Pre-Alert

A pre-alert aims to forewarn a hospital of a critical patients arrival with pertinent information. Before leaving a scene, the pre-hospital practitioner will aim to share relevant information including if a patient is intubated. The pre-alert was a key outcome of the NCEPOD 2007 report, Trauma: Who cares?

Ambulance trusts and emergency departments should have clear guidelines for the use of pre-alerts in the severely injured patient population to ensure an appropriate clinical response is available immediately. (NCEPOD, 2007).

There have been significant system improvements since the NCEPOD report including establishing major trauma networks in the UK since 2012. In 2016, NICE guideline 40 updated the parameters for major trauma service delivery, which included that standard for a trauma pre-alert. The minimum data recommended is;

1. ATMIST
2. Crew call sign
3. Estimated time of arrival
4. Any special requirements such as cardiac bypass. 

For medical patients there is good evidence that a pre-alert for patients improves clinical outcomes by ensuring timely clinical care on arrival. Work in 2020 from Manchester has shown that by refining the pre-alert process the door to scan time was significantly reduced. This work highlights the importance of accurate triage decision, pre-alerts and refinement of processes locally.

A pre-alert aims to include all the relevant information to ensure the receiving hospital is best prepared. Due to clinical need or equipment limitations the expected information may not be possible for every case, for example an AVPU is an acceptable alternative to GCS. The use of pre-agreed structure allows both the caller and receiver to know what information to give and what order to expect the information. ATMIST (UK standard) or ASHICE are the common handover structures.

Use of a proforma for the call receiver aims to enhance bandwidth, prevent missed information and allows dissemination of information to the wider team. This step helps enhance the shared mental model and primes the handover. Below is an example, blue pre-hospital pre-alert proforma and the red hospital pre-alert form.

_{(Images Courtesy of Dr D Maxwell)}

A pre-alert should come to an agreed single point, either a standby phone or radio. It is important to note that this call may be made by a call handler or clinician not present at the scene which will limit additional information.

Learning bite

• Pre-alert should be expected for all critically unwell patients.
• The ATMIST is the standard pre-alert tool in the UK.
• When you are next at work find out what structure your current hospital uses. But ask yourself critically does it give you all the information you need as the receiving unit? If not consider developing your local tool.