Impact of an emergency department rapid response system on inpatient clinical deterioration: A controlled pre-post study.

AIM: To determine the impact implementation of Emergency Department Clinical Emergency Response System (EDCERS) on inpatient deterioration events and identify contributing causal factors. METHODS: EDCERS was implemented in an Australian regional hospital, integrating a single parameter track and trigger criteria for escalation of care, and emergency, specialty and critical care clinician response to patient deterioration. In this controlled pre-post study, electronic medical records of patients who experienced a deterioration event (rapid response call, cardiac arrest or unplanned intensive care admission) on the ward within 72 h of admission from the emergency department (ED) were reviewed. Causal factors contributing to the deteriorating event were assessed using a validated human factors framework. RESULTS: Implementation of EDCERS reduced the number of inpatient deterioration events within 72 h of emergency admission with failure or delayed response to ED patient deterioration as a causal factor. There was no change in the overall rate of inpatient deterioration events. CONCLUSION: This study supports wider implementation of rapid response systems in the ED to improve management of deteriorating patients. Tailored implementation strategies should be used to achieve successful and sustainable uptake of ED rapid response systems and improve outcomes in deteriorating patients.

Implementation evaluation of a rapid response system in a regional emergency department: a dual-methods study using the behaviour change wheel.

BACKGROUND: Failure to recognise and respond to clinical deterioration is a major cause of high mortality events in emergency department (ED) patients. Whilst there is substantial evidence that rapid response teams reduce hospital mortality, unplanned intensive care admissions, and cardiac arrests on in-patient settings, the use of rapid response teams in the ED is variable with poor integration of care between emergency and specialty/intensive care teams. OBJECTIVES: The aim of this study was to evaluate uptake and impact of a rapid response system on recognising and responding to deteriorating patients in the ED and identify implementation factors and strategies to optimise future implementation success. METHODS: A dual-methods design was used to evaluate an ED Clinical Emergency Response System (EDCERS) protocol implemented at a regional Australian ED in June 2019. A documentation audit was conducted on patients eligible for the EDCERS during the first 3 months of implementation. Quantitative data from documentation audit were used to measure uptake and impact of the protocol on escalation and response to patient deterioration. Facilitators and barriers to the EDCERS uptake were identified via key stakeholder engagement and consultation. An implementation plan was developed using the Behaviour Change Wheel for future implementation. RESULTS: The EDCERS was activated in 42 (53.1%) of 79 eligible patients. The specialty care team were more likely to respond when the EDCERS was activated than when there was no activation ([n = 40, 50.6%] v [n = 26, 32.9%], p = 0.01). Six facilitators and nine barriers to protocol uptake were identified. Twenty behaviour change techniques were selected and informed the development of a theory-informed implementation plan. CONCLUSION: Implementation of the EDCERS protocol resulted in high response rates from specialty and intensive care staff. However, overall uptake of the protocol by emergency staff was poor. This study highlights the importance of understanding facilitators and barriers to uptake prior to implementing a new intervention.

Effect of an intervention for patients 65 years and older with blunt chest injury: Patient and health service outcomes.

INTRODUCTION: Blunt chest injury in older adults, aged 65 years and older, leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes in older adults with blunt chest injury. METHODS: ChIP comprised multidimensional implementation guidance in three key pillars of care for blunt chest injury: respiratory support, analgesia, and complication prevention. Implementation was guided using the Behaviour Change Wheel. This proof-of-concept controlled pre- and post-test study with two intervention and two control sites in Australia was conducted from July 2015 to June 2019. The primary outcomes were non-invasive ventilation (NIV) use, unplanned Intensive Care Unit (ICU) admissions, and in-hospital mortality. Secondary outcomes were health service and costing outcomes. RESULTS: There were 1122 patients included in the analysis, with 673 at intervention sites (331 pre-test and 342 post-test) and 449 at control sites (256 pre-test and 193 post-test). ChIP was associated with unplanned ICU admissions and in NIV use with a reduction of the odds in the post vs the pre periods in the intervention sites when compared to the controls (ratio of OR=0.13, 95%CI=0.03-0.55) and (ratio of OR=0.14, 95%CI=0.02-0.98) respectively. There was no significant change in mortality. Implementing ChIP was also associated with health service team reviews with an increased odds in the post vs pre periods in the intervention sites in comparison to the controls for surgical review (ratio of OR =6.93, 95%CI=4.70-10.28), ICU doctor (ratio of OR =5.06, 95%CI=2.26-9.25), ICU liaison (ratio of OR =14.14, 95%CI=3.15-63.31), and pain (ratio of OR =5.59, 95%CI=3.25-9.29). ChIP was also related to incentive spirometry (ratio of OR=6.35, 95%CI= 3.15-12.82) and overall costs (ratio of mean ratio=1.34, 95%CI=1.09-1.66) with a higher ratio for intervention sites. CONCLUSION: Implementation of ChIP using the Behaviour Change Wheel was associated with reduced unplanned ICU admissions and NIV use and improved health care delivery. TRIAL REGISTRATION: ANZCTR: ACTRN12618001548224, approved 17/09/2018.

Experiences and outcomes of women with bleeding in early pregnancy presenting to the Emergency Department: An integrative review.

BACKGROUND: Bleeding in early pregnancy occurs in approximately a quarter of all pregnancies and is a common reason for presentation to the Emergency Department (ED). This review combined current knowledge about experiences, interventions, outcomes and frequency of women presenting to the ED with per vaginal (PV) bleeding in the first 20 weeks of pregnancy. METHODS: This integrative literature review was conducted using electronic database and hand searching methods for primary research published from 2000; followed by screening and appraisal. Articles were compared and grouped to identify characteristics and patterns that guided the synthesis of categories. RESULTS: Forty-two primary research articles met inclusion criteria. Four main categories related to experiences and outcomes of women with bleeding in early pregnancy presenting to the ED were identified: presentation frequency and characteristics; women and their partners' experiences in the ED; interventions and treatments; patient and health service outcomes. CONCLUSIONS: Negative and often frustrating experiences are reported by women experiencing PV bleeding, their partners and ED healthcare providers. While strategies such as early pregnancy assessment services contribute to improved outcomes, the availability of these services vary. Further research is needed to identify specific needs of this group of women and their partners, and the staff providing their care in the ED, to inform strategies for improved quality of care.

Implementation of a hospital-wide multidisciplinary blunt chest injury care bundle (ChIP): Fidelity of delivery evaluation.

BACKGROUND: Ineffective intervention for patients with blunt chest wall injury results in high rates of morbidity and mortality. To address this, a blunt chest injury care bundle protocol (ChIP) was developed, and a multifaceted plan was implemented using the Behaviour Change Wheel. OBJECTIVE: The purpose of this study was to evaluate the reach, fidelity, and dose of the ChIP intervention to discern if it was activated and delivered to patients as intended at two regional Australian hospitals. METHODS: This is a pretest and post-test implementation evaluation study. The proportion of ChIP activations and adherence to ChIP components received by eligible patients were compared before and after intervention over a 4-year period. Sample medians were compared using the nonparametric median test, with 95% confidence intervals. Differences in proportions for categorical data were compared using the two-sample z-test. RESULTS/FINDINGS: Over the 19-month postimplementation period, 97.1% (n = 440) of eligible patients received ChIP (reach). The median activation time was 134 min; there was no difference in time to activation between business hours and after-hours; time to activation was not associated with comorbidities and injury severity score. Compared with the preimplementation group, the postimplementation group were more likely to receive evidence-based treatments (dose), including high-flow nasal cannula use (odds ratio [OR] = 6.8 [95% confidence interval {CI} = 4.8-9.6]), incentive spirometry in the emergency department (OR = 7.5, [95% CI = 3.2-17.6]), regular analgesia (OR = 2.4 [95% CI = 1.5-3.8]), regional analgesia (OR = 2.8 [95% CI = 1.5-5.3]), patient-controlled analgesia (OR = 1.8 [95% CI = 1.3-2.4]), and multiple specialist team reviews, e.g., surgical review (OR = 9.9 [95% CI = 6.1-16.1]). CONCLUSIONS: High fidelity of delivery was achieved and sustained over 19 months for implementation of a complex intervention in the acute context through a robust implementation plan based on theoretical frameworks. There were significant and sustained improvements in care practices known to result in better patient outcomes. Findings from this evaluation can inform future implementation programs such as ChIP and other multidisciplinary interventions in an emergency or acute care context.

Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study.

AIMS AND OBJECTIVES: To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. BACKGROUND: Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. DESIGN: A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. METHODS: HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data. RESULTS: The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. CONCLUSION: Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. RELEVANCE TO CLINICAL PRACTICE: The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.

Implementation of a structured emergency nursing framework results in significant cost benefit.

BACKGROUND: Patients are at risk of deterioration on discharge from an emergency department (ED) to a ward, particularly in the first 72 h. The implementation of a structured emergency nursing framework (HIRAID) in regional New South Wales (NSW), Australia, resulted in a 50% reduction of clinical deterioration related to emergency nursing care. To date the cost implications of this are unknown. The aim of this study was to determine any net financial benefits arising from the implementation of the HIRAID emergency nursing framework. METHODS: This retrospective cohort study was conducted between March 2018 and February 2019 across two hospitals in regional NSW, Australia. Costs associated with the implementation of HIRAID at the study sites were calculated using an estimate of initial HIRAID implementation costs (AUD) ($492,917) and ongoing HIRAID implementation costs ($134,077). Equivalent savings per annum (i.e. in less patient deterioration) were calculated using projected estimates of ED admission and patient deterioration episodes via OLS regression with confidence intervals for incremental additional deterioration costs per episode used as the basis for scenario analysis. RESULTS: The HIRAID-equivalent savings per annum exceed the costs of implementation under all scenarios (Conservative, Expected and Optimistic). The estimated preliminary savings to the study sites per annum was $1,914,252 with a payback period of 75 days. Conservative projections estimated a net benefit of $1,813,760 per annum by 2022-23. The state-wide projected equivalent savings benefits of HIRAID equalled $227,585,008 per annum, by 2022-23. CONCLUSIONS: The implementation of HIRAID reduced costs associated with resources consumed from patient deterioration episodes. The HIRAID-equivalent savings per annum to the hospital exceed the costs of implementation across a range of scenarios, and upscaling would result in significant patient and cost benefit.

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation.

BACKGROUND: Blunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury-respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel. METHODS: This controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality. RESULTS: There were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18-0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04-0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61-9.45), physiotherapy OR 2.17 (95% CI 1.52-3.11), ICU doctor OR 6.13 (95% CI 3.94-9.55), ICU liaison OR 55.75 (95% CI 17.48-177.75), pain team OR 8.15 (95% CI 5.52 --12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64-3.94) and regional analgesia OR 8.8 (95% CI 3.39-22.79), incentive spirometry OR 8.3 (95% CI 4.49-15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43-39.2) in the intervention group compared to the control group in the post- period. CONCLUSION: The implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement. TRIAL REGISTRATION: ANZCTR: ACTRN12618001548224, approved 17/09/2018.

Implementation strategy fidelity evaluation for a multidisciplinary Chest Injury Protocol (ChIP).

BACKGROUND: Blunt chest wall injuries can lead to complications, especially without early intervention. A blunt Chest Injury Protocol (ChIP) was developed to help improve the consistency of evidence-based care following admission to the emergency department. Implementation strategy fidelity is the extent to which the strategies of implementation are delivered in line with the intended plan. The aim of this study was to assess fidelity to the strategies of the implementation plan developed for ChIP. METHODS: A retrospective evaluation of strategies used for implementation was performed, specifically the behaviour change techniques (BCTs). BCTs were used as part of an implementation plan derived based on the Behaviour Change Wheel from results from a staff survey at two hospitals. Levels of implementation or adaptation for BCTs were scored by implementers as follows: 'Were the behaviour change interventions implemented?' (0 = 'not implemented', 1 = partially implemented, and 2 = fully implemented); 'Were adaptations made to the implementation plan?', scored 1 (many changes from plan) to 4 (just as planned). Free text explanation to their responses was also collected with supporting evidence and documentation (such as emails, implementation checklists, audit reports, and incident reports). RESULTS: There was high overall fidelity of 97.6% for BCTs partially or fully implemented. More than three quarters (32/42, 76.2%) of the BCTs were fully implemented with an additional 9/42 (21.4%) partially implemented. BCTs that were not fully implemented were social support, feedback on behaviour, feedback on outcomes of behaviour, adding objects to the environment, and restructuring the environment. The modes of delivery with poorer implementation or increased adaptations were clinical champions and audit/feedback. CONCLUSIONS: This study describes the evaluation of implementation strategy fidelity in the acute care context. The systematic use and application of the behaviour change wheel was used to develop an implementation plan and was associated with high implementation strategy fidelity. A fidelity checklist developed during the implementation process may help implementers assess fidelity. TRIAL REGISTRATION: Trial registered on ANZCTR. Registration number ACTRN12618001548224 , date approved 17/09/2018.

Translation of evidence into policy to improve clinical practice: the development of an emergency department rapid response system.

BACKGROUND: Undetected clinical deterioration is a major cause of high mortality events in Emergency Department (ED) patients. Yet, there is no known model to guide the recognition and response to clinical deterioration in the ED, integrating internal and external resources. METHODS: An integrative review was firstly conducted to identify the critical components of recognising and responding to clinical deterioration in the ED. Components identified from the review were analysed by clinical experts and informed the development of an ED Clinical Emergency Response System (EDCERS). RESULTS: Twenty four eligible studies were included in the review. Eight core components were identified: 1) vital sign monitoring; 2) track and trigger system; 3) communication plan; 4) response time; 5) emergency nurse response; 6) emergency physician response; 7) critical care team response; and 8) specialty team response. These components informed the development of the EDCERS protocol, integrating responses from staff internal and external to the ED. CONCLUSIONS: EDCERS was based on the best available evidence and considered the cultural context of care. Future research is needed to determine the useability and impact of EDCERS on patient and health outcomes.

Does electronic medical record redesign increase screening of risk for pressure injury, falls and substance use in the Emergency Department? An implementation evaluation.

BACKGROUND: Following the provision of urgent care, screening for risks known to impact patient outcomes is an extension of safe emergency nursing care, in particular for falls, pressure injury and substance use. Screening is a process that primarily aims to identify people at increased risk for specific complications. This study aimed to describe and evaluate the implementation of a consolidated electronic checklist on the screening completion rates for falls, pressure injury and substance use in a regional health district. METHODS: This pre-post study used emergency data from four Emergency Departments (EDs) in southern NSW, Australia between November 2016 and February 2019. Patient characteristics, triage category, discharge diagnosis, arrival date and time, screening completion date and time and treatment location were extracted. Descriptive statistics were used to describe the characteristics of the presentations. Z test with adjusted p-values using Bonferroni Correction method was used to compare the characteristics of the presentations and the rates of screening completion. The Theoretical Domains Framework was used to identify any deficits in the implementation. RESULTS: There were 33,561 patients in the pre and 35,807 in the post group. There were no differences in patient characteristics between the two groups. The mean emergency department (ED) length of stay was unchanged (490.5min pre vs 489.9min post). The proportion of patients who had all three screens completed increased from 1.3% to 5.5% (p<0.001). Pressure injury risk screening increased from 46.6% (pre) to 53.1% (post) (p<0.001) as did substance use screening (1.7% vs 12.4%, p<0.001). Screening was strongly associated to which hospital the patient was admitted, their age and ED length of stay. Of the 51 mapped intervention functions, 20 (39%) were used in the implementation. CONCLUSIONS: The introduction of a consolidated electronic checklist for use by emergency nurses to complete fall, pressure injury and substance use screening resulted in an overall increase in risk screening. However screening rates remained poor. Implementation that considers the capability, opportunity and motivation of those that need to alter their behaviour would likely improve the overall compliance.

The implementation and usability of HIRAID, a structured approach to emergency nursing assessment.

BACKGROUND: Emergency nurses are responsible for the initial assessment, management and safety of critically ill patients. HIRAID, an evidence-informed emergency nursing assessment framework, is known to improve emergency nursing patient-assessment in the simulated environment however has not been evaluated in the clinical setting. METHODS: A pre-post design was used to assess the usability and impact of HIRAID on emergency nurses self-efficacy in the emergency department (ED). Nursing and medical staff from three Australian EDs were surveyed. Descriptive and optimal pooled sample t-tests statistics were conducted. RESULTS: One hundred and two emergency nurses completed the pre-intervention self-efficacy survey and 63 completed the post-intervention self-efficacy and satisfaction survey. Forty-two and 17 medical officers completed the pre- and post-intervention satisfaction surveys, respectively. Nursing staff self-efficacy levels were unchanged pre- and post-HIRAID implementation (Mean (SD): 8.8 (0.21) vs. 8.7 (0.20)) as was medical staff satisfaction (Mean (SD):7.5 (1.43) vs. 7.8 (1.07)), although there was a trend towards improved communication. CONCLUSION: The HIRAID structured approach to patient assessment is acceptable, feasible, practical and appropriate for use in the clinical environment. Further research will demonstrate the direct effects of HIRAID on clinical performance.

Designing strategies to implement a blunt chest injury care bundle using the behaviour change wheel: a multi-site mixed methods study.

BACKGROUND: Blunt chest injury can lead to significant morbidity and mortality if not treated appropriately. A blunt chest injury care bundle was to be implemented at two sites to guide care. AIM: To identify facilitators and barriers to the implementation of a blunt chest injury care bundle and design strategies tailored to promote future implementation. METHODS: 1) A mixed-method survey based on the theoretical domains framework (TDF) was used to identify barriers and facilitators to the implementation of a blunt chest injury care bundle. This survey was distributed to 441 staff from 12 departments across two hospitals. Quantitative data were analysed using SPSS and qualitative using inductive content analysis. 2) The quantitative and qualitative results from the survey were integrated and mapped to each of the TDF domains. 3) The facilitators and barriers were evaluated using the Behaviour Change Wheel to extract specific intervention functions, policies, behaviour change techniques and implementation strategies. Each phase was assessed against the Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects or safety and Equity (APEASE) criteria. RESULTS: One hundred ninety eight staff completed the survey. All departments surveyed were represented. Nine facilitators and six barriers were identified from eight domains of the TDF. Facilitators (TDF domains) were: understanding evidence-informed patient care and understanding risk factors (Knowledge); patient assessment skills and blunt chest injury management skills (Physical skills); identification with professional role (Professional role and identity); belief of consequences of care bundle (Belief about consequences); provision of training and protocol design (Environmental context and resources); and social supports (Social influences). Barriers were: not understanding the term 'care bundle' (Knowledge); lacking regional analgesia skills (Physical skills); not remembering to follow protocol (Memory, attention, and decision processes); negative emotions relating to new protocols (Emotions); equipment and protocol access (Environmental context and resources). Implementation strategies were videos, education sessions, visual prompt for electronic medical records and change champions. CONCLUSIONS: Multiple facilitators and barriers were identified that may affect the implementation of a blunt chest injury care bundle. Implementation strategies developed through this process have been included in a plan for implementation in the emergency departments of two hospitals. Evaluation of the implementation is underway.

Development of a blunt chest injury care bundle: An integrative review.

BACKGROUND: Blunt chest injuries (BCI) are associated with high rates of morbidity and mortality. There are many interventions for BCI which may be able to be combined as a care bundle for improved and more consistent outcomes. OBJECTIVE: To review and integrate the BCI management interventions to inform the development of a BCI care bundle. METHODS: A structured search of the literature was conducted to identify studies evaluating interventions for patients with BCI. Databases MEDLINE, CINAHL, PubMed and Scopus were searched from 1990-April 2017. A two-step data extraction process was conducted using pre-defined data fields, including research quality indicators. Each study was appraised using a quality assessment tool, scored for level of evidence, then data collated into categories. Interventions were also assessed using the APEASE criteria then integrated to develop a BCI care bundle. RESULTS: Eighty-one articles were included in the final analysis. Interventions that improved BCI outcomes were grouped into three categories; respiratory intervention, analgesia and surgical intervention. Respiratory interventions included continuous positive airway pressure and high flow nasal oxygen. Analgesia interventions included regular multi-modal analgesia and paravertebral or epidural analgesia. Surgical fixation was supported for use in moderate to severe rib fractures/BCI. Interventions supported by evidence and that met APEASE criteria were combined into a BCI care bundle with four components: respiratory adjuncts, analgesia, complication prevention, and surgical fixation. CONCLUSIONS: The key components of a BCI care bundle are respiratory support, analgesia, complication prevention including chest physiotherapy and surgical fixation.

Optimising implementation of a patient-assessment framework for emergency nurses: A mixed-method study.

AIMS AND OBJECTIVES: To determine potential facilitators and barriers and tailor interventions to optimise future implementation of a patient-assessment framework into emergency nursing practice. BACKGROUND: An evidence-informed patient-assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) improves the quality of patient assessments performed by emergency nurses. Facilitators and barriers must be understood and tailored interventions selected to optimise implementation. DESIGN: A mixed-method convergent study design was used. METHODS: Thirty eight early career emergency nurses from five Australian hospitals participated in an education workshop on the HIRAID assessment framework. Simulated clinical scenarios enabled participants to experience conducting a patient assessment with and without using the framework. All participants completed surveys, interviews and focus groups to identify potential facilitators and barriers. Twenty three participants completed follow-up telephone surveys 4-6 months later. Quantitative and qualitative data were analysed separately using descriptive statistics and inductive content analysis, prior to integration. Implementation interventions were selected using the Behaviour Change Wheel. RESULTS: Nine facilitators and nine barriers were identified to potentially effect implementation of the HIRAID assessment framework. Twelve of the 23 participants (52.2%) who completed follow-up surveys reported using the framework in the clinical setting. To optimise future implementation, the education workshop needs refinement, and environmental restructuring, modelling and social support are required. CONCLUSION: A multimodal strategy is needed to promote future successful implementation of the HIRAID assessment framework into emergency nursing practice. RELEVANCE FOR CLINICAL PRACTICE: The successful implementation of the HIRAID assessment framework has the potential to improve nursing assessments of patients in emergency and other acute care settings. This study demonstrates how to systematically identify facilitators and barriers to behaviour change and select interventions to optimise implementation of evidence-informed nursing practices.

A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation.

AIMS AND OBJECTIVES: The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness. BACKGROUND: Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients. DESIGN: A pre-post design was used. METHODS: The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention. RESULTS: From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness. CONCLUSION: The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care. RELEVANCE TO CLINICAL PRACTICE: HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.

Designing and implementing full immersion simulation as a research tool.

Simulation is a valuable research tool used to evaluate the clinical performance of devices, people and systems. The simulated setting may address concerns unique to complex clinical environments such as the Emergency Department, which make the conduct of research challenging. There is limited evidence available to inform the development of simulated clinical scenarios for the purpose of evaluating practice in research studies, with the majority of literature focused on designing simulated clinical scenarios for education and training. Distinct differences exist in scenario design when implemented in education compared with use in clinical research studies. Simulated scenarios used to assess practice in clinical research must not comprise of any purposeful or planned teaching and be developed with a high degree of validity and reliability. A new scenario design template was devised to develop two standardised simulated clinical scenarios for the evaluation of a new assessment framework for emergency nurses. The scenario development and validation processes undertaken are described and provide an evidence-informed guide to scenario development for future clinical research studies.

The impact of HIRAID on emergency nurses' self-efficacy, anxiety and perceived control: A simulated study.

INTRODUCTION: Emergency nurses must perform accurate and complete comprehensive patient assessments to establish patient treatment needs and expedite care. AIM: To evaluate the impact of a structured approach to emergency nursing assessment following triage, on novice emergency nurses' anxiety, self-efficacy and perceptions of control. METHODS: Thirty eight early career emergency nurses from five Australian hospitals performed an initial patient assessment in an immersive clinical simulated scenario, before and after undertaking training in HIRAID, an evidence-informed patient assessment framework for emergency nurses. Immediately following each scenario the nurses completed a questionnaire scoring anxiety, self-efficacy and perceptions of control levels. Paired sample t-tests and effect sizes were calculated. RESULTS: Participant anxiety levels were lower after HIRAID training compared to before undertaking the training (Mean (SD) = 53.26 (10.76) vs 47.46 (9.96), P = 0.002). Self-efficacy levels in assessment performance increased (189.32 (66.48) vs 214.06 (51.35), P = 0.001). There was no change in perceptions of control (31.24 (7.38) vs 30.98 (8.38), P = 0.829). DISCUSSION: High levels of anxiety and low levels of self-efficacy are known to be negatively correlated with clinical reasoning skills and performance. CONCLUSION: The effect of HIRAID training on reducing anxiety and increasing self-efficacy has the potential to improve emergency nurses' assessment performance and the quality and safety of patient care.

HIRAID: An evidence-informed emergency nursing assessment framework.

INTRODUCTION: Emergency nurses must be highly skilled at performing accurate and comprehensive patient assessments. In 2008, the inaugural emergency nursing assessment framework (ENAF) was devised at Sydney Nursing School, to provide emergency nurses with a systematic approach to initial patient assessment. In 2014 the assessment framework was re-developed to reflect the most recent evidence. AIM: To describe the process and evidence used to re-develop ENAF, to provide ED nurses with an evidence-informed approach to the comprehensive assessment of patients presenting to ED after triage, so that it may be implemented and tested in the clinical (simulated) setting. METHODS: A thorough literature review was conducted to inform the re-development of ENAF. Literature review findings were reviewed and ENAF was re-developed by a panel of expert emergency nursing clinicians using the Delphi Technique. RESULTS: Modifications to ENAF were undertaken and a new, more comprehensive assessment framework was developed titled 'HIRAID'. HIRAID is informed by current evidence, comprising of seven assessment components: History; Identify Red flags; Assessment; Interventions; Diagnostics; reassessment and communication. CONCLUSION: HIRAID provides an evidence-informed systematic approach to initial patient assessment performed by emergency nurses after triage. Evaluation is now needed to determine its impact on clinician performance and patient safety.

The impact structured patient assessment frameworks have on patient care: an integrative review.

AIMS AND OBJECTIVES: To evaluate structured patient assessment frameworks' impact on patient care. BACKGROUND: Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care. DESIGN: Integrative review. METHODS: An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings. RESULTS: Twelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes. CONCLUSION: Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing. RELEVANCE TO CLINICAL PRACTICE: Acute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.