Pre-alerts were valued in enabling preparedness but used significant ED resources

Pre-alerts enable staff to prepare physically and psychologically for the pre-alerted patient’s arrival, judging patient needs based on the information communicated during the call. In the context of high ED demand, creating space for incoming patients often involved relocating critically ill patients who would otherwise have remained in resus, while also trying to protect space for potentially more critical cases. This ‘juggling available space and staff’ (ED56, consultant) was repeatedly observed and commented on.

Having that information beforehand is really handy because if our resus room is full then we need to kind of step people down into the majors area or […] maybe move them further down the resus rooms so we’ve got an airway bay free. (ED03, senior nurse)

Pre-alert calls involved significant staff resources and potential risk for other patients when staff or other patients were moved in response to pre-alert calls.

A pre-alert is not a harm free intervention. Sometimes in resus there is only 1 spare bed. And a pre-alert might take a reg[istrar], ED nurse, anaesthetist, consultant, [allied health professional]. (Site D MTC Obs 3a)

Responding to the pre-alert phone was always observed to be prioritised by staff regardless of the level of demand at the time of the call. The call also influenced the behaviour of other nearby staff who often listened in, read what was being written and sometimes started to act before the call was complete. Resource demands were greater for complex cases (eg, major trauma) or where immediate life support was requested involving the readying of equipment and calling specialist teams from elsewhere in the hospital. For example, the following pre-alert case involved 17 staff over a half-hour period.

Extract from observation notes (site A MTC Obs 1)—impact of pre-alert on staff resources.

Due to the workload involved in acting on pre-alerts, timing of the call was perceived as critical to maximising the benefit for both patients and staff, particularly when substantial preparation was needed. ED clinicians expressed frustration at underestimated arrival times resulting in wasted resources especially when large teams of specialist staff had been assembled in anticipation of the imminent arrival of a time-critical patient. Short notice calls (less than 5 min) were also challenging, but ED staff valued some advance warning despite expressing frustration at very last-minute pre-alerts and where ambulance clinicians did not pre-alert because they were nearby.

I would rather a crew rung me and said, I’m two min away. I’ve got a really poorly one, can you look at them? So then at least I’ve got those two min to mentally say like, right, this patient can move here, this patient can move here. (ED49, senior nurse)

12:50 Critical care paramedics bring a patient in who wasn’t pre-alerted. Apparently this happens often. I asked them why they didn’t pre-alert and they said it was because they were only 2 minutes away. (Site E MTC Obs2b)

Even when staff did not make any immediate practical change within the department in response to the pre-alert, they still valued the pre-alert as enabling them to mentally plan and prepare. Even short-notice pre-alerts enabled some mental preparedness through awareness of the risk profile of patients arriving into the ED.

Part of the whole essence of pre-alerts is for your own mental model, isn’t it? It’s for your own preparation. (ED18, registrar)

You are aware of what’s there, it’s not a hidden risk, it’s a, you’re aware of the risks. (ED43, consultant)

ED crowding and increased ambulance wait times contributed to an increased perceived need to pre-alert

During fieldwork, we found that EDs often had high levels of crowding and ambulance queues. Pre-alerts were perceived by ED staff to be more important in this context due to the increased risk for patients waiting on ambulances, and were considered necessary in anticipation of likely deterioration. However, ED crowding and patient queues were also identified as contributing to an increase in unnecessary pre-alert calls where ambulance clinicians had concerns about the patient having to wait in the ambulance and/or wanting advice. This was thought to result in a higher volume of calls to the pre-alert phone, increasing workload and pressures for EDs.

I think the pre-alert is even more important now, because it makes the difference between knowing you’ve got to find a space that is gonna be hard to find for someone in an immediate time frame, vs them being able to wait for twelve hours on the back of a truck. (ED18, registrar)

Now, we get a phone call where actually it’s not really a critically ill patient. It’s just for advice, you know “What do we do with…?” and this has come out of the fact that, if they can’t drop the patient off in resus, then we are committing them to queueing up in the corridor for hours. (ED46, consultant)

While acknowledging the validity of ambulance clinician concerns and potential patient safety benefits, individual clinician attitudes towards these calls and perceptions of what the ‘red phone’ should be used for caused some frustration and tensions due to the increase in workload created. Some commented that advice calls should be managed elsewhere, potentially via an alternative line or ambulance service support.

I know we get quite a few where they may be more junior paramedics who will ring up for advice on the pre-alert phone to say y’know I’m not sure if this needs pre-alerting, but this is what I’ve got. Which of course, nobody minds that, it’s just difficult. If you’ve got a busy resus, and that phone’s constantly going, and they’re not pre-alerts. So it’s almost like we need a pre-alert phone and an advice phone. (ED55, senior nurse)

When pre-alerted patients were sent to the usual ED entrance, they were often prioritised by offering an immediate quick review to ensure that nothing significant had been missed during the pre-alert call. One site also offered this for patients who had not been pre-alerted, meaning that ambulance clinicians could receive immediate reassurance about a patient they had concerns about without the need to pre-alert.

Pregnant lady in resus not pre-alerted by double technician crew because ‘if it’s borderline we normally ring the doorbell and see what they want’. ‘Turn up and check’ has been observed at least three times now, maybe as the ambulance door is close to resus so it’s easy to stop and check as the crew are walking through to [usual ED area]. (Site E MTC Obs 3b)

The challenge of balancing the risks associated with underalerting and overalerting

ED clinicians favoured a risk-averse approach to pre-alerting, whereby ‘it’s better knowing about them than not knowing about them’ (ED4, registrar). They also identified specific conditions as being underalerted, for example, elderly (silver) trauma. Being given information about borderline cases enabled them to prepare for potential deterioration and the chance to ‘eyeball’ a patient if necessary but did not mean they were required to act on the information.

If you’re being pragmatic about it, any information is useful. And I think that just because they’re pre-alerted doesn’t necessarily mean we have to respond in a way that they would perceive they would want to be responded to. (ED30)

Pre-alert information and judgements based on telephone communication could involve a degree of ambiguity but the consequences of underalerting were felt to be more serious than those of overalerting, providing no opportunity to identify and prepare for a time-critical patient.

In any triage system you have to overtriage, if every call you’re bringing in is entirely appropriate then you’re missing things. Anything that encourages people to alert less, it’s fraught with danger. (ED38, registrar)

However, ED staff raised concerns about the risk of pre-alert fatigue where pre-alert calls may not be taken as seriously if overused. This was raised particularly in relation to sepsis where ambulance clinician protocols were regarded as more risk-averse and recommended pre-alerting but ED staff were confident that the patient could be managed outside of resus. Within fieldwork, we observed a number of pre-alerts where pre-alert calls for suspected sepsis were sent elsewhere in the ED rather than resus.

The classic red flag sepsis is the one that gets our eyes rolling most of the time, to be honest. Most patients with sort of sepsis probably don’t need to be in resus. (ED5, consultant)

[Practitioner] says ‘there’s a lot of pre-alert fatigue here. A lot of sepsis that really aren’t that unwell. When they arrive their numbers are okay and they’re sat up texting. And you want to say, what needs resuscitating here? We get sepsis after sepsis after sepsis. We get annoyed and then they get annoyed at us because we’re not letting patients in.’ (Site D MTC Obs 3a)

Variation in pre-alert response was influenced by individual and organisational factors within ED settings

Potential pathways for pre-alerted patients varied across the sites reflecting different approaches to managing risk, historical processes and capacity, layout and resourcing of the ED (see online supplemental table 3). Over one-third of the pre-alerts observed (53/143) were not sent to resus or similar high-level care. Pre-alert responses varied between different ED clinicians depending on their experience, attitudes to risk and situational awareness. Trust in the information provided during pre-alert calls was potentially influenced by established relationships with ambulance clinicians.

Certainly if the senior paramedic’s brought the patient in and they’re saying they’re really poorly I’ll listen to them. I mean that’s just, if they’re concerned about the patient then I’m concerned as well. (ED42, consultant)

Conversation with [role]: Some crews alert everything, whereas others if they say someone is sick, you know they are sick, take it seriously whatever the obs. (Site A MTC Obs 5a)

ED staff commented that while ambulance clinicians may have expectations regarding the ED response to their pre-alert (eg, placed in resus) there are a number of factors that may mean their expectations are not met. The ED resources available at the time of call influenced the ED response (ie, where they told the ambulance clinician to bring the patient). When EDs were busy, this involved balancing patients that were ‘least sick’ (rather than ‘most well’) and/or directing all but the most critically ill patients to a different area of the ED. During the majority of observations, pre-alert demand was high with repeated calls in quick succession creating notable pressure on staff and space, particularly when space in other areas of the ED and wider hospital was limited.

Clinician in charge arrives—“I hate shifts like this, who’s coming out?” and says “they’re trying to work out who’s the least worst, not who’s well enough to move out, but who’s the least likely to arrest on me if I move them out there.” (Site D MTC Obs 4a)

Conversation about the two pre-alerts [that had just been called in]. ‘What’s yours? Is yours more important than mine? We’ve only got one space.’ (Site D MTC Obs 1a)

Lack of clearly defined processes for receiving, documenting and communicating pre-alerts affects usefulness of pre-alerts

Experience and seniority were regarded as important in understanding what information from the ambulance clinician would influence where the patient should be seen on arrival. Despite an understanding that it was preferable for more senior clinicians (medical or nursing) to answer pre-alert calls, preferably also one with an oversight role in the department aware of resource availability, many EDs lacked formal policies for who should answer a pre-alert. During observations, responses from less experienced staff required input from a senior clinician, sometimes in the background, directing the call taker on what to ask or to advise.

F2 [doctor] answers, Nurse in charge comes and stands behind. Consultant and more senior reg also there—unintentional overdose of codeine. The consultant circles GCS [Glasgow Coma Scale] on the form to indicate what to ask. Consultant says he can go to [usual ED entrance]. (Site F TU Obs 2)

If it’s really busy, junior doctor or junior sister/staff nurse will answer but they sometimes will forget to ask something even though it’s on the sheet so I think that’s why it is quite important that it is a senior member of the team or, say if I’m present, at least I’m stood next to them to kind of prompt them ’ (ED3, senior nurse)

Processes for documenting, managing and sharing pre-alert information varied. Observations and interviews identified the potential for this to result in clinicians being unaware of pre-alerted patients and the inability to identify from case notes whether a patient was pre-alerted (see online supplemental table 4). Pre-alert information was communicated to staff within the ED verbally (bleep or face-to-face) or via written information taken to the receiving area but the information was not always consistently conveyed, particularly when patients were not brought into resus. Where processes for information flow following the pre-alert were less clear or where information flow was interrupted by other pressures, this could lead to pre-alerts not being communicated effectively, causing frustration for both ED and ambulance clinicians.

Some of our junior doctors, they’ll just take the call, they won’t tell the crew where to go. And sometimes what they haven’t done, or done in the past, is just left the form on my desk and not told me about it, and we’ve had crews rock up with an alert and I don’t know about them. (ED33, senior nurse)

Communication could be much better to make sure that everybody knows that an alert is coming in and because sometimes alerts arrive and nobody but the nurse in charge and the nurse in the area is expecting them. There are times when I don’t know anything about an alert and it will arrive in the department and or you’ll find that there’s an alert on an ambulance that we didn’t know about. (ED36, consultant)