The article by Curtis et al. (2021) reports on a quasi-experimental study that evaluated the impact of implementing a standardized emergency nursing assessment framework called HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication, and reassessment) on patient safety in the emergency department. Curtis et al. (2021) begin by providing substantial background on the importance of timely recognition and management of deteriorating patients in emergency care as a fundamental priority for healthcare quality and safety. They highlight through multiple sources that emergency nurses have an exceedingly crucial role in accurate assessment, interpretation, intervention, and escalation when caring for undifferentiated patients across a broad spectrum of acuity in the chaotic emergency environment. However, they note that approaches to nursing assessment vary widely across nurses and departments and contribute to unwarranted variation, delays in treatment initiation and provision, and avoidable patient clinical deterioration. This often occurs in the emergency department but also following discharge, leading to adverse events.
HIRAID was developed as an evidence-based structured framework following a rigorous process to enable emergency nurses to systematically assess, manage, and communicate about patients. It incorporates a focused primary survey aligned with the reliability of clinical data to recognize deterioration risk. This is in contrast to traditional approaches to nursing assessment, such as body systems that are not evidence-based or framed around patient safety. Previous simulation research found HIRAID substantially improved nurses’ prioritization, treatment initiation, and handover quality. However, simulation studies have limited generalizability. Therefore, this study aimed to generate real-world clinical evidence by evaluating HIRAID’s impact on patient safety under normal emergency department conditions using a robust quasi-experimental pre-post design. The setting was two medium-sized emergency departments in regional New South Wales, Australia, which transfer higher acuity patients to metropolitan tertiary hospitals. The participating emergency departments treat between 65,000 and 13,000 patients annually and employ between 110 and 2 nurses, respectively. HIRAID was implemented over 12 months using a multi-pronged behavior change strategy informed by barriers assessment at each site to maximize uptake. This included e-learning, workshops, integration into orientation, mandated documentation audits, visual cues, videos, and the required use of a HIRAID-based assessment template. Data were collected on 920 patients who deteriorated within 72 hours of emergency admission – 374 pre-implementation and 546 post-implementation.
Key results showed that patients in the post-HIRAID group had significantly more comorbidities yet experienced markedly fewer episodes of deterioration related to emergency care (27% pre vs. 13% post). Specific statistically significant reductions occurred in treatment delays, failure to escalate clinical abnormalities, and nursing-specific factors as causes of deterioration. Time to deterioration decreased notably from 19.5 to 11 hours. Curtis et al. (2021) conclude that implementing a standardized nursing assessment framework like HIRAID is strongly associated with substantially reduced clinical deterioration related to emergency care through enhanced recognition, timely nursing intervention, and appropriate escalation. They recommend broader implementation and evaluation across health systems.
This article presents robust quasi-experimental research that implemented and evaluated an evidence-based nursing assessment framework in the emergency department. The use of HIRAID was associated with measurable and clinically essential improvements in crucial patient safety outcomes and the quality of emergency nursing care. The study provides compelling evidence underscoring the vital importance of equipping nurses with structured tools and processes to maximize early identification and mitigation of patient deterioration. The setting was two emergency departments in regional Australia. HIRAID was implemented over 12 months using a multi-pronged behavior change strategy informed by barriers assessment at each site. This tailored approach included diverse components such as e-learning modules, hands-on workshops, integration into nursing orientation programs, mandated documentation audits with feedback, visual cues placed in the workplace, brief educational videos, and the required use of a HIRAID-based assessment template. These strategies were designed to address the complex, chaotic emergency environment and gain buy-in across all levels of staff. Substantial effort went into the implementation planning to ensure HIRAID would be successfully adopted into routine practice.
Data were collected on a sizable sample of 920 patients who deteriorated within 72 hours of emergency admission – 374 in the 12-month pre-implementation period and 546 in the 12-month post-implementation period. Patients were identified through a review of organizational databases for triggers such as rapid response calls and unplanned ICU transfers. Three experienced external auditors abstracted detailed data from the medical records on patient characteristics, deterioration event details, and factors potentially contributing to the deterioration. This provided robust, objective data. The Human Factors Classification Framework was used to categorize contributing factors and errors, enabling rigorous assignment of causality related to emergency care versus other issues. Key results showed patients in the post-HIRAID group had significantly more comorbidities, indicating higher complexity, yet experienced markedly fewer episodes of deterioration related to emergency care (27% pre vs. 13% post). The proportion of deteriorations attributable to emergency care decreased by half. Specific statistically significant reductions occurred in treatment delays, failure to escalate clinical abnormalities, and nursing-specific factors as causes of deterioration. The median time from emergency department discharge to deterioration decreased notably from 19.5 to 11 hours, indicating quicker identification of problems after HIRAID implementation.
Curtis et al. (2021) thoughtfully acknowledge limitations, including the pre-post design, which has inherent risks of confounding variables changing over time. However, they took steps to mitigate this by confirming that no other significant interventions occurred during the study period. The single-site regional setting may limit generalizability. Regardless, this study offers robust real-world evidence that implementing a thoughtfully designed, evidence-based nursing assessment framework like HIRAID is strongly associated with substantially reduced clinical deterioration related to emergency care through enhanced recognition, timely nursing intervention, and appropriate escalation. Based on these clinically meaningful results, the authors strongly recommend broader HIRAID implementation and evaluation across health systems, locally and globally, to continue improving emergency nursing practice and patient outcomes.
In summary, this article presents rigorous, well-designed quasi-experimental research that implemented and evaluated an evidence-based nursing assessment framework in the high-risk emergency department setting. The study followed gold-standard methods, including a tailored, multi-modal implementation strategy, valid data collection processes, and appropriate statistical analyses. The use of HIRAID was associated with measurable and clinically essential improvements in crucial patient safety outcomes and the quality of emergency nursing care. This adds to the body of evidence underscoring the vital importance of equipping nurses with structured tools and processes to maximize early identification and mitigation of patient deterioration. Overall, this study provides compelling evidence to spur continued optimization of emergency nursing practice through frameworks like HIRAID to improve patient care quality, safety, and outcomes.
Reference
Curtis, K., Munroe, B., Fry, M., Considine, J., Tuala, E., Watts, M., … & Shaban, R. Z. (2021). The implementation of an emergency nursing framework (HIRAID) reduces patient deterioration: A multi-center quasi-experimental study. International emergency nursing, 56, 100976.
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