PP26 Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and emergency department staff: protocol for a mixed methods study

Abstract

BackgroundAmbulance clinicians use pre-alert calls to inform receiving emergency departments (EDs) of the arrival of a critically unwell patient that will require a specialised response. Little is known about how a decision to pre-alert is made and how this is communicated and acted upon in the receiving ED. Whilst appropriate use of pre-alerts benefits patient care, their overuse carries a risk of harm or opportunity costs. The impact of pre-alerts on ambulance clinicians, ED staff and patients is not currently well understood.MethodsWe are conducting a mixed methods study with five inter-related work packages. We will analyse 12 months of routine data from ambulance pre-alerts in three regions to identify factors in the variation of pre-alert use, including pre-hospital decision-making. We will undertake a national online Qualtrics survey of ambulance clinician perspectives and experience of pre-alerts. We will explore the impacts of a pre-alert on staff, ED facilities and the patient using semi-structured interviews with ambulance clinicians, ED staff, patients and carers and undertake non-participant observation of ED pre-alert response.Expected ResultsWe will describe current pre-alert practice using 12 months’ data for 3 Ambulance Services, including volume and types of pre-alerts. We will identify specific conditions or patient groups for whom pre-alerts are most likely to lead to change in clinical practice, or for whom action is unlikely to provide benefit. We will hold a feedback workshop in which we will share and discuss our findings with key stakeholders.ConclusionsCurrent variation in pre-alert processes, both pre-hospital and in-hospital and the impact on patient care is not understood. The outputs of this study will establish an evidence base to update national guidance for pre-alert practice and identify areas of good pre-alert practice for both ambulance service and Emergency Department staff.

Variation in ambulance pre-alert process and practice: Cross-sectional survey of ambulance clinicians

“…We undertook a cross sectional online survey nested with a larger mixed methods study. (8) The survey aimed to explore ambulance clinician's understanding and experiences of the pre-alert process.…”

“…Whilst the findings reflect what the participants reported rather than what happened, they align with routine data showing that variation in practice that is unexplained by clinical need. (20) Some variation in practice may be due to service level variation. For example, pre-alert recording in the patient notes may be impacted by mandated information recording policies.…”

“…In England over 1 in 10 ambulance conveyances are pre-alerts, however analysis of routine data shows variation in which patients get pre-alerted and in which conditions. (1)…”

“…In England over 1 in 10 ambulance conveyances are pre-alerts, however analysis of routine data shows variation in which patients get pre-alerted and in which conditions. (1) Due to inconsistency in pre-alert processes, the Healthcare Safety Investigation Bureau recommended that the Ambulance Association of Chief Executives work with appropriate partners to define and operationalise best practice standards and processes and led to the development of the AACE/RCEM pre-alert guidance in 2020 (2) However, there is still significant variation and lack of consistency in pre-alert guidance across different ambulance services, with ambulance service guidance varying from the national AACE/RECEM guidance. (3) Pre-alerts have been shown to result in earlier initiation of time-critical treatments, improved processes and clinical outcomes for patients (4,5) particularly for conditions such as stroke.…”

How do Emergency Departments respond to ambulance pre-alert calls? A qualitative exploration of the management of pre-alert in six UK Emergency Departments

“…(8-10) In the UK, joint guidance from RCEM/AACE also recommends pre-alerting for a range of other conditions or physiological criteria although there is significant variation in guidance recommendations for pre-alert and of pre-alert rates for different conditions across different ambulance services. (11,12) * The term 'front door' is used to describe all department's initial assessment and treatment area i.e. where those patients not being taken to resus etc are received.…”