An evaluation of a new prehospital pre-alert guidance tool

An evaluation of a new prehospital pre-alert guidance tool

Emerg Med J 2013;30:820-823

Background The requirement for guidance regarding ambulance crews pre-alerting patients into hospital emergency departments (ED) has been well established, but a clear guidance tool that supports a decision to pre-alert a receiving hospital is lacking.

Aims To investigate the impact of a new pre-alert tool on current alerting practice and evaluate its ability to take the place of a pre-hospital early warning system. The study evaluated a newly introduced pre-alert guidance tool which was developed in conjunction with the JRCALC guidelines.

Methods Data were collected for a sample of patients brought by ambulance to the resuscitation area of Aberdeen Royal Infirmary ED over a 7-week period. Basic demographic information plus alert status and guidance prompt status was collected and compared with a pragmatic alert requirement. Analysis of ambulance crew alert decisions and the pre-alert guidance prompt advice was undertaken and compared.

Results Ambulance crew decisions to alert had a sensitivity of 72% (CI 62% to 80%), specificity of 50% (CI 27% to 73%), positive predictive value (PPV) of 90% and negative predictive value (NPV) of 22%. The pre-alert guidance alert prompt had a sensitivity of 99% (CI 94% to 100%), specificity of 64% (CI 39% to 84%), PPV of 95% and NPV of 90%. 28% of patients were under-alerted by ambulance crews, mostly medical patients presenting with chest pain.

Conclusions The pre-alert guidance tool shows face validity and superior ability to advise a pre-alert than ambulance crew decisions. It supplements a practitioners’ clinical decision-making and has been regarded as having a positive impact on ED triage and utilisation of resources. It proved to have superior sensitivity and specificity to that of ambulance crew decisions; the latter having a significant level of under-alerts.  However, these values were considerably less than those in the literature, suggesting the tool may have prompted an increased number of appropriate alerts by the ambulance crews involved. The findings support the use and development of such a tool that complements the autonomous decision -making skills of ambulance crews in the present pre-hospital environment. The core strengths of the tool are its simple structure and no requirement for calculations to be done. One major predicted weakness of the tool was that it may have prompted many over-alerts in order to eliminate any under-alerts, but this was not found to be the case. Further levels of validity are expected to be achieved with continued audit and ongoing use of this tool.

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