Background Ambulance clinicians use pre-alert calls to inform receiving Emergency Departments (EDs) of the imminent arrival of a patient who they perceive will require non-standard ED response. Although some pre-alert decisions will be clear (e.g cardiac arrest), in many cases the decision about whether to pre-alert is more complex. We undertook qualitative research to explore factors affecting how decisions are made.

Methods We undertook semi-structured interviews with ambulance clinicians (n=35) from three ambulance services and ED clinicians (n=32) from 6 EDs and non-participant observation in 6 EDs (86 hours, 109 pre-alerts). Detailed observation notes and verbatim interview transcripts were imported into NVIvo and analysed thematically.

Results We identified that thresholds for pre-alerting varied between clinicians, with decision-making affected by experience (including role), confidence, risk-tolerance and decision-support availability. Approaches to managing the professional and personal risk associated with pre-alert decisions included: always adhering to pre-alert criteria, pre-alerting or seeking advice (from colleagues or ED clinicians) for ambiguous cases; and documenting the rationale for pre-alert decisions. Where clinicians were less confident, or the clinical criteria less clear, clinicians sometimes used pre-alert calls as a two-way discussion rather than information-provision call, passing the responsibility for the patient’s destination to the ED staff.

Contextual factors such as long delays at ED may influence decisions as clinicians weighed up their ability to effectively manage the patient during a standard ED response and perceived higher stakes of not pre-alerting.

A lack of formal training on undertaking pre-alerts and lack of feedback on decisions could influence confidence and consistency of pre-alert practice. Negative feedback experiences from ED staff could also influence clinician confidence and future pre-alerting behaviour.

Conclusion Improved feedback, training and support for decision-making is required in order to ensure greater consistency in pre-alert practice, particularly in the context of high ED demand.