Reducing inpatient deterioration and improving patient safety in emergency departments with a standardised nursing...

Patients admitted via Emergency Departments (EDs) sustain twice as many in-hospital adverse events than non-emergency admissions. Unwarranted variation in care, that is, differences not explained by patient illness, care needs, or patient preferences, contributes to adverse patient outcomes. The HIRAID® framework [History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, reassessment, and communication], standardises nursing assessment and management of patients in the ED. The aim of this study was to test the effect of HIRAID® on the quality and safety of emergency care.

A modified (staircase) stepped-wedge, cluster randomised controlled trial was conducted in 29 Australian metropolitan, regional, rural Emergency Departments involving 1377 nurses from June 2020 to February 2024. The 29 Emergency Departments were allocated to four clusters and randomised to one of four sequences, with three-six month intervention periods. HIRAID® was implemented with a multifaceted strategy comprising 21 behaviour change techniques including an education program, and modifications to nursing documentation. The primary outcome was inpatient deterioration as evidenced by a rapid response team call within 72 h of admission via ED. Secondary outcomes were the proportion of rapid response team calls where emergency nursing care was a contributor; time to first dose analgesia; patient/carer experience with emergency nursing care; and staff satisfaction with clinical handover. Contributing factors to 2211 inpatient rapid response team calls within 72 h of admission via emergency department were categorised using the Human Factors Classification Framework. Time to analgesia was extracted during medical record review (n = 1374). Patient experience (n = 2704) and clinical handover quality were measured using surveys (n = 1205 nurses). A regression approach was used to model the effect of HIRAID® implementation on primary outcomes adjusting for cluster effects and confounders.

Of the 106,047 patients admitted via the ED, there were 2729 (1342 control, 1387 intervention) patients with a rapid response call within 72 h of admission. HIRAID® reduced the proportion of patients requiring a rapid response team call by 7.4 % (OR = 0.92, 95 % CI = 0.81-0.99) including 8.2 % fewer calls related to emergency nursing care (47 % to 38.8 %, OR = 0.72, 95 % CI = 0.56-0.93). Patient experience improved in all measures, particularly feeling more informed (OR = 1.74, 95 % CI = 1.37-2.19). There was no change in time to first analgesia. There was a 7.0 % improvement in handover of relevant history (t = 5.57, p < 0.001) and physical assessment (t = 4.72, p < 0.001).

Emergency nurses' use of HIRAID® significantly reduced inpatient deterioration requiring a rapid response team call and improved patient experience and perceived quality of clinical handover.

Australian New Zealand Clinical Trials Registry 25 October 2021, (ACTRN12621001456842), recruitment commenced 6 November 2020. Social media abstract: Implementing HIRAID® reduces patient deterioration. More info here #HIRAID.