Background Pre-alert calls involve an ambulance clinician contacting an ED/hospital about a seriously ill patient prior to arrival and enables receiving EDs to prepare appropriate responses e.g. ensure appropriate staff/resources are in place to facilitate timely care on arrival. Approximately 1/10 English Emergency Department (ED) conveyances are pre-alerted.

There is trust-level variation around pre-alert guidance. This research aims to explore the pre-alert purpose and process from an ambulance perspective and identify sources and impacts of variation.

Methods We report qualitative findings from a mixed-method study (semi-structured interviews n=35 paramedics/EMTs/specialist paramedics at 3 ambulance services and observation of 109 pre-alerts at 5 EDs). Data collection occurred between August 2022-February 2023. Interview transcripts and observation notes were analysed thematically within NVivo.

Results Ambulance clinicians identified multiple pre-alert purposes, ranging from getting a different response from receiving EDs, obtaining ED advice about where to take the patient, giving a ‘heads up’ that a poorly patient was en-route and ‘courtesy calls’ to adhere to pre-alert protocols. Some pre-alert calls sought advice about borderline pre-alert cases.

Variation was identified throughout the pre-alert process, including variation in how EDs were informed about pre-alerts (by crew on scene/trauma desk/ambulance control); contact methods used (ambulance mobile phone/personal mobile/ambulance radio); handover formats (ATMIST/SBAR/personal preference/ED preference); ED instructions on where to take the patient (Resus/ED majors/check-in at front door/clinician review elsewhere).

Our interviews identified process variation can make pre-alerts more challenging for ambulance crews when operating out of their usual locality. Some ambulance clinicians favoured a separate advice line for borderline pre-alert cases.

Conclusion Pre-alert process variability was identified within and between ambulance services. Consultation with the study PPI group highlights a preference for more consistency and less variability in pre-alert practice and this was identified in our interviews with ambulance clinicians as a potential area for improvement.