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.

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.

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.

10:57 - Consultant passing info [about pre-alert] to nurse and doctor waiting by pre-alert phone—patient is on their way. Conversations between various members of staff. Equipment and trolleys moved so there is room for people. Ultrasound wheeled over.

11:04 - Consultant pushing screens back for more space. Staff put on their role labels. More info is added to the board. Call going out to the trauma team and cardiothoracic. Sister checking notification has gone.

11:08 - People start arriving—major trauma consultant, radiographer, others, discussing plan of action. Five staff in the bay, another five by reception.

11:14 - Formal briefing. Now 17 staff in the area waiting. Going through basics, what needs doing, by who. Consultant asks if there are any questions. Checking the neurosurgeon, agree to call once the patient is here. People discussing roles. Consultant is discussing treatment plan. People asked to sign in on the checklist.

11:24 - Patient arrives.

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.