Pre-alerts study

Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and Emergency Department staff.


Summary of research

Research Question

How are out-of-hospital pre-alert decisions made and communicated and what is the impact of these pre-alerts on receiving EDs and patients?


Ambulance Clinicians use pre-alert calls to inform receiving Emergency Departments (EDs) of the arrival of a critically unwell or rapidly deteriorating patient who they believe requires senior clinical review and time-critical treatment immediately upon arrival. By enabling EDs to prepare for the patient’s arrival, pre-alerts can lead to earlier initiation of time-critical treatment, improved processes and better clinical outcomes for patients (James et al, 2019, Kelleher et al, 2014). However, over- or inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill ED patients, which has important risks for patient safety. There is currently a lack of evidence about the impact of pre-alerts on patients, ED staff or ambulance clinicians. In particular, there is limited guidance about how pre-alerts should be undertaken, delivered and communicated with EDs, in order to optimise their use for patient benefit.  

Principal investigator (PI), Dr Fiona Sampson

Aims and objectives

This study aims to understand how pre-alert decisions are made and implemented by the pre-hospital staff, and the impact of these on receiving EDs and patients, in order to identify principles of good practice, areas of uncertainty and areas for improvement. 


  1. To map current pre-alert practice in terms of volume and types of pre-alerts and explore potential reasons for variation in practice by reviewing existing Ambulance Service patient records and mapping to local guidance. (WP1)

  2. To explore and understand pre-alert decision-making by undertaking semi-structured interviews with Ambulance Clinicians from three Ambulance Services and a national survey of Ambulance Clinicians to identify key areas of uncertainty where further guidance would be useful. (WP2)

  3. To identify how pre-alert decisions are communicated, and what information needs to be communicated in order to improve patient care, by interviewing pre-hospital and ED staff. (WP2 & 3)

  4. To understand how pre-alerts influence patient care in the ED, including potential benefits and unintended consequences, by observing pre-alert processes and responses to them within two EDs in each of the three Ambulance Service areas/regions. (WP3)

  5. To explore whether there are specific conditions or patient groups for whom pre-alerts are most likely to lead to action, or for whom action is unlikely to provide benefit, and explore factors that affect whether action is taken within the ED. (WP3)

  6. To understand the service user experience of pre-alerts by interviewing patients and/or carers. (WP4)

  7. To identify good pre-alert practice, areas where further guidance is needed and co-produce information to inform the development of pre-alert guidance with research participants and other key stakeholders. (WP5)


We will undertake a mixed methods study with five interrelated work packages.

We will map current existing policies and guidance from ambulance services to identify areas where guidance is unclear or inconsistent.

We will analyse 12 months’ ambulance routine data to understand how pre-alerts are currently being used and to identify any factors that may explain variation in pre-alert use.

We will explore how ambulance clinicians undertake pre-alerts by undertaking semi-structured interviews with up to 36 ambulance clinicians followed by a national survey of ambulance clinicians. This will help us to understand how pre-alerts are made, factors affecting decision-making and how they are communicated to ED, and the clinician experience of undertaking pre-alerts.

We will explore the impact of pre-alerts on the ED by undertaking observation of pre-alert calls and the ED response within 6 EDs, and use semi-structured interviews with ED staff to understand the impact of these calls on ED staff.

We will also undertake interviews with patients and their carers to understand the impact of pre-alerts on patients.

Finally, we will co-produce recommendations for improving pre-alert practice through a national feedback workshop including ED and ambulance staff and stakeholders and PPI.

Timelines for delivery

The project will take place over 29 months, including five months for the project setup and NHS ethics and research governance approval.

WP1: Mapping existing guidance and describing current pre-alert practice using routine data analysis will take place in months 6-13.

WP2 (exploring how Ambulance Clinicians undertake pre-alerts), WP3 (understanding the impact of pre-alerts on the ED) and WP4 (understanding the patient perspective of pre-alerts) will take place concurrently in months 12-23).

Data Analysis and integration of WPs 1-4 will take place from months 21-27, with WP5 (co-production of guidance) and dissemination of findings from months 27-29. 

Anticipated impact

We anticipate that the project will deliver pragmatic recommendations developed by ambulance and ED staff, incorporating views of the public and patients, to support effective delivery and receipt of pre-alerts.

We will share our findings with key professional organisations who are involved in developing guidance on the use of pre-alerts, and work to enable inclusion of pre-alert practice recommendations in training programmes for staff in the urgent and emergency care system.

We will disseminate via academic conferences and open-access journals, and disseminate professional and plain language summaries to professional organisations to enable them to make an evidence-based case for improvement to current practice.

Conference presentations

Sampson FC, Bell F, Webster P, Coster J, O’Hara R, Goodacre S et al.  Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and Emergency Department staff: protocol for a mixed methods study 999 EMS Research Forum 2022, online March 2022

Boyd A, Sampson FC, Bell F, Spaight R, Rosser A, Coster J, Millins M, Pilbery R. How should ambulance clinicians undertake pre-alerts? Review of UK ambulance service guidelines. College of Paramedics conference, Nottingham, UK. May 2023

Sampson F, Pilbery R, Herbert E, Long J, Coster J, Bell F. What factors influence prehospital decisions to pre-alert emergency departments of a potentially deteriorating patient’s arrival? International Conference for Emergency Medicine, June 2023, Amsterdam, Netherlands.

Boyd A, Sampson FC, Pilbery R, Bell F, Millins M, Coster J, Rosser A, Spaight R. When should ambulance clinicians undertake pre-alerts? Review of UK ambulance service guidelines. 999 EMS Research Forum June 2023, Manchester, UK. 
Long J, O’Hara R, Sampson FC, Coster J, Bell F, Webster P. How do pre-alerts influence patient care in the Emergency Department? Findings from qualitative research within three UK Ambulance Services. 999 EMS Research Forum June 2023, Manchester, UK. 

Sampson FC, Pilbery R, Herbert E, Bell F, Rosser R, Spaight R, Goodacre S, Pountney A, Millins M. What factors affect pre-hospital pre-alerts? Analysis of routine ambulance data. 999 EMS Research Forum June 2023, Manchester, UK.

Sampson FC, Coster J, Long J, O’Hara R, Bell F, Webster P, Pilbery R, Goodacre S, Foster A, Miles J, Millins M, Pountney A, Rosser A, Spaight R, Turner J, Boyd A. What is a pre-alert? Exploring ambulance and Emergency Department staff perspectives of the pre-alerts process. 999 EMS Research Forum June 2023, Manchester, UK

Important documents

Information sheets, consent forms and the protocol (downloadable) are available by clicking the respective links below.

Information sheet: ED Observations (Word, 71.4KB)

Information sheet: Staff (Word, 57.1KB)

Information sheet: Patients and carers (Word, 60.6KB)

(If you are a patient or carer who has been asked to take part in this research project, the participant information sheet is also available in video form).

Consent form: Patients and carers (Word, 66.8KB)

Consent form: Staff (Word, 65.6KB)

Prealerts protocol (Word, 96KB)

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