Bell, Fiona

Boyd, Aimee

Coster, Joanne

Millins, Mark

Pilbery, Richard

Rosser, Andy

Sampson, Fiona

Spaight, Robert

Ambulance Research Repository

Which patients should be pre-alerted?A review of UK ambulance service guidelinesThis project is funded by the National Institute for Health Research (NIHR HS&DR 131293). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Boyd A1, Sampson FC2, Pilbery R1, Bell F1, Millins M1, Coster J2, Rosser A3 , Spaight R41Yorkshire Ambulance Service NHS Trust, 2The University of Sheffield, 3West Midlands Ambulance Service University NHS Foundation Trust, 4East Midlands Ambulance Service NHS Trust Introduction• Pre-alert calls made by ambulance clinicians make the receiving emergency department (ED) of the imminent arrival of critically unwell or deteriorating patients.• Patient presentations requiring a pre-alert are varied, but may include abnormal physiology (e.g GCS) and time-critical presentations e.g acute stroke and STEMI• Over or inappropriate use of pre-alerts may lead to pre-alerts not being responded to appropriately, and diverts resources from critically unwell patients• We undertook an appraisal of ambulance service guidance on pre-alerts to explore how the guidance differs between services and national pre-alert guidance.Results• Responses from 15/19 Ambulance Services.• 2 services reported that they had no specific pre-alert guidance.• 1 service had policies regarding the process of pre-alerts only (No clinical conditions listed).• 2 services were unable to locate guidance relating to presentations requiring a pre-alert.• 1 service exclusively utilised the AACE/RCEM guidance.• Between 4-45 different conditions listed• Significant inconsistencies in the criteria for pre-alerts and the language and terminology used, even with known care pathways• Variation in physiological thresholds for pre-alerts.Implications• Variation in terminology could cause confusion for ED’s that receive pre-alerts from multiple ambulance service.• Differing pre-alert thresholds for pre-alerting can cause variations in care.• Policies should focus on clinical care, not processes.• Tools should complement policies to assist clinicians in the decision to make a pre-alert.Methods• Contacted all 19 UK ambulance services and asked for latest pre-alert guidance.• Summarised the clinical conditions, terminology and physiological thresholds listed by each ambulance service• Compared to RCEM/AACE guidelines (2021).RCEM/AACE East of England London North West South Central South Western West Midlands Yorkshire WelshConditions matched with RCEM/AACE Guidelines- 3/23 4/23 6/23 10/23 7/23 19/23 10/23 10/23Respiratory Rate <10 or >30 for adultsAbnormal breathing rate of irregular breathing pattern (e.g. Cheyne Stokes Breathing)<10 or ≥29 (for adults)≤8 or ≥25 ≤8 or ≥25Chest Pain ST elevation MIComplete heart block or broad complex tachycardia with adverse features (shock, syncope, heart failure, myocardial ischaemia)Current cardiac chest pain with abnormal ECG (e.g. heart block, BBB)STEMI, or Cardiac Chest pain where cardiac cause is suspectedSTEMI, or patients with signs of cardiogenic shockSTEMI or circulatory compromiseSTEMI or incomplete heart blockSTEMI ST Elevation indicative of an MI for early thrombolysis, or haemodynamically unstable with signs and symptoms of shock.Stroke FAST-positive stroke within timeframe for thrombolysisUse BE-FAST standardised frameworkAny new limb weakness, speech impairment, sudden change in behaviour, FAST +veNew stroke with symptom onset of no more than 4 hoursAcute stroke (FAST positive) including sub-arachnoid haemorrhageFAST positive strokeFAST positive and within time frame for thrombolysisFAST positive -Level of ConsciousnessUnconscious with a GCS motor score of less than 4- Reduced ACVPU GCS <8 P/U on ACVPU scale, or injured with GCS Motor Score <4GCS <14 Unconscious with GCS Motor Score <4Trauma patients with GCS <9 or fall of >2 since patient contact.Medical patients –unconscious* Table omits services with no conditions matching with AACE/RCEM guidance

Which patients should be pre-alerted? A review of UK ambulance service guidelines

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Which patients should be pre-alerted? A review of UK ambulance service guidelines

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