Background
Ambulance clinicians use pre-alert calls to emergency departments to enable them to prepare for the arrival of a patient. This can lead to improved time-critical treatment. However, pre-alerts should be used judiciously, as over-alerting may add pressures on busy emergency departments, while under-alerting may lead to delays in time-critical patient care. We undertook a mixed-methods study to explore how pre-alerts are used and their impact on patients, ambulance and emergency department staff.
Method and design
The mixed-methods study integrated data from: (1) linked routine data set of 12 months’ (2020–1) electronic patient records (3 ambulance services), clinician information and routine hospital statistics, (2) semistructured interviews with 34 ambulance clinicians and 40 emergency department staff and 162 hours non-participant observation of pre-alerts across 6 emergency departments, (3) national online survey of ambulance clinicians (1298 responses). Multivariate logistic regression was undertaken in R™ (The R Foundation for Statistical Computing, Vienna, Austria) to identify factors associated with pre-alert rates in terms of patient (National Early Warning Score 2, working diagnosis, age, sex), ambulance clinician (experience, role, sex, time to end of shift) and hospital factors (journey time, percentage of ambulances waiting > 30 minutes). Qualitative data were analysed using thematic analysis in NVivo™ (QSR International, Warrington, UK). Findings were integrated using a triangulation protocol.
Findings
Pre-alerts are key to enabling emergency department staff to prepare physically and psychologically for critically ill patients, particularly when resources are constrained. We identified significant variation in pre-alert practice and pre-alert rates at both individual and organisational level that was not explained by patient case mix.
Pre-alert decisions were based on clinician risk perception, clinical experience (pattern recognition), protocols and anticipated response by emergency department staff, including consideration of different emergency department expectations regarding pre-alerts. Pre-alert calls included advice calls, ‘courtesy’ or ‘heads up’ calls where clinicians had no immediate clinical concern, but called due to protocol requirements or concern about the potential for subsequent deterioration during a handover delay. Frustrations arose from different individual expectations of a pre-alert.
Inconsistent guidance between ambulance services and emergency departments, and limited clinician knowledge and awareness of guidance, led to uncertainty and misunderstanding regarding who required pre-alerting. Understanding how to pre-alert was based primarily on learning ‘on the job’ and informal feedback mechanisms rather than formal training and feedback, including emergency department response to previous pre-alerts.
Pre-alert calls created interruptions but were valued by emergency department staff. Emergency department response to pre-alert calls was highly variable and dependent principally upon resource availability (staffing, crowding, acuity of other patients) at the time of pre-alert. Variation in individual emergency department's clinician practice and in emergency departments processes for managing pre-alerted patients (particularly for patients not brought into resuscitation bay) contributed to different responses for similar types of pre-alert calls.
Different protocols and documentation used by emergency department and ambulance staff to deliver and document the pre-alert created interruptions and frustration during the pre-alert call. Provision of a headline clinical concern to frame the pre-alert was perceived as useful, particularly when observations and clinical concern did not align.
Limitations
Despite flexible recruitment procedures, no patients were interviewed.
Implications and future work
Pre-alert decision-making and communication may be improved by increased consistency of emergency department and ambulance service pre-alert guidance and training. Improved ambulance service and emergency department communication and co-produced shared documentation may help improve pre-alert clarity and usefulness while reducing tensions.
Funding
This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131293.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)