1641 responses to the survey were received and 343 were excluded. Reasons for exclusion were: missing data, n=298; responses from private providers n=18; responses from devolved countries n=27. This left 1298 complete responses from English ambulance services included in the analysis.

Table 2 reports respondent characteristics, and online supplemental table 1 describes respondent characteristics by service. Response rates varied by service. Two services (4 and 6) did not have capacity to promote the survey internally resulting in a lower response. Over 50% of the sample were paramedics, with a further 14% being specialist or senior paramedics. Almost half (45%) had over 6 years in their role. Most respondents were white males 56.5% (n=734), or white females 36.5% (n=473), which reflects the NHS workforce survey ethnicity profile.13

Respondent and workforce characteristics

Table 2 reports reasons for making a pre-alert call and factors impacting these decisions. Online supplemental tables 2 and 3 report pre-alert practice by ambulance service and clinician’s reasons for making pre-alert calls. Clinicians mostly reported making pre-alert calls to inform the ED of a deteriorating patient or to make space in the resuscitation. Phoning for advice about where to take the patient was the least common, though in some services, over a third of staff always used pre-alerts for advice. Text comments identified other reasons for pre-alerts: informing receiving hospital of additional needs, for example, translation services, mental health, infectious patient; to comply with protocols; requesting specialists; warning of violent or difficult patients; ambulance clinicians also pre-alerted when patients were too sick to queue but did not require resuscitation.

The patient doesn't need resus but cannot be at the back of an 11 patient queue in the corridor. They need rapid assessment and triage, though not necessarily rapid treatment in resus (Paramedic, 2 – 5 years’ experience Service 1)

The survey asked which sources of guidance do you use to help you decide whether to make a pre-alert (Q4), and identified a range of guidance sources (table 3). Local ambulance trust guidance was identified as most used and this was consistent across different types of ambulance clinicians. There was variation in the use of the national AACE/RCEM guidance8; overall analysis showed a fifth of ambulance clinicians never using this guidance; however, this ranged by ambulance service from 3.9% to 29.2%. Text comments identified differences in the pre-alert guidance and thresholds used by ambulance clinicians and those used by the ED, which sometimes led to EDs seemingly rejecting or responding dismissively to a pre-alert which met local or national ambulance pre-alert guidance.

Types of patients where further guidance would be welcomed, by job role type

It’s infuriating when following specific guidance which dictates pre-alert but finding ED essentially not taking it seriously on your arrival (Paramedic > 10 years experience Service 5)

One of the biggest challenges is ambulance services and hospitals having differing views/policies on what would warrant a pre alert. There needs to be a clear, consistent criteria that both ambulance staff and hospitals follow. Sometimes, I am met by a poor attitude from staff in ED due to them thinking an alert is unnecessary even though it is within my guidance to make the alert. (Paramedic < 2 years experience Service 2)

I have found one of my local hospitals have staff who have different expectations about which patients we should pre-alert. We have pre-alerted a patient in Fast [Atrial Fibrillation] with a rate of 160 and been told by a consultant that he wasn't bothered if it wasn't over twice their age and then on another occasion I did not pre-alert a patient who was in AF with a rate of 110 and was treated as though I should have pre-alerted her. There should be more consistency in the staff in the hospitals. (Paramedic <2 years Service 9)

JRCALC [Joint Royal Colleges Ambulance Liaison Committee] guidelines are good and I try to follow these where possible. However I have had to learn that certain hospitals want pre alerts for other things that I have just had to figure out as I go along. (Paramedic < 2 years experience Service 5)

Table 4 also shows variation in pre-alert practice for clinical pathways where there is clear national guidance around making a pre-alert. Three quarters of clinicians reported always pre-alerting cardiac/respiratory arrest compared with under a quarter stating they alert for patients with tachycardia of ≥131 and respiratory rate of ≥25.8 Variation was identified in relation to pre-alert decision-making where there was no condition specific clinical pathway (table 4). Hospital destination had the most impact on pre-alert decision-making for all staff groups. Approaching end of shift was considered to have the least impact on pre-alert decision-making.

Reasons for making a pre-alert call and factors impacting on pre-alert decisions

Text comments identified that pre-alert decisions were multifactorial and were also dependent on the requirements and varying guidance of local EDs.

Every ED seems to be different and there is a huge variation even between staff within the same ED to pre-alerted patients, which makes it seem like whatever you do/don't pre-alert, you are invariably in the wrong (according to them). I also think it is difficult with conditions such as sepsis, where if you follow the trust policy and pre-alert, you will get eye-rolled and no bed/quicker treatment/response for the patient, so it almost feels embarrassing doing the pre-alert but then it feels like there’s the risk of getting into ‘trouble’ from the ambulance trust if you don't stick to the policy they have written. (Paramedic > 10 years experience Service 10)

The challenge is not just the pre-alert process but also navigating which types of patients which hospitals want pre-alerted or not. For instance, in my area, one hospital has a fractured NOF pathway and want a pre-alert, but the other hospital doesn't, so don't want a pre-alert for fractured NOF patients. The local Tus [trauma units] will often tell you that you should take a trauma patient to an MTC [Major Trauma Centre] during the pre-alert call, despite the patient not meeting the local decision-tree criteria for MTC (Specialist paramedic 2- 5 years experience Service 7)

Survey question 7 asked ambulance clinicians whether they would find additional guidance useful and in what areas. Respondents indicated that in most areas, more guidance would be well received, particularly in older person trauma (65% would like more guidance); in medical pre-alerts 57% would like more guidance. table 3 reports these results by staff type.

The survey asked ambulance clinicians what they would do if they were unsure about whether to make a pre-alert call. Over half stated they would make the pre-alert call anyway, with another quarter stating they would call the pre-alert phone to discuss with the ED (table 4). Text responses identified a practice of making ‘courtesy calls’ or ‘heads up’ calls.

Either make a "courtesy call" to the pre alert phone to give them a heads up you’re coming, this [patient] could deteriorate but also could be absolutely fine, so when you turn up it’s not a massive surprise if they're on the edge of deteriorating (Paramedic 6 – 10 years experience Service 8)

Online supplemental table 2 reports pre-alert practice by ambulance service and shows that over 80% of respondents reported making a pre-alert either frequently, often or once or twice a week (1061/1298) (online supplemental table 2). However, free-text responses showed that this was difficult to quantify due to the variability of patients seen.

Very much pot luck. You can have a run of shifts where every other job is a pre alert and others where you do none. (EMT, > 10 years experience Service 2)

Variation in how pre-alert calls came through to the ED was mostly service based. In over half of services (54.8%; 711/1298) common practice was for the ambulance clinician on scene to make the call to the ED, whereas in some other services standard practice was for the ambulance clinician on scene to phone through to the ambulance control desk, who would then call the ED pre-alert phone and pass on the information. Practice was sometimes different for medical and trauma calls.

The hardware for pre-alert calls also varied by service (online supplemental table 2). Ambulance radios were used infrequently in most services, with most calls made using personal mobile phones. Most respondents reported always recording the pre-alert in the patient notes and using a tick box plus free text; however, some variation by service was observed (online supplemental table 2).

Online supplemental table 2 also reports responses to questions 12 and 13, which asked ambulance clinicians how they learn to make a pre-alert and if they had ever received feedback on how they make pre-alert calls or decisions. Most respondents reported they had not received any specific training on how to make a pre-alert call (65.8%; 854/1298). Other, more informal training methods, were used, such as 59.2% (769/1298) reported learning from a mentor or senior colleague; 58.6% reported learning as they went along/on the job (761/1298); and 20.6% reported learning from written guidelines (267/1298). Most staff members (53.5% 695/1298) reported that they had never received feedback from either EDs or their ambulance service and this was consistent across most different services. Text comments highlighted the perceived usefulness of feedback, but cautioned that feedback was very negative for a perceived wrong pre-alert decision.

I was questioned by a clinician receiving the pre-alert on why I was pre-alerting a patient into hospital, despite a genuine clinical concern from ourselves for the patient. The person on the phone stated she thought it was an inappropriate pre-alert. (Student paramedic, 2 – 5 years experience Service 2)

As a graduate paramedic I received helpful feedback on every pre-alert I made as a student but I have received no feedback as a qualified paramedic. (Paramedic, 2 – 5 years experience Service 8)

The majority of the time I worry about pre-alerting too much and then worry about making pre-alert calls for pts I am unsure about. A feedback system would be greatly appreciated, as I have never received formal feedback from a hospital. I tend to base my pre-alert decisions on my own clinical judgement (need, observations, intervention, overall clinical picture, ongoing care, formal pathways etc.) in the hopes that this is appropriate. (Paramedic < 2 years experience Service 7)

I feel that the JRCALC guidance suggests a pre-alert for too many conditions, some staff follow this guidance. I know that at our local hospital, ED staff ask which trust you are from before deciding whether to action the pre-alert or not. (Paramedic 2 – 5 years experience Service 3)

9% of ambulance clinicians felt that ED clinicians always listen and take the call seriously, always listen without interrupting and always make appropriate arrangements in the ED. There was little variation by role reported; however, student paramedics reported experiencing more interruptions on calls, while senior paramedics had the highest ratings for being listened to and taking the call seriously (see online supplemental table 4).

Often interrupted or questioned about my decision to pre-alert which takes time away from patient care. (Paramedic, 2 – 5 years experience Service 7)

ED staff often interrupt and do not fully listen and can sound dismissive. (Paramedic, > 10 years experience Service 10)

ED staff often lack insight into the fact we have very little bandwidth for the pre-alert. Often a paramedic is managing an acutely unwell patient and ED staff forget this. ED staff often interrupt and ask questions that can be better answered at handover or simple are not relevant at that time. (Paramedic, 6 – 10 years experience Service 2)

The seniority of the staff member who picks up the phone seems directly linked to how much they interrupt the pre-alert, i.e. a doctor will often just listen, a nurse will interrupt to fit the information in the order they are running through the list their side, which may differ to how the handover is being given. It is easier to pre-alert to a member of hospital staff that you already know because they trust your clinical judgement, as opposed to someone who does not know you. (Paramedic 6 – 10 years experience Service 6)

Local hospital will always try to interrupt, they are not trained in how to take a pre-alert. (Paramedic >10 years experience Service 9)

The format of the verbal communication with the ED varied overall and also by staff type. A third of ambulance clinicians reported always using a fixed format (35.7%; 464/1298); however, 1 in 10 reported always providing observations but not following a fixed format (10.2%; 133/1298). Specialist/senior paramedics had less agreement for using a fixed format and more agreement for using the format that the receiving ED uses and providing observations but not following a fixed format.

We serve several hospital[s] in my area - each hospital appears to have different pre-alert rules - this would determine which hospital receives a pre alert or not – (Paramedic, > 10 years experience Service 1)

We have a particular hospital that is notorious for not taking pre-alerts seriously. Last week I pre-alerted a patient with a NEWS 2 of 13 - red flag sepsis & reduced GCS. We had a travel time of 20 minutes yet the p/t was not placed into resus because ‘there are no nurses to watch him’ No doctor had been informed & the p/t placed onto a normal handover bed in ED where he deteriorated & was moved into resus 20 minutes after we arrived. (Paramedic, >10 years experience Service 3)

The destination is a key decision maker, some hospitals are better than others when taking pre alerts, some turn into a lengthy unnecessary conversation. As well the level of incivility experienced over the phone and on handover influence a decision to pre alert or not. (Specialist paramedic, < 2 years experience Service 1)