Exploring the use of pre-hospital pre-alerts and their impact on patients, Ambulance Service and Emergency Department staff.

Research question

How are out of hospital pre-alert decisions made and communicated and what is the impact of these pre-alerts on receiving Emergency Departments (EDs) and patients? Background

Ambulance Clinicians use pre-alert calls to inform receiving EDs of the arrival of a critically unwell or rapidly deteriorating patient who they believe requires senior clinical review and time-critical treatment immediately upon arrival. Pre-alerts can help ED staff prepare for the patient’s arrival and lead to earlier initiation of time-critical treatment, improved processes and better clinical outcomes for patients (2, 3).

However, over- or inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill ED patients, with important risks for patient safety. There is currently a lack of evidence about how pre-alerts should be undertaken and communicated with EDs for optimal patient benefit.

Aims and objectives

This study aims to understand how pre-alert decisions are implemented by ambulance clinicians, and the impact of these on receiving EDs, to identify principles of good practice, areas of uncertainty and areas for improvement. Specific objectives will be to: 1. Map current pre-alert practice and explore potential reasons for variation in practice (WP1)

2. Explore how pre-alert decisions are made and communicated and identify key areas of uncertainty where further guidance would be useful (WP2) 3. Identify what information needs to be communicated in order to improve patient care (WP2&3)

4. Understand how pre-alerts influence patient care in the ED, including potential benefits and unintended consequences, and explore factors that affect whether action is taken within the ED (WP3) 5. Understand service user experience of pre-alerts (WP4) 6. Co-produce recommendations for good pre-alert practice and identify areas where further guidance is needed (WP5)

Methods & Timelines We will meet these objectives via a mixed methods study with five inter-related work packages.

WP1: Map latest policies & guidance from ambulance services to identify areas of uncertainty. Analyse 12 months’ routine data from three Ambulance Services to understand pre-alert practice (volume, types) and explore potential reasons for variation.(Month 6-13)

WP2: Understand how pre-alert decisions are made and delivered, by undertaking semi-structured interviews with Ambulance Clinicians from three Ambulance Services (n=24-28) and a national survey of Ambulance Clinicians (Month 12-23)

WP3: Explore the impact of pre-alerts on the ED using semi-structured interviews with ED staff and non-participant observation of pre-alert processes and responses to them within two EDs in each of three Ambulance Services (n=24-36)(Month 12-23)

WP4: Understand the impact of pre-alerts on patients and carers using semi-structured interviews (n=6-8 pairs) (Month 12-23)

WP5: Undertake national feedback workshop and co-produce guidance and simple infographics with ED, ambulance staff and stakeholders and PPI (Month 27) Impact and dissemination.

We will use our links with key professional organisations to ensure that the revised guidelines on pre-alerts and relevant staff training programmes are based upon our findings. We will deliver pragmatic recommendations and simple infographics developed with ambulance and ED staff, public and patients, to support effective use of pre-alerts.