None listed
Conditions
Brief summary
Australia’s 287 emergency departments (EDs) see more than 8 million patients a year. Failure to assess, treat comprehensively and escalate appropriately can be catastrophic. Emergency nurses are the first clinicians with whom patients have contact, so patient safety is contingent on their accurate assessment, interpretation of clinical data, intervention and escalation. Particularly as across Australia in 2017-18, only 64% of urgent patients were seen by medical officers within 30mins of ED arrival and were solely in the care of emergency nurses during this time. Patient assessment and management by Australia’s 29,000+ emergency nurses is hospital dependent and inconsistent resulting in avoidable patient deterioration, poor pain management, poor nursing documentation, human suffering and patient dissatisfaction with emergency care. We propose a solution - HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment). HIRAID is the only validated framework designed to teach emergency nurses how to systematically assess and manage emergency patients. We have successfully piloted HIRAID across rural, regional EDs for usability. In the simulated environment HIRAID improved nurse assessment and communication. We now need a multi-centre RCT to generate the ultimate evidence for embedding of HIRAID into policy and practice. Over 5 years, our team of Australia’s leading emergency clinician, nurse and health economic researchers will use an effectiveness-implementation hybrid design including a step–wedge cluster RCT across 31 NSW and Qld hospitals. We hypothesise that when HIRAID is implemented there will be a 20% reduction in inpatient deterioration events related to emergency nursing care and an increase in patient/carers who report their ED experience as very good. Our partners have been engaged with this proposal since inception and represent several of the key agencies that deliver or support emergency care in Australia.
Interventions
The framework ‘History, Identify red flags, Assessment, Interventions, Diagnostics, communication and reassessment’ (HIRAID) is a mixed methods pre-intervention / post-intervention study aiming to evaluate the impact of the implementation of HIRAID. There will be four steps to test the study hypotheses during the five years we estimate it will take for the framework to be rolled out across all participating clusters/sites:
Step 1 - Behavioural Diagnostics and Baseline data: Short surveys will b
The framework ‘History, Identify red flags, Assessment, Interventions, Diagnostics, communication and reassessment’ (HIRAID) is a mixed methods pre-intervention / post-intervention study aiming to evaluate the impact of the implementation of HIRAID. There will be four steps to test the study hypotheses during the five years we estimate it will take for the framework to be rolled out across all participating clusters/sites: Step 1 - Behavioural Diagnostics and Baseline data: Short surveys will be distributed to all nursing staff to collect baseline data to inform implementation. Similarly, surveys for patient care experience, nursing communication and medical officer satisfaction with request for medical review, or handover, will be distributed during step 1. All of the pre-implementation surveys across participating sites will be managed via REDCap (Research Electronic Data Capture), and will take no longer than 15 minutes to complete. It is estimated that the baseline data collection and behavioural diagnostics will take around 12 months for each participating cluster/site. Step 2 - Implementation strategy development: Behavioural diagnostic data collected in step one will inform the implementation strategy for each participating cluster. The implementation strategy will be developed in consultation with end users, nurse educators and executive through and iterative process. It is estimated that the implementation strategy development will take approximately 6 months for each participating cluster/site. Step 3 - Implementation of HIRAID: A staged roll out of the HIRAID emergency nursing framework across participating clusters/sites will take place. Roll out will be undertaken using strategies identified as effective in other health districts and previous feasibility research and informed by baseline data as outlined in step 2. These strategies will be applied consistently to ensure implementation fidelity, this will be achieved through HIRAID nurse facilitators or clinical champions. The facilitators will be part of the existing workforce of each site and in a position where they will be able to facilitate the change as part of their roles, such as the site Clinical Nurse Educators (CNEs) and Clinical Nurse Consultants (CNCs), some of whom are study investigators. HIRAID Training: HIRAID education will be rolled out by the site Clinical Nurse Educators (CNEs) and Clinical Nurse Consultants (CNCs) following the ‘train the trainer’ education. The HIRAID education program will be integrated into the education calendar at each site by the CNEs and CNCs and will consist of the following elements: 1) An available participant workbook: to guide ED nurse educators to teach the HIRAID assessment framework as part of an interactive group workshop. 2) An e-learning module: a 20-30 minutes HIRAID-specific module already developed by the NSW Ministry of Health. 3) A short education face to face workshop (or online based on local context/circumstances): a 45-minute workshop to go through each component of the framework, to reflect on and discuss the role of the ED nurse in performing initial patient assessment; discuss the importance of a structured approach to initial nursing assessment in the ED; provide a brief overview of the HIRAID framework to another colleague; and understand what is expected of participants during the HIRAID workshop. The workshops across participating clusters/sites will use lecture, power point presentation, handout/poster/reference cards/practical examples and group discussions. 4) A 1-day train the trainer session to reflect on and discuss the role of the ED nurse in performing initial patient assessment; discuss the importance of a structured approach to initial nursing assessment in the ED; to understand the cyclic nature of the framework and how components may be performed singularly or simultaneously; to apply the HIRAID framework to preform/model structured patient assessments and to deliver short education on HIRAID to peers. Implementation Fidelity: Site HIRAID nurse facilitators or clinical champions will attend weekly implementation team meetings of an hour maximum, facilitated by the cluster/site nursing unit manager and asked about any implementation complications or adjustments. It is estimated that the actual implementation of HIRAID will take approximately 12-18 months for each participating cluster/site. Step 4 - Evaluation of HIRAID implementation and effectiveness: Surveys used in baseline data collection to assess patient/ carer satisfaction and medical officer satisfaction (step 1) will be repeated among similar populations and will evaluate the implementation strategies developed in step 2, from the end user perspective. These 15-minute surveys will contribute to the evaluation of implementation strategies and the dose of interventions, in conjunction with other data sources. To further explore the results of the intervention, 20–30-minute semi-structured interviews with emergency nurses will take place. It is estimated that the evaluation of HIRAID will take approximately 12-18 months for each participating cluster/site.
Sponsors
The University of Sydney
Study design
Allocation
Randomised controlled trial
Intervention model
Other
Primary purpose
Educational / counselling / training
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
There are six different populations, with key inclusion criteria for this study: Source 1: Patient’s with clinical deterioration in 72 hours - medical record review: - Rapid response equal or less than 72 hours post Emergency Department Discharge (EDD) - Rapid response call - Admitted via Emergency Department (includes admission to ward via interhospital transfer direct from ED within Southern NSW LHD) Source 2: Patient presenting to ED with painful conditions: Clinical records of patients meeting one or more of the study inclusion criteria, and no exclusion criteria, will be reviewed retrospectively. - Presented to ED and given a triage category 2, 3, 4 or 5; AND - Presented to the ED with chest pain, abdominal pain, hip or limb pain Source 3: Patient or carer: All patients presenting to the ED, meeting study inclusion criteria will be provided with a participant information sheet for the study. - Patient, or carer of a patient admitted to the ED during study period; - Patient/ carer over 18 years of age. Source 4: Staff surveys-nursing: All nursing staff permanently employed in the EDs/ MPS across each LHD, pre and post implementation, will be invited by their ED/MPS Manager, Medical Director or Research Nurse via email to participate. Source 5: Staff surveys-medical staff: All medical staff, employed on a regular basis, will be invited to complete a survey related to medical staff satisfaction related to clinical handover pre and post the intervention. Source 6: Nursing staff interviews: All nursing staff employed in the EDs/ MPS across each LHD, during the implementation period will be eligible to participate. Staff who complete the nursing survey post will have the opportunity to indicate their willingness to participate and provide contact details (phone and/ or email) to the researchers.
Exclusion criteria
There are six different populations for this study: Source 1: Patient’s with clinical deterioration in 72 hours - medical record review: Exclusion Criteria - ICU admission prior to call - Operation prior to call Source 2: Patient presenting to ED with painful conditions: - Triage category 1 - Patients receiving a team response in the ED e.g. trauma team response, stroke, etc Source 3: Patient or carer: - patient, or carers of patients, at end-of-life care; OR - triage category 1; OR - patients/ carers with cognitive impairment (eg. intoxication, dementia). Source 4: Staff surveys-nursing: Nil Source 5: Staff surveys-medical staff: Nil Source 6: Nursing staff interviews: Nil
Outcome results
None listed