The University of Sydney Page 1

Improving the safety and quality of emergency nursing care

HIRAID (emergency nursing framework)

The University of Sydney Page 2

340 nurses, 6 EDs, 27 authors, 6 Unis, 2 Agencies, a PhD & $217064

– Kate Curtis

– Margaret Murphy

– Sarah Hoy

– Melinda J. Lewis

– Belinda Munroe

– Julie Considine

– Thomas Buckley

– Luke Strachan

– Jennifer Hardy

– Judith Fethney

– Prabhu Sivabalan

– David S. Bedford

– Alfa D’Amato

– Nada Shepherd

– Lou Atkins

– Connie Van

– Tiana-Lee Elphick

– Margaret Fry

– Erin Tuala

– Michael Watts

– Hatem Alkhouri

– Kate Ruperto

– Jacquie Barrass

– Sharyn Balzer

– Bronwynne Chisholm

– Ramon Z Shaban

– Richard Morris

The University of Sydney Page 3

The case for change

– 2,880,287 patients, 186 EDs, xxx Nurses?

– Complexity, ambiguity and urgency of ED presentations

– 9500 reported adverse events in NSW EDs /year (CEC)

– 50% suboptimal ED nursing assessment, observations and monitoring and 71% of patients died.

– Consistency? Equity? Reliability?

– Standardised way to teach

The University of Sydney Page 4

Emergency nursing = HIRAID

– Beyond A-G

– Includes all known components that

influence patient outcomes, flexible

Cyclical

– Adaptable

– embed in eMR templates, orientation

– Foundational

– Magic wand?

– Enable good assessment / doc

© Curtis, Munroe, Murphy, Strachan, Lew is & Buckley 2016, adapted from Curtis et al, 2009

The University of Sydney Page 5

The evidence for HIRAID – Phase 1 – Evidence and Sim

– Evidence for components

– Increased nurse self efficacy, reduced anxiety (confidence, improved performance)

– Identify and escalate more redflags (critical indicators of urgency)

– Increased reassessment (including vital signs)

– Improved decision making and task management

– Graded assertiveness

– PhD, ECI, WSLHD, ISLHD

The University of Sydney Page 6

Diagnostics and Implementation in ISLHD

The University of Sydney Page 7

Initial outlay hours and line activ ity cost estimate Ongoing outlay hours and line activ ity cost estimate

Implementation itemHours

CNC 3

Hours

NE

Hours

SS

Hours

RN3

Hours

HSM2

Hours

CNECash outlay

Cost by line

activ ity

Hours

CNC 3

Hours

NE

Hours

SS

Hours

RN3

Hours

HSM2

Hours

CNE

Cost by line

activ ity

eLearning module development: CNC, Emergency Physician,

Education Officer, RNs for testing40 4 16 4 4 4 0.00 $ 6,486 20 4 4 2 2 $ 2,713

Video for education/training included in eLearning module:

Development of script (CNCs), filming (actors), production costs

6 4 0 2 2 2 0 $ 1,154 6 4 0 2 2 $ 1,023

Revision of orientation manual 30 2 0 0 0 8 0 $ 3,117 30 2 0 0 0 8 $ 3,117

Curriculum development, teaching and training for train the

trainers / 58 senior nursing staff over 8 days260 64 0 512 24 $ 50,982 130 64 0 192 24 $ 50,982

Short education (1hour) for 220 staff 220 24 $ 11,668 220 24 $ 11,668

Implementation nurse educator to embed HIRAID for 1 month

at each ED896 $ 58,274 896 $ 58,274

development of manuals by CNC and reviewed by 2 experts,

paper manual provided to CNC, NE, 8 8 8 $ 1,756 8 8 8 $ 1,756

Development and production 5 posters per ED 8 $ 520 8 $ 520

Production costs of lanyard flip card for each RN in each ED 2 $ 163 2 $ 163

Additional in kind support of CNEs over 3 month

implementation period564 $ 36,681 $ -

Promotional video 25 $ 2,042 25 $ 2,042

Development of clinical documentation templates 2 1 1 $ 301 2 1 1 $ 301

Altering of documentation policy 5 $ 408 5 $ 408

Development of audit tool 6 $ 490 6 $ 490

CNE, NUM enagement 4 4 $ 618 4 4 $ 618

Evaluation funded by research grants (Emergency Care

institute, Australian College of Nursing, NSW Health/ISLHD Nurse Strategy Funding, Agency for Clinical Innovation)

318255 $ 318,255 $ -

Total cost $ 492,917 $ 134,077

The University of Sydney Page 8

The evidence for HIRAID – Phase 2: Usability

– Nurses like it (useful assessment and documentation tool, easy to use)

– Improved MO handover

My responsibilities as an ED nurse are to accurately assess the patient, initiate appropriate treatment, escalate

where required and communicate effectively. HIRAID provides a vehicle to facilitate all these aspects of

patient care

“Works for new nurses who are not sure what to document”

The University of Sydney Page 9

The evidence for HIRAID: Impact on patient deterioration 72 hours admit via ED

– Staff action/comms, organisational, equipment, patient, individual

– Clear relationship with deterioration event. egprogressive deterioration in emergency with no identification or escalation

– 920 patients (374 pre and 546 post)

– post group more comorbidities

– Reduction in

– deterioration associated with care delivered in the ED (27% to 13%)

– treatment delays [28.3% to 15.1%]

– delay or failure to escalate care when abnormal vital signs were identified [20.2% to 6.9%].

– isolated nursing-related factors (21% to 8%).

The University of Sydney Page 10

Evidence for HIRAID – Documentation – 120 records

– Accurate nursing structure

describing all the essential

assessment components increased from 5% to 80%

– Quantity and quality of patient’s

history improved

– Quantity and quality of the

physical assessment.

– clear, linguistically correct, concise, and contain all relevant information

needed to act. Abnormal vital signs

noted in documentation

The University of Sydney Page 11

The evidence for HIRAID – Cost benefit

– Implementation costs initial ($492,917) and ongoing ($134,077)

– Average (sd) treatment costs for patients who deteriorated within 72 hours

– $26,778 ($34,007) compared to $7,727 ($12,547) (no deterioration)

– LOS 8 days longer

– Controlling for LOS and ARDRG, incremental cost per episode of deterioration was $14,134.

– Hospital net benefit $1,305,831 (conservative) to $2,522,673 (optimistic), ongoing $2,472,610.

– Hospital payback period 100 days (conservative) 60 days (optimistic).

– Ongoing investment of HIRAID, 26 days (conservative) to 15 days (optimistic).

The University of Sydney Page 12

The big one

– Cluster RCT

– NHMRC Partnership $3million +

– ACI, Chief Nurse (Commonwealth), LHDs, DONs, ACN, CENA, Thyne

Reid, ACSQHC

– 32 EDs

– HIRAID CNCs

– Implementation strategy (BCW)

– Impact on

– Patient outcomes (deterioration, satisfaction, human factors)

– Staff (handover, confidence)

– Documentation

– Cost benefit

The University of Sydney Page 13

Implementation plan

– eLearning module

– Train the Trainer course

– In-service (short education)

– eMR- Documentation templates

– Incentives / prizes

– On the floor support (clinical champions)

– Communications from exec

– Reporting/ Auditing

– Staff Orientation

– https://youtu.be/zbVvN6Qa05Q