Objectives Pre-hospital notifications (pre-alerts) enable Emergency Department (ED) staff to prepare for the arrival of patients requiring a time-critical response. Effective communication of the pre-alert is key to enabling the ED to prepare appropriately but evidence on communication practices is lacking. We undertook qualitative research to understand how pre-alert communication may be improved to optimise the ED response for pre-alerted patients.

Design, setting and participants Data collection took place within three UK Ambulance Services and six EDs between August 2022-April 2023. We undertook semi-structured interviews with 34 ambulance and 40 ED staff and 156 hours non-participation observation of pre-alert practice (143 pre-alerts). Verbatim interview transcripts and observation notes were imported into NVivo™ and analysed using a thematic approach.

Results We identified significant variation in how pre-alerts were communicated that influenced how effectively information was transferred. Ambulance and ED staff demonstrated a shared recognition that pre-alerts need to be communicated concisely, but both received minimal training in how to give and receive pre-alerts. Efficient pre-alerting was influenced by clinician experience and seniority. ED and ambulance clinicians following different information sharing formats (e.g. ATMIST, SBAR) sometimes led to interruptions, information loss and tensions, particularly when an early ‘headline’ clinical concern had not been shared. Ambulance clinicians sometimes questioned the appropriateness of their pre-alert when ED clinicians did not explain the rationale for not giving the expected response (i.e. being accepted into a high-priority area of ED). Additional sources of frustration included technological problems and poor communication of ETA and caller/responder identities.

Conclusions Use of shared format including a headline ‘cause for concern’ may improve the clarity, usefulness and civility of pre-alerts, particularly when the clinician concern is not obvious from observations. Basic training on how to undertake pre-alerts for both ED and ambulance clinicians may improve understanding of the importance of pre-alert communication.

Strengths and limitations of the study

This study triangulated findings from Emergency Department staff and Ambulance Clinicians from across three Ambulance Service regions in England to provide insights into the causes of incivility relating to pre-alert communications.

Semi-structured interviews and non-participant observation provide rich data regarding the experiences and practice of undertaking pre-alerts.

Fieldwork took place within larger Emergency Departments (major trauma centres and trauma units) rather than minor units where pre-alerts occur less frequently and may be managed differently.

The setting included only ambulance services where ambulance clinicians principally call directly to the ED, limiting transferability of findings for ambulance services who call via a control centre.

Non-participant observation was undertaken in Emergency Departments but not within Ambulance Services due to the small number of pre-alerts occurring per shift.

The authors have declared no competing interest.

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.

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:

Ethical approval for the pre-alerts project has been obtained from Newcastle & North Tyneside 2 Research Ethics Committee (Ref: 21/NE/0132).

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

r.oharasheffield.ac.uk

jaqui.longsheffield.ac.uk

j.e.costersheffield.ac.uk

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.

Ethical considerations: Ethical approval for the pre-alerts project has been obtained from Newcastle & North Tyneside 2 Research Ethics Committee (Ref: 21/NE/0132). Participants provided informed consent.

Competing interests: None declared.

Data Sharing 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.

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.