What influences ambulance clinician decisions to pre-alert Emergency Departments: a qualitative exploration of decision-making in three UK Ambulance Services

Background Ambulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving Emergency Department or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel ‘pre-alert fatigue’ amongst ED staff. This research aims to provide a better understanding of pre-alert decision-making practice. Methods Semi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis. Findings Pre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement, and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care upon arrival or were at highest risk of deterioration. Ambulance clinicians primarily learned to pre-alert ‘on the job’ and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians. Conclusion We identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback, and cross-service collaboration to minimise potential sources of tension. ### 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. The views expressed are those of the author(s) and not necessarily those of the NIHR or the 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: NHS ethics North East - Newcastle & North Tyneside 2 Research Ethics Committee (Ref: 21/NE/0132) gave ethical approval for this work 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.