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Doctors and nurse wheeling patient on stretcher in hospital's corridor.
Research_

Project HIRAID

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.

A flow chart displaying the steps within the HIRAID process.

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.

Download a list of our publications (pdf, 170KB)

Our team

Led by Professor Kate Curtis, Professor of Trauma and Emergency Nursing, and project managed by PhD candidate Belinda Kennedy, the HIRAID team has an impressive track record of implementing widespread change to improve patient and health service outcomes and have worked productively together in the field for over 10 years.

  • Professor Kate Curtis
    Lead Investigator, University of Sydney
  • Professor Margaret Fry
    Chief Investigator, UTS
  • Professor Julie Considine
    Chief Investigator, Deakin University and Principal Investigator Eastern Health
  • Professor Ramon Shaban
    Chief Investigator, University of Sydney and Principal Investigator WSLHD
  • Dr Hatem Alkhouri
    Chief Investigator
  • Professor Steven McPhail
    Chief Investigator, QUT
  • Clinical Associate Professor Michael Dinh
    Chief Investigator, University of Sydney
  • Associate Professor Christina Aggar
    Chief Investigator, SCU and Principal Investigator, NNSWLHD
  • Dr James Hughes
    Chief Investigator, QUT and Principal Investigator, Metro North Health Royal Brisbane & Women’s Hospital
  • Dr Margaret Murphy
    Chief Investigator and Principal Investigator, WSLHD
  • Professor Donna Waters
  • Dr Sarah Kourouche
  • Dr Mary Lam 
  • Adjunct Associate Professor Alfa D’Amato, NSW Health
  • Dr Heather Buchan, Australian Commission on Safety and Quality in Health Care
  • Alison McMillan, Commonwealth Department of Health
  • Marghie Murgho, Australian Commission on Safety and Quality in Health Care
  • Adjunct Professor (Practice) Alison McMillan
    Chief Nursing and Midwifery Officer, Commonwealth Department of Health
  • Associate Professor Christina Aggar
    Nursing Research Academic, Northern NSW LHD
  • Professor Donna Waters 
    Professor of Nursing, University of Sydney
  • George Reid
    Philanthropist, Jean Thyne Reid Foundation
  • Dr Hatem Alkhouri
    Research Fellow, Emergency Care Institute
  • Dr Heather Buchan
    Senior Medical Advisor, Australian Commission on Safety and Quality in Health Care
  • Dr James Hughes
    Lecturer, QUT School of Nursing
  • Associate Professor Julia Morphet
    President, College of Emergency Nursing Australasia (CENA)
  • Professor Julie Considine
    Chair in Nursing Eastern Health
  • Adjunct Professor Kylie Ward
    Chief Executive Officer, Australian College of Nursing (ACN)
  • Professor Margaret Fry
    Director Research and Practice Development Nursing and Midwifery Directorate, Northern Sydney Local Health District
  • Dr Margaret Murphy
    Clinical Nurse Consultant and Researcher, Western Sydney LHD
  • Marghie Murgho
    Senior Nursing Advisor, Australian Commission on Safety and Quality in Health Care
  • Clinical Associate Professor Michael Dinh
    Clinical Director, NSW Institute of Trauma and Injury Services
  • Professor Ramon Shaban
    Clinical Chair of Infection Prevention and Disease Control, Western Sydney LHD
  • Professor Steven McPhail
    Director of the Australia Centre for Health Services Innovation, Queensland University of Technology
  • Dr Trevor Chan
    Clinical Director, Emergency Care Institute

To effectively influence practice and policy, we've built partnerships with health care policymakers including:

  • NSW Emergency Care Institute (ECI)
  • Australian Commission on Quality and Safety in Health Care (ACSQHC)
  • Chief Nurse and Midwifery Officer of Australia
  • Australian Council of Deans of Nursing and Midwifery
  • Australian College of Nursing
  • College of Emergency Nursing Australasia (CENA)
  • Jean Thyne Reid Foundation - philanthropy partner

HIRAID works also with health districts of Northern NSW, Southern NSW, Western Sydney, Metro-North Qld and Eastern Health Victoria.

HIRAID has been implemented across Illawarra Shoalhaven Local Health District and Southern NSW Local Health District.

It has also been rolled out across Northern NSW Local health District and Western Sydney Local health  District will follow late 2022.

Queensland and Victoria participating sites will initiate implementation late 2022/early 2023.