Making judgements about the need for pre-alert based on immediate and potential clinical risk

Pre-alert decisions involve a rapid assessment of clinical risk to identify those patients in need of immediate attention at hospital (eg, access to a space in resus, with specialist staff and equipment ready). Assessments were based on physiological observations, clinical judgement and perceived risk of deterioration, taking account of guidance specifying which patients need to be pre-alerted. Additional considerations that could modify a risk assessment based on their immediate presentation included pre-existing conditions or previous medical history, either due to different baseline observations (eg, respiratory rate for patients with COPD) or the potential for deterioration.

When you’ve got somebody who’s - for example, a heart attack, it’s a no brainer. Then you’ve got things such as working with sepsis tools where it’s very, very “Shall we? Shan’t we?” - there’s other times, with 15 years’ experience, where the numbers might look right but the patient doesn’t (AS17_Paramedic)

It’s not just how they present and how their observations are, it’s also about which direction the observations are going in (AS21_Paramedic)

Any breathing difficulties you think - well that needs a pre-alert…But there are plenty of patients that have pre-existing conditions, and it’s an exacerbation of that. Such as COPD, Chronic Obstructive Pulmonary Disease, where even though they are quite poorly-seeming, actually it’s not that different from their baseline (AS1_Emergency Medical Technician)

Certain clinical conditions were acknowledged as clearly necessitating a pre-alert for time critical intervention (eg, ST-elevation myocardial infarction, stroke, major trauma). Medical pre-alerts were often less obvious and based on clinical observations (eg, heart/respiratory rate, blood pressure, temperature), but the patient’s appearance alone could give cause for concern. Clinicians commented that decisions were more difficult where observations were within relatively normal range, but the patient looked severely ill as they will have to justify a pre-alert to the receiving ED.

You do the ECG and it’s normal - something is telling you that something is not quite right. I think they’re the more tricky ones, because you’re trying to convince the hospital that you need something different … so I think it’s just about having that confidence that if something is not right then just make the call (AS41_Specialist Paramedic)

I think a lot of the time the ambulances are quite good at just phoning up and saying yeah they don't trigger (pre-alert criteria) but they just look awful (ED40_Registrar).

Children triggered a higher degree of concern and increased likelihood of pre-alert, partly due to concerns about the risk of sudden deterioration, but also clinicians limited experience with this patient group. ED staff noted that elderly trauma patients generate relatively less concern as ambulance clinicians possibly underestimate the risk associated with falls.

The grey areas in every way shape or form - children. We worry, and rightly so, we worry a lot about children, before we’ve examined them properly (AS17_Paramedic)

I think a lot of paediatrics is over alerted, but I think that’s purely because of the emotiveness of the scene and the experience of the clinicians seeing the children (ED30_Consultant)

The older adults with trauma…there’s been an under appreciation that they’ve got significant injuries… there is a massive under use of that [silver trauma] tool… So then I think there is a delay for them to be seen by senior decision makers, doctor, a delay to imaging, delay to getting off scoop, or having their head immobilised. And laying flat for an older patient is not good (ED43_Consultant)

The role of clinical experience and confidence in pre-alert decision-making

Experience and confidence were identified as key factors in decision-making. Ambulance clinicians used clinical experience (pattern recognition and intuition) to make judgements based on previous exposure to specific clinical presentations and conditions. This enabled them to differentiate between critical and less obviously critical patients and potential deterioration.

By experience you’ve seen the same thing a lot of times and you can perhaps see a pattern where you know what’s going to happen, it just hasn’t happened yet (AS17_Paramedic)

Subconsciously, you recognise things differently, the more experience you get and the more knowledge that you gain (AS4_Paramedic)

As I’ve gone through my career as a technician, you pick up more while you’re on the road… I maybe pre-alert a bit more than what I maybe did right at the beginning. For example when I did my tech training seven years ago, aortic dissection was unheard of (AS43_Emergency Medical Technician)

Clinicians regarded pre-alerts as necessary when they were unable to stabilise the patient, which varied according to their role-related knowledge and skills. The scope of practice for ambulance clinicians in advanced practice roles allows them to deliver certain treatments not available to other clinicians to stabilise patients or reduce the risk of deterioration.

Am I happy that my patient is stable enough that I can look after them or do I want sort of sooner intervention? (AS16_Paramedic)

Supra-ventricular-tachycardia…they can need medications that we can’t give, that they need at hospital…equally it’s a long term condition they suffer with and they aren’t otherwise compromised. So that can be a bit of a judgement call, not everyone would pre-alert (AS1_Emergency Medical Technician)

The more experienced paramedics that’d be less likely to pre-alert because they’d feel more comfortable managing the patients themselves and aren’t so worried about things (ED25_Consultant)

UK ambulance crews comprise different combinations of roles (eg, technician, paramedic, specialist and advanced paramedic) according to local staffing models, which ranged from having a paramedic on the majority of vehicles to having predominantly technician-led crews. This was identified by ED clinicians as a factor in pre-alert variation between different ambulance services. Lower skilled clinicians and private crews were perceived as pre-alerting more.

There’s always going to be a variation in individual practice but there is notable variation between ambulance services. Pre-alerts from non-regular paramedic teams or tech crews are less likely to match what they then bring in (ED56_Consultant)

Experience was identified as affecting confidence and risk tolerance. While newly qualified clinicians were generally regarded as more risk-averse, their lack of exposure to infrequent high acuity conditions could also lead to over confidence. Concerns were raised that delays at hospitals limit the exposure of newly qualified and trainee clinicians to different patients, affecting their pre-alert experience and confidence. The risk of underalerting by less experienced clinicians was raised as an issue by ED staff due to large numbers of newly qualified ambulance clinicians.

I’m still quite new to it, so…probably, as a clinician, err on the side of caution a lot more than more experienced people (AS11_Newly Qualified Paramedic)

When I first qualified I was probably more cautious. Whereas now obviously six years in you just get a feeling for things more. And I think that I’m more confident now in saying this patient’s stable (AS31_Paramedic)

I think certainly the experience levels of paramedics generally has changed and I think there are a lot more junior paramedics (ED36_Consultant)

Ambulance crew mentioned the importance of being able to justify their decisions and documenting the reasons to safeguard themselves personally and professionally. They attributed risk-averse decisions to perceptions of a ‘blame culture’ within their organisation and a lack of confidence that they would be supported if something went wrong. This could be mitigated by calling the ED for advice, which provided reassurance that concerns were shared. ED staff also commented on apparent defensive decision-making by ambulance clinicians but understood the reasons for this.

I didn’t think it needed pre-alerting either, but ultimately if I don’t, I’m going against procedure, and if anything goes wrong, where do I stand there?….leaves not a lot of leeway for clinical judgement (AS28_Paramedic)

If we get pre-alerted about a kid, from our perception of it is we think what have they rung that through for…if they hadn’t have rung it through and they missed it, and there was something wrong, then they’d be the first people to be criticised and probably hung out to dry about it. As much as we probably whinge about being pre-alerted, probably better to be pre-alerted (ED23_Consultant)

The paramedics are often very worried about making the wrong decision, and so will telephone to see what we think…that’s not always that helpful, and is not what the process is supposed to be. But, they’re in a tough situation and they are often terrified of making the wrong decision. (ED5_Consultant)

Learning and developing good decision-making practice

Ambulance clinicians generally learnt to pre-alert ‘on the job’ via a mentor or other experienced clinicians rather than formal training. Some ambulance clinicians had accessed resources for personal learning (eg, podcasts) to understand how to undertake pre-alerts but most expressed a desire for better training. Clinicians from both ED and ambulance services highlighted the need for opportunities to enhance their understanding of practice in the other setting, for example, placements and joint events to share perspectives on pre-alert practice.

A lot of it comes from my experience as a student, seeing what other paramedics did, and speaking to other paramedics…So that is largely where my decisions come from (AS5_ Newly Qualified Paramedic)

I had a really good paramedic mentor who had a lot of clinical experience…I think I’ve stayed in that method (AS12_ Newly Qualified Paramedic)

Just more training and engagement and maybe just even hospital staff coming into ambulance stations or us having joint training with the staff and saying what do you do, what do you need from me (AS24_Paramedic)

Feedback on pre-alert outcomes was regarded as key to informing future practice and developing confidence by reassuring clinicians about the appropriateness of decisions, rather than making assumptions based on the ED response experienced or observed. However, both ambulance and ED clinicians discussed the challenges of sharing feedback, particularly in the context of extremely busy and pressured environments.

I think sometimes hospitals can make it difficult, because you want to alert something in, and then they turn round and go what are you alerting this in for. But then, you don’t alert the same thing in next time and somebody else tells you something different…I don’t really care to be honest, I think if they’re sick, they are being alerted in (AS18_Paramedic)

When clinicians that have been in the service longer sometimes say you don’t need to pre-alert. The argument I put forward is it’s easier to step someone down from resus rather than have to escalate upwards…this is what I’ve always been told by ED staff (AS7_Paramedic)

You often hear crews “ooh last time I got told off for not calling this through”, or “last time I did call this through and I got in trouble”. So you do hear a lot of that, which I think’s a bit of a shame really. But perhaps that negative behaviour, in their reception before, has sort of influenced their ongoing practice (ED2_Consultant)

We have a tendency to sort of roll our eyes at some of the paramedic decisions. But, I think it is really, really tough for those guys cos the high acuity stuff they get to see very infrequently (ED5_Consultant)

Limited use of formal systems for feedback was identified (eg, patient QR codes and request cards), but most feedback occurred informally via clinician interactions at handover or later that day. On some occasions, a paramedic located in the ED acting as a Hospital Ambulance Liaison Officer (HALO) to support the management of ambulance patients was able to facilitate communication and feedback.

Sometimes I might have a word with the HALO officer and just go “By the way, can you make sure they know X, Y and Z for next time” (ED14_Consultant)

Ambulance clinicians expressed a desire for individual-level and organisational-level feedback on pre-alert practice to support learning and development.

I think we need some regional shared learning and training. I think that would be the way. Look at areas of really good practice and really poor practice (AS29_Specialist Paramedic)

Access to clinical decision support

Ambulance clinicians identified a range of sources of decision support, including guidance, protocols, decision tools (eg, major trauma tool, sepsis tool) and telephone support. For some conditions, pre-alert recommendations are built into treatment protocols available via an app, which provides clinical guidelines for UK paramedics.15 Protocols and decision tools were considered valuable in decision-making, particularly for less experienced clinicians, potentially reducing decision variation and the risk of underalerting. However, ambulance clinicians highlighted concerns, including increased time taken to make a decision and the inability to take contextual factors into account (eg, underlying conditions).

I didn’t actually feel that this person needed resus, the only reason I was pre-alerting was because we have guidance that says they needed pre-alerting (AS5_ Newly Qualified Paramedic)

If you’re taking 20 minutes to make a clinical decision because you’re going through all this criteria, that’s 20 minutes of dilly dallying about maybe on scene (AS4_Paramedic)

There was concern about the retention of clinical judgement and autonomy, particularly where patients might not meet certain thresholds but appear very ill and are judged to need pre-alerting. Where patients met predefined pre-alert criteria but were not considered to be time-critical, clinicians indicated that they would generally pre-alert, but also inform the ED of their opinion. Some viewed this as reducing their personal responsibility, whereas others felt more confident to exercise their clinical judgement over the need to pre-alert.

Going on the major trauma tool I didn’t need to alert the receiving hospital, however using my judgement of this…he would be (a) inappropriate to hold outside A&E especially with his injuries and (b) he’s going to need a trauma CT, trauma survey…I’ve always thought anyway there needs to be an element of being an autonomous paramedic rather than just following a flow chart in front of you (AS7_Paramedic)

Now it doesn’t really allow for a competent experienced clinician to use their judgement (AS20_Paramedic)

Ambulance clinicians generally valued telephone advice and support, preferably timely and provided by clinicians with more expertise than them (eg, doctor, nurse specialist, advanced paramedic), acknowledging the limits of support from others who could not see the patient. Access to trauma and medical telephone advice/support varied between ambulance services, with the trauma desk often regarded as helpful with decisions about which hospital to attend (TU or MTC). ED staff noted that crews sometimes called them for advice but considered that this support should be provided by the ambulance service. A lack of a clinical support/trauma desk in one ambulance service was regarded as a factor in pre-alert variation and ED calls for advice.

Can request EOC consultants to call if they’re on shift. ‘They’re absolutely amazing…we’ve got something called the Clinical Assessment Team. Now, they are paramedics. So, for me, are of no clinical benefit because it’s somebody of the same grade (AS9_Paramedic)

If we’re somewhere else on the patch and we’re not sure who can deal with what, we’ll ring up the trauma desk (AS20_Paramedic)

It’s time critical, I need this advice now…they [clinical support] just don’t answer the phone (AS27_Paramedic)

It does seem that [Ambulance service] has a lower level of qualification, generally, there are a lot more techs than paramedics, and they don’t have so much central support. They don’t have a trauma desk…they seem overly reliant on ED staff (ED46_Consultant)

Colleagues were also mentioned as a potentially valuable source of support, depending on their level of experience and qualification. More experienced/specialist staff could be called to attend where necessary. The hospital-based HALO also sometimes acted as a helpful intermediary, passing on information and advocating for crew decisions.

I’ll always talk it [decision] through…any of my colleagues input is just as important, doesn’t mean I’m going to do what they think but just getting their input can help my decision-making (AS43_ Emergency Medical Technician)

Consideration of differences between receiving EDs

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 and when pre-alerting an out-of-area ED.

Each hospital seems to have a different level of what they would like to be pre-alerted… that makes the decision making difficult (AS4_Paramedic)

When you work at [Ambulance Service], then you’ve got 6/7 different hospitals that all work differently…phone numbers change, policies change and its generally word of mouth with each other that we get it passed round (AS19_Paramedic)

If we go 6 miles further south from our location, we’ve got a choice of two hospitals that we go to… both of them are completely out of area and have local protocols where they’ll change things and people in the area will know but people from out the area don’t necessarily know (AS20_Paramedic)

Ambulance service protocols were generally perceived to have lower thresholds for triggering pre-alerts, especially for children and suspected stroke or sepsis, which was attributed to organisational risk aversion.

What makes the pre-alert decision hard as a clinician is if our policy and protocols are saying it’s for pre-alert, but they don’t marry up to the hospitals expectations of what they’d accept in resus (AS39_Clinical Lead)

All strokes have to be alerted whether they are in time or not. That is definitely over-alerting it. Children and children that are alerted, I think because again, their [ambulance service] markers are different to ours… when they’ve inputted their obs. it can automatically trigger that they need to alert the patient (ED15_Senior Nurse)

Frustration was expressed by both services regarding the sepsis protocols as crews feel obliged to alert due to the low threshold, and while EDs recognised this to be the case, ‘protocol-driven’ pre-alerts could be a source of tension, particularly when very busy.

Sepsis pre-alerts are always ones that you might be umm-ing and ahh-ing because with sepsis, the sepsis inclusion criteria are quite low for the threshold (AS37_Paramedic)

Our [ambulance service] interpretation of sepsis is far different than an ED (AS20_Paramedic)

When ambulance and ED pre-alert criteria differed, ambulance clinicians experienced anxiety about the reaction they would receive. Similarly, a degree of hesitancy was experienced when deciding to pre-alert hospitals perceived as generally less receptive to pre-alerts. Decisions about which hospital to attend were sometimes more difficult than identifying that a pre-alert was needed due to variations in criteria, especially whether the patient needs to go to a specialist centre (eg, MTC).

Some of my hospital colleagues, I also don’t think they really understand the context in which we work, and the fact that we don’t always get it right. But actually the best hospitals recognise that, accept what we’re saying (AS29_ Specialist Paramedic)

Delays at receiving hospitals were a consideration where there was a choice of hospitals to attend and concerns over potential deterioration if they had to wait. ED staff recognised that a reduced threshold for pre-alerting was inevitable due to delays.

Would I want this patient sat in a corridor for a little while or not? And if the answer’s no then I pre-alert it (AS31_Paramedic)

We can be waiting one, two hours potentially. So if you know it’s a busy one at the hospital then I might be more inclined to pre-alert just so then the hospital staff have got the opportunity, if they want to, to potentially jiggle things around in the HDU and make some room… Obviously once we get there it can be downgraded (AS31_Paramedic)

[If] we’re equidistant between the 2 hospitals, we’ll always pick the one with the lower queue (AS19_Paramedic)

Clinicians reported not making pre-alert calls for time-critical patients when close to the hospital and when alternative mechanisms in place enabled them to ask resus for an assessment on arrival. Some concern was expressed about pre-alerts being used to circumvent queues, but many commented that this view was unwarranted, with ambulance clinicians emphasising that doing so would undermine trust in their pre-alerts.

A lot of the time it’s to do with distance, so they'll say well we were only five minutes around the corner…but it still would have given me four or five minutes to set things up for this patient, and that is part of their protocol so it’s a bit unacceptable really, but again I always speak to the crews (ED33_ Senior Nurse)

pre-alerting doesn’t necessarily improve your chances of not waiting in overflow, so I wouldn’t say it gets used that way (AS1_Emergency Medical Technician)

I’ve not met a crew that have alerted a patient to finish on time (ED44_Nurse)