Research_
HIRAID™ Nursing Framework
Improving the safety and quality of emergency nursing care
HIRAID™ is the only validated framework designed to support emergency nurses in assessing and managing emergency department patients after triage. It combines all essential elements in delivery of safe, quality nursing care.
Why nurses need HIRAID™
The complexity, uncertainty and sometimes urgency surrounding Emergency nursing practice requires a structured approach.
When a patient first presents to the emergency department (ED), the triage nurse performs a brief assessment and allocates a triage category based on their clinical urgency.
Following triage, the allocated nurse must perform a more comprehensive assessment and commence nursing care. Previously there was no standardised validated structure to guide emergency nursing assessment and care post triage.
This has led unwarranted variation in nursing care, avoidable patient deterioration, poor pain management, poor nursing documentation, human suffering and patient dissatisfaction with emergency care.
HIRAID™ adddresses thse issues by providing emergency nurses with an evidence-based structured approach to emergency nursing care post triage.
The framework improves:
- emergency nursing assessment
- recognition and escalation of clinical deterioration
- pain management
- patient experience
- and clinical handover.
HIRAID™ was developed with experts, designed on research evidence and validated in both the simulated and clinical settings with 302 Emergency nurses in regional NSW.
The framework has been successfully piloted with nurses across rural, regional and metropolitan EDs, and is used routinely in Illawarra Shoalhaven and Southern NSW LHDs. The team has published 10 related publications in high impact scientific journals to date and currently supports one PhD candidate with a focus on implementation.
HIRAID™ has also been awarded the Clinical Excellence and Patient Safety Award for safer, better emergency nursing care. It has been touted as: "A proven, up-scalable emergency nursing framework aimed at ensuring Emergency nurses have an evidence base to their initial assessment and management of patients who enter Emergency."
Watch the submission video here.
The HIRAID™ process (click to open larger version).
History, Identify Red flags, Assessment, Interventions, Diagnostics.
The framework encapsulates the cyclic nature of patient assessment, in which more than one element may be performed simultaneously. It also embraces the importance of reassessment and communication – vital components of emergency nursing.
- History: the process of collecting details about why the patient has presented and relevant background information about the patient. Infection Risk: nested within history, and refers to the patient’s risk of infection or suspected/confirmed communicable disease, including precautions required.
- Identify Red flags: historical or physiological indicators of urgency that identify potential or actual threat to life or limb, highlighting the need for timely escalation of care.
- Assessment: comprehensive physical examination, prioritised to ensure life threatening conditions are identified first, followed by focused assessment guided by the presenting problem.
- Interventions: the delivery of appropriate and prioritised interventions based on historical and physical assessment findings.
- Diagnostics: the ordering, performing and reviewing of further investigations including pathology and diagnostic imaging.
Other elements within the HIRAID framework:
Reassess: The evaluation of care and monitoring of patient progress. Maintain a structured approach, repeat at appropriate intervals per condition of the patient.
Communicate: Verbal/non-verbal skills necessary to effectively communicate with patients, families and clinicians. Use structured approach for clinical handover; graded assertiveness to escalate if needed; accurate and comprehensive clinical documentation.
There are three significant outcomes associated with HIRAID™ determined using robust data collection and analyses.
1. 50% reduction in patient deterioration associated with care delivered in the ED [27% to 13%].
This is despite 12,000 more ED presentations, a 6.3% higher admission rate and sicker patients in the HIRAID™ intervention period.
Per the well validated Human Factors Classification Framework for patient safety the use of HIRAID™ resulted in fewer treatment delays (28.28% vs 15.07%) and failure to escalate (20.20% vs 6.85%).
2. HIRAID™ equivalent savings exceed the costs of implementation.
The estimated preliminary savings to ISLHD (through less deterioration) was $1,914,252 with a payback period of 75 days. Conservative projections estimated a net benefit of $1,813,760 pa by 2022-23, even when controlling for LOS, diagnosis and age.
3. Nursing documentation describing all essential assessment components increased from 5% to 80% in a random audit of 120 random paediatric and adult medical records for all presentation types.
In particular the quantity (completeness) and quality (completeness and linguistic correctness) of patient history and physical assessment per the validated D-Catch instrument.
- Curtis K, Hoy S, Murphy M, et al. The emergency nursing assessment process: A structured framework for a systematic approach. Australasian Emergency Nursing Journal 2009;12(4):130-36.
- Munroe B, Curtis K, Considine J, et al. The impact structured patient assessment frameworks have
on patient care: an integrative review. Journal of Clinical Nursing 2013;22(21-22):2991-3005.
- Munroe B, Curtis K, Murphy M, et al. HIRAID: an evidence-informed emergency nursing assessment
framework. Australasian Emergency Nursing Journal 2015;18(2):83-97.
Munroe B, Curtis K, Murphy M, et al. A structured framework improves clinical patient assessment and non-technical skills of early career emergency nurses: a pre-post study using full immersion simulation. Journal of Clinical Nursing 2016;25(15-16):2262 - 74.
- Munroe B, Buckley T, Curtis K, et al. The impact of HIRAID on emergency nurses’ self-efficacy,
anxiety and perceived control: A simulated study. International Emergency Nursing 2016;25:53-58.
- Munroe B, Curtis K, Buckley T, et al. Optimising implementation of a patient-assessment framework
for emergency nurses: A mixed-method study. Journal of Clinical Nursing 2018;27(1-2):e269-e86.
- Curtis K, Munroe B, Van C, et al. The implementation and usability of HIRAID, a structured approach
to emergency nursing assessment. Australasian Emergency Care 2020;23(1):62-70.
- Curtis K, Munroe B, Fry M, et al. The implementation of an emergency nursing framework (HIRAID)
reduces patient deterioration: A multi-centre quasi-experimental study. International Emergency
Nursing 2021;56:100976.
- Munroe B, Curtis K, Fry M, et al. Increasing accuracy in documentation through the application of a
structured emergency nursing framework: A multisite quasi-experimental study. Journal of Clinical
Nursing 2021;00:1-12.
- Curtis K, Sivabalan P, Bedford DS, et al. Implementation of a structured emergency nursing framework results in significant cost benefit. BMC Health Services Research 2021;21(1):1381.
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