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

Background Whilst pre-alerts have been shown to improve outcomes for some patients requiring immediate time-critical treatment (e.g. stroke), little is known about their usefulness for other patients and what processes are used by Emergency Department (EDs) to respond to them. In the current context of high demand, it is important to understand how pre-alerts affect EDs. Methods We undertook non-participation observation (162 hours, 143 pre-alerts) and semi-structured interviews (40 staff) within six UK Emergency Departments (EDs), between August 2022-April 2023. Interview transcripts and observation notes were imported into NVivo™ and analysed using a thematic approach. Results Pre-alert calls involved significant time and resources for ED staff but enabled staff to prepare for patient’s arrival both practically and psychologically, particularly when demand was high. High demand created additional pre-alerts due to advice or ‘heads up’ calls from ambulance clinicians concerned about handover delay. Despite some pre-alert fatigue regarding patients who did not always require a special response (e.g. sepsis), ED clinicians prioritised and valued pre-alerts, perceiving higher risks from under-alerting than over-alerting. Variation in ED processes for a) senior clinical review of pre-alerted patients not brought into resus and b) receiving, documenting and informing others of pre-alerts resulted in inconsistent response to ambulance clinicians. ED response (where the patient should be taken) largely reflected resources available (beds, staffing, acuity of other patients) rather than appropriateness of the pre-alert. Implications In the context of high demand, much variation in response to pre-alerts is outside ED staff’s control. There is potential for EDs to increase consistency in reviewing how pre-alert calls are answered, what information is documented and how this is communicated to others, including when they are not accepted into resus. Improved communication between ambulance and ED services may help avoid tension caused by different perceptions or understandings of pre-alerts. What is known on this topic? What this study adds How this study might affect research, practice or policy ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This research was funded by the National Institute for Health and Care Research (NIHR HS&DR 131293). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK Department of Health and Social Care. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for the pre-alerts project has been obtained from Newcastle & North Tyneside 2 Research Ethics Committee (Ref: 21/NE/0132) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data generated for this study is in the form of confidential transcripts of interviews that are not available for sharing. Participants consented for anonymised quotations to be shared but did not consent to share the full transcripts.