Title: Exploring the use of pre-hospital pre-alerts and their impact on patients, Ambulance Service and Emergency Department staff.
Funder: Department of Health and Social Care

Abstract: When a patient is seriously ill, ambulance staff may call the Emergency Department (Emergency Department) to let them know the patient is on their way. This is known as a ‘pre-alert’ and can help the Emergency Department to free up a trolley space or bed and get specialist staff ready to treat the patient as soon as they arrive. If used correctly, pre-alerts can help to provide better care, earlier access to time-critical treatment and improved outcomes for patients. However, if pre-alerts are used for the wrong patients, or used too often, then the Emergency Department staff may not be able to respond properly and may stop taking them seriously._x000D_ _x000D_ When Emergency Department staff prepare for a pre-alerted patient, they may have to move patients who are less seriously ill, and take staff away from other work. It is therefore important that pre-alerts are only used when absolutely necessary. There is some guidance telling ambulance staff who they should do pre-alerts for, and how this should be done. However, the guidance is not always clear and varies for each ambulance service. This creates a risk that ambulance staff may not pre-alert appropriate patients, or may pre-alert when it isn’t necessary. This may cause difficulties for the Emergency Department and tensions between ambulance and Emergency Department staff. There are important risks for patient safety._x000D_ _x000D_ Although pre-alerts are being used more often, little is known about how they are used, who they are used for or how the Emergency Departments respond to them. Given how important pre-alerts are for patient safety it is important that we understand the impact of pre-alerts on patients, ambulance staff and Emergency Department staff._x000D_ _x000D_ We propose to do some research to understand how pre-alerts take place at the moment and how this varies between ambulance services and between different types of ambulance staff. We will try to identify how the processes of doing pre-alerts can be improved and identify areas of good practice. We will do this within 5 separate research activities. We will involve patients and the public in designing and carrying out this research._x000D_ _x000D_ 1. We will look at existing ambulance service policies and data to understand how pre-alerts are currently being done, and what may be causing variation._x000D_ _x000D_ 2. We will talk to ambulance staff to understand how they decide to make pre-alert calls and which patients are difficult to decide whether to pre-alert. We will also ask what information they give to the Emergency Department staff, and how they expect Emergency Department staff to respond. We will explore findings from these interviews in a survey of all ambulance staff in 3 ambulance services to identify areas where they need improved guidance._x000D_ _x000D_ 3. We will talk to staff in Emergency Departments and watch them taking pre-alert calls. This will help us to understand how they use the information given in a pre-alert to change what they do, and to understand what makes a useful pre-alert._x000D_ _x000D_ 4. We will talk to patients and their friends and family to find out what they understand about pre-alerts, what they are told about pre-alerts and whether this changes their expectations once they arrive in hospital._x000D_ _x000D_ 5. We will discuss the findings from this research in a national workshop with key people, including patients and the public, to identify how pre-alerts can be improved. We will produce short, written guidance to ambulance and Emergency Department staff about how they should manage pre-alerts in future. We will identify key areas of uncertainty that should be addressed within future national guidance.

Lay abstract: Research question_x000D_ 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?_x000D_ _x000D_ Background_x000D_ 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._x000D_ _x000D_ Aims and objectives_x000D_ 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: _x000D_ 1. Map current pre-alert practice and explore potential reasons for variation in practice (WP1)_x000D_ 2. Explore how pre-alert decisions are made and communicated and identify key areas of uncertainty where further guidance would be useful (WP2)_x000D_ 3. Identify what information needs to be communicated in order to improve patient care (WP2&3)_x000D_ 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)_x000D_ 5. Understand service user experience of pre-alerts (WP4)_x000D_ 6. Co-produce recommendations for good pre-alert practice and identify areas where further guidance is needed (WP5)_x000D_ _x000D_ Methods & Timelines_x000D_ We will meet these objectives via a mixed methods study with five inter-related work packages. _x000D_ 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) _x000D_ 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)_x000D_ 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)_x000D_ WP4: Understand the impact of pre-alerts on patients and carers using semi-structured interviews (n=6-8 pairs) (Month 12-23)_x000D_ WP5: Undertake national feedback workshop and co-produce guidance and simple infographics with ED, ambulance staff and stakeholders and PPI (Month 27)_x000D_ _x000D_ Impact and dissemination._x000D_ 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.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE