Project HIRAID

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.

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

• 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.