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Background:  Reducing unnecessary conveyances to hospital can help relieve pressure on emergency departments. Making decisions about conveyance in rural areas is particularly challenging because of the travel distances involved.    Aims:  To explore perceptions of paramedics in a rural setting about how they make decisions regarding conveyance and non-conveyance for patients categorised as ‘amber’ (serious but not life-threatening).    Methods:  Data were collected through interviews with 17 paramedics working in rural areas, which were analysed using inductive thematic analysis.    Findings:  Paramedics perceive hospitals as places of safety for themselves (psychological safety) and for patients (patient safety). Lower levels of psychological safety (e.g. because of an organisational blame culture) and perceived increased risks to patient safety (e.g. because of a lack of health resources in the community) influence paramedic decision making on conveying patients to hospital.    Conclusion:  Current practice contributes to increasing pressures on emergency departments. Ambulance services should work towards a non-punitive culture of safety where paramedics feel they can make decisions based on their experience and expertise rather than to protect themselves.

Decision making for patients categorised as ‘amber’ in a rural setting