Pre-alerts study
Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and Emergency Department staff.
Summary of research
Research Question
How are out-of-hospital pre-alert decisions made and communicated and what is the impact of these pre-alerts on receiving EDs and patients?
Background
Ambulance Clinicians use pre-alert calls to inform receiving Emergency Departments (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. By enabling EDs to prepare for the patient’s arrival, pre-alerts can lead to earlier initiation of time-critical treatment, improved processes and better clinical outcomes for patients (James et al, 2019, Kelleher et al, 2014).
However, over- or inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill ED patients, which has important risks for patient safety. There is currently a lack of evidence about the impact of pre-alerts on patients, ED staff or ambulance clinicians. In particular, there is limited guidance about how pre-alerts should be undertaken, delivered and communicated with EDs, in order to optimise their use for patient benefit.
Principal investigator (PI), Dr Fiona Sampson
Aims and objectives
This study aims to understand how pre-alert decisions are made and implemented by the pre-hospital staff, and the impact of these on receiving EDs and patients, in order to identify principles of good practice, areas of uncertainty and areas for improvement.
Objectives
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To map current pre-alert practice in terms of volume and types of pre-alerts and explore potential reasons for variation in practice by reviewing existing Ambulance Service patient records and mapping to local guidance. (WP1)
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To explore and understand pre-alert decision-making by undertaking semi-structured interviews with Ambulance Clinicians from three Ambulance Services and a national survey of Ambulance Clinicians to identify key areas of uncertainty where further guidance would be useful. (WP2)
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To identify how pre-alert decisions are communicated, and what information needs to be communicated in order to improve patient care, by interviewing pre-hospital and ED staff. (WP2 & 3)
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To understand how pre-alerts influence patient care in the ED, including potential benefits and unintended consequences, by observing pre-alert processes and responses to them within two EDs in each of the three Ambulance Service areas/regions. (WP3)
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To explore whether there are specific conditions or patient groups for whom pre-alerts are most likely to lead to action, or for whom action is unlikely to provide benefit, and explore factors that affect whether action is taken within the ED. (WP3)
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To understand the service user experience of pre-alerts by interviewing patients and/or carers. (WP4)
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To identify good pre-alert practice, areas where further guidance is needed and co-produce information to inform the development of pre-alert guidance with research participants and other key stakeholders. (WP5)
Methods
We will undertake a mixed methods study with five interrelated work packages.
We will map current existing policies and guidance from ambulance services to identify areas where guidance is unclear or inconsistent.
We will analyse 12 months’ ambulance routine data to understand how pre-alerts are currently being used and to identify any factors that may explain variation in pre-alert use.
We will explore how ambulance clinicians undertake pre-alerts by undertaking semi-structured interviews with up to 36 ambulance clinicians followed by a national survey of ambulance clinicians. This will help us to understand how pre-alerts are made, factors affecting decision-making and how they are communicated to ED, and the clinician experience of undertaking pre-alerts.
We will explore the impact of pre-alerts on the ED by undertaking observation of pre-alert calls and the ED response within 6 EDs, and use semi-structured interviews with ED staff to understand the impact of these calls on ED staff.
We will also undertake interviews with patients and their carers to understand the impact of pre-alerts on patients.
Finally, we will co-produce recommendations for improving pre-alert practice through a national feedback workshop including ED and ambulance staff and stakeholders and PPI.
Timelines for delivery
The project will take place over 29 months, including five months for the project setup and NHS ethics and research governance approval.
WP1: Mapping existing guidance and describing current pre-alert practice using routine data analysis will take place in months 6-13.
WP2 (exploring how Ambulance Clinicians undertake pre-alerts), WP3 (understanding the impact of pre-alerts on the ED) and WP4 (understanding the patient perspective of pre-alerts) will take place concurrently in months 12-23).
Data Analysis and integration of WPs 1-4 will take place from months 21-27, with WP5 (co-production of guidance) and dissemination of findings from months 27-29.
Anticipated impact
We anticipate that the project will deliver pragmatic recommendations developed by ambulance and ED staff, incorporating views of the public and patients, to support effective delivery and receipt of pre-alerts.
We will share our findings with key professional organisations who are involved in developing guidance on the use of pre-alerts, and work to enable inclusion of pre-alert practice recommendations in training programmes for staff in the urgent and emergency care system.
We will disseminate via academic conferences and open-access journals, and disseminate professional and plain language summaries to professional organisations to enable them to make an evidence-based case for improvement to current practice.
Publications
Sampson FC, Long J, O’Hara R, Coster J. Understanding good communication in ambulance pre-alerts to Emergency Department. Findings from a qualitative study of UK emergency services. BMJ Open 2025 https://bmjopen.bmj.com/content/15/1/e094221
Coster J, Sampson FC, Long J, O’Hara R. Variation in pre-alert processes and practice: findings and insights from a national survey of ambulance clinicians in England. Emergency Medicine Journal. 2024 doi: 10.1136/emermed-2023-213851
Long J, Sampson FC, Coster J, O’Hara R, Bell F, Goodacre S. How do EDs respond to ambulance pre-alert calls? A qualitative explorations within six UK EDs. Emergency Medicine Journal. 2024 https://doi: 10.1136/emermed-2023-213854
O’Hara R, Sampson FC, Long J, Coster J, Pilbery R. What influences ambulance clinician decisions to pre-alert patients to ED? A qualitative exploration of decision-making in three UK ambulance services. Emergency Medicine Journal. 2024 https://doi.org/10.1136/emermed-2023-213849
Boyd A, Sampson FC, Bell F, Spaight R, Rosser A, Coster J, Millins M, Pilbery R. How consistent are pre-alert guidelines? A review of UK ambulance service guidelines. Br Paramed J. 2024 Mar 1;8(4):30-37. doi: 10.29045/14784726.2024.3.8.4.30 PMID: 38445108; PMCID: PMC10910291.
Conference presentations
Sampson FC, Bell F, Webster P, Coster J, O’Hara R, Goodacre S et al. 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 999 EMS Research Forum 2022, online March 2022
Boyd A, Sampson FC, Bell F, Spaight R, Rosser A, Coster J, Millins M, Pilbery R. How should ambulance clinicians undertake pre-alerts? Review of UK ambulance service guidelines. College of Paramedics conference, Nottingham, UK. May 2023
Sampson F, Pilbery R, Herbert E, Long J, Coster J, Bell F. What factors influence prehospital decisions to pre-alert emergency departments of a potentially deteriorating patient’s arrival? International Conference for Emergency Medicine, June 2023, Amsterdam, Netherlands.
Boyd A, Sampson FC, Pilbery R, Bell F, Millins M, Coster J, Rosser A, Spaight R. When should ambulance clinicians undertake pre-alerts? Review of UK ambulance service guidelines. 999 EMS Research Forum June 2023, Manchester, UK.
Long J, O’Hara R, Sampson FC, Coster J, Bell F, Webster P. How do pre-alerts influence patient care in the Emergency Department? Findings from qualitative research within three UK Ambulance Services. 999 EMS Research Forum June 2023, Manchester, UK.
Sampson FC, Pilbery R, Herbert E, Bell F, Rosser R, Spaight R, Goodacre S, Pountney A, Millins M. What factors affect pre-hospital pre-alerts? Analysis of routine ambulance data. 999 EMS Research Forum June 2023, Manchester, UK.
Sampson FC, Coster J, Long J, O’Hara R, Bell F, Webster P, Pilbery R, Goodacre S, Foster A, Miles J, Millins M, Pountney A, Rosser A, Spaight R, Turner J, Boyd A. What is a pre-alert? Exploring ambulance and Emergency Department staff perspectives of the pre-alerts process. 999 EMS Research Forum June 2023, Manchester, UK
Coster J et al. Time critical care at the ambulance and ED interface: qualitative research exploring UK ambulance clinician and ED staff perspectives and practice of pre-hospital pre-alerts. European Emergency Medicine Congress, September 2023, Barcelona, Spain. (Oral presentation)
Sampson FC et al. Mixed methods study exploring factors influencing ambulance clinician decisions to pre-alert Emergency Departments (EDs) of a patient's arrival. RCEM Annual Scientific Conference, September 2023 Glasgow UK. (Oral presentation)
Sampson F, Coster J, Long J et al. Using triangulated findings from a mixed methods study to improve ambulance service and emergency department pre-alert processes and practice. Health Services Research UK conference July 2024, Oxford, UK. Oral presentation
Sampson F et al. What factors influence prehospital decisions to pre-alert emergency departments of a potentially deteriorating patient’s arrival? International Conference for Emergency Medicine, June 2023, Amsterdam, Netherlands. (Oral presentation)
Coster J et al. What is a pre-alert? Exploring ambulance and Emergency Department staff perspectives of the pre-alerts process. 999 EMS Research Forum June 2023, Manchester, UK (Elevator Pitch) EP11
Sampson FC et al. Factors that influence ambulance clinician’s decisions to pre-alert Emergency Departments in advance of a patient’s arrival: findings from a UK mixed-methods study. European Emergency Medicine Congress, September 2023, Barcelona, Spain. (ePoster presentation)
Sampson FC et al. Is a shared understanding of the purpose of pre-hospital pre-alerts important? Qualitative research exploring UK ambulance and Emergency Department staff perspectives and practice of pre-alerts. RCEM Annual Scientific Conference, September 2023 Glasgow UK. Poster
Boyd A et al. How should ambulance clinicians undertake pre-alerts? Review of UK ambulance service guidelines. College of Paramedics conference 2023
Boyd A et al. Which patients should be prealerted? Review of UK ambulance service guidelines. 999 EMS Research Forum June 2023, Manchester, UK. PP34
Long J et al. How do pre-alerts influence patient care in the Emergency Department? Findings from qualitative research within three UK Ambulance Services. 999 EMS Research Forum June 2023, Manchester, UK. PP31
Pilbery et al. What factors affect pre-hospital pre-alerts? Analysis of routine ambulance data. 999 EMS Research Forum June 2023, Manchester, UK. PP35
Sampson FC et al. 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 999 EMS Research Forum 2022, online March 2022. PP26
Workshops and events
Pre-alerts study workshop at the 999 EMS Research Forum Conference, 18th September 2024, Cambridge. Facilitated by Jo Coster, Fiona Sampson, Fiona Bell and Chandrika Kaviraj (PPI). Attended by approx 20 conference attendees with most attendees being ambulance clinicians but also with representation from PPI and ED nursing staff attendees. The workshop consisted of a presentation of key study findings and PPI insights, followed by small group work and discussion about how to optimise pre-alert communication
PPI key message development workshop to understand PPI perspectives and interpretation of the pre-alert results. Online 7th September 2023. (Jo Coster) -
Pre-alerts stakeholder event. Online 12th September 2023. Discussion of results of pre-alerts study and understanding the key messages. Attended by 28 ED and ambulance clinicians and policy makers.
Podcast of three January papers in EMJ - https://www.podbean.com/ew/pb-n8b3y-17967c0 and included in the issue editorial Primary survey: highlights from this issue | Emergency Medicine Journal
Invited talks
- Sampson F. Communicating pre-alerts. Royal College of Emergency Medicine. Annual Scientific Conference. Recent Emergency Care research highlights. Gateshead, UK. October 2024
- Sampson F. British Association for Immediate Care (BASICS). Pre-alerts study, implications for practice, 11th October, Leicestershire, UK 2024
- Yorkshire Ambulance Service Research Institute launch event. Invited speaker: results of the pre-alerts study. Hepworth Gallery Wakefield 4th October 2023 (Fiona Sampson & Jo Coster)
- CDPme Webinar. How should we improve the use and communication of pre-hospital pre-alerts? 12th December 2023 (Fiona Sampson)
- Royal College of Surgeons of Edinburgh Faculty of Prehospital Care Pre-alerts Webinar. Results of the pre-alert study and implications for practice. 5th March 2024 (Fiona Sampson)
- Presentation of summary and findings and PPI perspective to Sheffield Emergency Care Forum 18th January 2024 (Jo Coster)
Important documents
Information sheets, consent forms and the protocol (downloadable) are available by clicking the respective links below.
Information sheet: ED Observations (Word, 71.4KB)
Information sheet: Staff (Word, 57.1KB)
Information sheet: Patients and carers (Word, 60.6KB)
(If you are a patient or carer who has been asked to take part in this research project, the participant information sheet is also available in video form).
Consent form: Patients and carers (Word, 66.8KB)
Consent form: Staff (Word, 65.6KB)