the potential benefits of rapid transport. In addition, vibration, general noise, change in temperature, restricted space in the ambulance, and unexpected events influence the clinical condition of critically ill intensive care patients during interhospital transport [29]. It seems reasonable that the same effects also apply to non-critical patients. However, this review indicates that negative influences from lights and sirens, as well as other environmental aspects, might be mitigated or enlarged by the way the ambulance is driven, thereby confirming the importance of integrating the actual driving within the overall emergency medical services context of care. None of the studies included focused on how the technical design of the ambulance or the patient stretcher influenced the experience of being transported in the ambulance. However, since environmental aspects seem to be of importance for both the medical condition and safety of the patient, such studies are needed.
Several studies have focused on the safety aspects of ambulance transports. Patient safety usually refers to the absence of preventable harm to a patient during the health care process and the reduction of the risk of unnecessary harm associated with health care to an acceptable minimum [30]. The occurrence of ambulance crashes causes both injuries and death of patients and EMS personnel. The risk of transportation-related injury for EMS personnel has been reported to be about five times higher than the national average [31]. Training, risk awareness, and management by the drivers may be effective approaches in reducing the occurrence of emergency vehicle accidents [32]. Time pressure, multitasking activities, long shift hours, and the use of lights and sirens have been identified as risk factors for emergency vehicle crashes [33]. No studies were identified that explored ambulance crashes from the patients’ or relatives’ perspective. Being safe is not always the same as feeling safe. Information, communication, and a feeling of being accounted for have been suggested as tools to increase patients’ feelings of being safe [34]. In this study, being fastened with the seat or stretcher belt was found to increase the patient’s feeling of safety. Given the special context of being transported in an ambulance, further research on how to, in practice, promote feelings of safety in the patient (and significant others) is of interest.
Given the general idea of EMS, it was surprising that studies about the driving of the ambulance from a patient’s perspective were limited. However, this is in line with previous findings that caring science research with an explicit patient perspective within emergency medical services is limited [5]. It should be remembered that the transport of a person is not just a physical movement, as in moving a patient from the scene of an accident or from home to a hospital. It also entails a personal process. Only one of the studies touched on this phenomenon, in which patients described the value of being informed about what was going to happen next during the actual ambulance transport [20]. Transition means to pass from one condition, action, or place to another [35]. The first phase of a transition process is the movement from a situation or a physical place. This phase includes a separation. In the next phase, the person is in the middle of something but has not yet ended up in a new state. Being transported in an ambulance entails several impressions that have an impact on both medical condition and wellbeing, but it is also the middle phase of the transition process. Since disorientation, disintegration, and discovery are attributed to this phase [35], the ability to establish timely, safe, and comfortable transport that does not negatively affect the patient’s medical condition is essential. The third phase, a new beginning, where the person tries to incorporate new identities, behavioural patterns, and new ways of dealing with themselves and others in a new physical environment [35], can be seen as the arrival at the emergency department or new hospital ward. Exploring the actual transport of a patient within the EMS process from a transition perspective as well as an EMS caring perspective may promote increased wellbeing and comfort.
Differences in how ambulance services are organized and the large variation in the ambulance personnel’s general competence make it difficult to generalize concepts or standards for the driving of an ambulance. Drivers can be dedicated team members with limited medical education, volunteers, firefighters, or people with other professional backgrounds. In some contexts, the driver is one member of an equally trained ambulance crew, and the driving duty is shared within the team. Despite these differences, this study has pointed out that the actual transport and the way the ambulance is being driven is an important part of care provided within the EMS. Sufficient teamwork between the person driving the ambulance and the personnel providing direct care to the patient seems essential. However, no study in this review mentioned this aspect. That could either indicate a lack of understanding of the role of driving among medical and nursing researchers, or it could indicate that this is already a well-established way of working within the ambulance team that does not require further scientific attention. However, since few studies were found, the first option seems more likely. Likewise, studies did not reflect the relative risks or benefits of transporting patients, in particular during circumstances that might increase the risks, such as bad weather, snowstorms or bad road conditions. Given the increased rate of interhospital transports, such risks should be part of the medical risk assessment when transferring a patient. It seems reasonable to consider the actual driving of the ambulance as a specific skill and competence among EMS services, essential to providing high-quality and safe care. It can be suggested that driving the ambulance requires knowledge of how the actual driving affects the medical conditions and wellbeing of patients as well as safety aspects for patients and the EMS team. The driver must also have technical driving skills. Furthermore, personal competences such as stress management and the ability to manage complex traffic are important, as is the physical health and wellbeing of the driver.
Limitations
This study was based on scientific papers published within the last ten years. With a longer timeframe, more papers would likely have been identified. However, most of the included papers were published in 2019 or 2020, indicating a growing interest in researching aspects of ambulance driving. Without standardized search terms for this topic, the literature search was based on keywords. This might have limited the possibilities of identifying relevant studies. Finally, as in every review, it cannot be assumed that the search or selection process identified all papers of interest.