The impact of whole of patient nursing assessment frameworks on hospital inpatients: A scoping literature review.

INTRODUCTION: A comprehensive patient assessment is essential for safe patient care. Patient assessment frameworks for nurses are generally restricted to patients who already have altered vital signs and are at risk of deterioration, or to specific risks or body systems such as falls, pressure injury and the Glasgow Coma Score. Comprehensive and structured evidence-based nursing assessment frameworks that consider the whole patient and extend beyond vital signs, specific risks and single systems are not routinely used in inpatient settings but are important to establish early risks for patient deterioration. AIM: The aim of this review was to identify nursing assessment tools or frameworks used to holistically assess hospitalized patients and to identify the impact of these tools on patient and health service outcomes. METHODS: A scoping literature review was conducted. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), ProQuest Dissertations and Thesis, Embase and Scopus were databases used in the search. The initial search was conducted in August 2021 and repeated in November 2022. No date parameters were set. The Participants, Concept, Context (PCC) framework was used to guide the development of the research question and consolidate inclusion and exclusion criteria. The PRISMA-ScR Checklist Item was followed to ensure a methodologically sound checklist was used. RESULTS: Ten primary research studies evaluating six nursing assessment frameworks were included. Of the five nursing assessment frameworks, none were explicitly designed for general ward nursing, but rather the emergency department or specific patient cohorts, such as oncology. Four studies reported on reliability and/or validity; two reported on patient outcomes and four on staff satisfaction. CONCLUSION: Evidence-based nursing patient assessment frameworks for use in general inpatient wards are lacking. Existing assessment tools are largely designed for specific patient cohorts, specific body systems or the already deteriorating patient. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: A framework to enable a structured approach to patient assessment in this environment is needed for patient safety, consistency in assessment, nursing staff enablement and confidence to escalate care. Routine systematic nursing assessment could also aid timely patient escalation. IMPACT: What problem did the study address? This study addresses the lack of evidence-based nursing assessment frameworks for use in hospitalized patients. The impact of this is that it highlights the need for an evidence-based, whole of patient assessment framework for use by nurses for patients admitted to a ward environment. What were the main findings? This review identified limited comprehensive, patient assessment frameworks for use in general ward inpatient areas. Those identified were not validated for this patient cohort and are aimed at patients already deteriorating. Where and on whom will the research have an impact? This review has the potential to impact future research and patient care. It highlights that most research is focussed on processes to detect and escalate care for the already deteriorating patient. There is a need for an evidence-based routine nursing assessment framework for patients admitted to a ward environment to promote positive patient outcomes and prevent deterioration. PATIENT AND PUBLIC CONTRIBUTION: This review contributes to existing knowledge of nursing patient assessment frameworks, yet it also highlights several gaps. Currently, there are no known, validated, holistic, structured nursing patient assessment frameworks for use in general ward inpatient settings. However, areas that do use such assessment frameworks (e.g. the emergency department) have shown positive patient outcomes and staff usability. Hospitalized ward patients would benefit from routine, structured nursing assessments targeting positive patient outcomes prior to the onset of deterioration.

Emergency nurses' perceptions of the utility, adaptability and feasibility of the emergency nursing framework HIRAIDTM for practice change in US: An exploratory study.

BACKGROUND: Patient assessment is a core component of nursing practice and underpins safe, high-quality patient care. HIRAIDTM, an evidence-informed emergency nursing framework, provides nurses with a structured approach to patient assessment and management post triage. In Australia, HIRAIDTM resulted in significant improvements to nurse-led communication and reduced adverse patient events. OBJECTIVES: First, to explore United States (US) emergency nurses' perceptions of the evidence-informed emergency nursing framework, HIRAIDTM; second, to determine factors that would influence the feasibility and adaptability of HIRAIDTM into nursing clinical practice in EDs within the US. METHODS: A cross-sectional cohort study using a survey method with a convenience sample was conducted. A 4-hour workshop introduced the HIRAIDTM framework and supporting evidence at the Emergency Nurses Association's (ENA) conference, Emergency Nursing 2022. Surveys were tested for face validity and collected information on nurse-nurse communication, self-efficacy, the practice environment and feedback on the HIRAIDTM framework. RESULTS: The workshop was attended by 48 emergency nurses from 17 US States and four countries. Most respondents reported that all emergency nurses should use the same standardised approach in the assessment of patients. However, the greatest barriers to change were a lack of staff and support from management. The most likely interventions reported to enable change were face-to-face education, the opportunity to ask questions and support in the clinical environment. CONCLUSION: HIRAIDTM is an acceptable and suitable emergency nursing framework for consideration in the US. Successful uptake will depend on training methods and organizational support. HIRAIDTM training should incorporate face-to-face interactive workshops.

Implementation evaluation of an evidence-based emergency nursing framework (HIRAID): study protocol for a step-wedge randomised control trial.

INTRODUCTION: Poor patient assessment results in undetected clinical deterioration. Yet, there is no standardised assessment framework for >29 000 Australian emergency nurses. To reduce clinical variation and increase safety and quality of initial emergency nursing care, the evidence-based emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) was developed and piloted. This paper presents the rationale and protocol for a multicentre clinical trial of HIRAID. METHODS AND ANALYSIS: Using an effectiveness-implementation hybrid design, the study incorporates a stepped-wedge cluster randomised controlled trial of HIRAID at 31 emergency departments (EDs) in New South Wales, Victoria and Queensland. The primary outcomes are incidence of inpatient deterioration related to ED care, time to analgesia, patient satisfaction and medical satisfaction with nursing clinical handover (effectiveness). Strategies that optimise HIRAID uptake (implementation) and implementation fidelity will be determined to assess if HIRAID was implemented as intended at all sites. ETHICS AND DISSEMINATION: Ethics has been approved for NSW sites through Greater Western Human Research Ethics Committee (2020/ETH02164), and for Victoria and Queensland sites through Royal Brisbane & Woman's Hospital Human Research Ethics Committee (2021/QRBW/80026). The final phase of the study will integrate the findings in a toolkit for national rollout. A dissemination, communications (variety of platforms) and upscaling strategy will be designed and actioned with the organisations that influence state and national level health policy and emergency nurse education, including the Australian Commission for Quality and Safety in Health Care. Scaling up of findings could be achieved by embedding HIRAID into national transition to nursing programmes, 'business as usual' ED training schedules and university curricula. TRIAL REGISTRATION NUMBER: ACTRN12621001456842.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study.

BACKGROUND: The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW. METHODS: The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs. RESULTS: There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F2,65 = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F2,398 = 51.5, p < 0.001). CONCLUSION: Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia.

BACKGROUND: Timely definitive paediatric trauma care influences patient and parental physical and emotional outcomes. New South Wales (NSW) covers a large geographical area with all three NSW paediatric trauma centres (PTC) located in two approximated major cities, meaning it is inevitable that some injured children receive initial treatment locally and then require transfer. Little is known about the factors that then impact timely arrival of injured children to definitive care. METHODS: This included children admitted between July 2015 and September 2016, <16 years with an injury severity (ISS) ≥9; or requiring intensive care admission; or deceased following injury. Children were identified through the three PTCs, NSW Trauma Registry and NSW Medical Retrieval Registry. RESULTS: There were 593 children admitted following injury and 46% required transfer to a PTC. There was no significant difference in age, ISS, ICU admission or head injury (AIS >2) between transferred and directly transported cohorts. There were significant differences in mechanism of injury between the two groups (χ2(9) = 45.9, p < 0.001). The median (IQR) time to book a transfer from arrival at the referring facility, was 146.5 (86-238) minutes. Time from injury to arrival at the PTC more than doubled for children transferred, with significant and unwarranted variability between transporting agencies resulting in unwarranted delays to surgical intervention. For example, time spent at the referring facility by Aeromedical Retrieval Service was less than half that of the Newborn & paediatric Emergency Transport Service [53 (IQR:47-61) vs 115 (84-155) minutes (p <0.001)]. CONCLUSION: Clinicians caring for paediatric trauma patients in facilities outside trauma centres require the capability and opportunity to identify and notify early those requiring transfer for ongoing management. The provision of a streamlined referral and transfer process for all paediatric trauma patients requiring treatment in NSW PTCs would reduce the burden on the referring facility, reduce variation amongst transport providers and improve time to definitive care.

Emergency department management of severely injured children in New South Wales.

OBJECTIVE: Presentations to EDs for major paediatric injury are considerably lower than for adults. International studies report lower levels of critical intervention, including intubation, required in injured children. A New South Wales study demonstrated an adverse event rate of 7.6% in children with major injury. Little is known about the care and interventions received by children presenting to Australian EDs with major injury. METHODS: The ED care of injured children <16 years who ultimately received definitive care at a New South Wales Paediatric Trauma Centre between July 2015 and September 2016, and had an Injury Severity Score ≥9, required intensive care admission or died were included. RESULTS: There were 491 injured children who received treatment at 64 EDs, half (49.4%, n = 243) were treated initially in a Paediatric Trauma Centre. One third (32.8%) sustained an Injury Severity Score >12, more than half (n = 251, 51.1%) of children were classified as a triage category 1 or 2, and 38.3% received trauma team activation. Critical intervention was infrequent. Intubation was documented in 9.2% (n = 45), needle thoracostomy and activation of massive transfusion protocol in two (0.4%) and eight (1.6%) had intraosseous access established. Only a small proportion (14.7%, n = 63) had two or more observations outside the normal range. CONCLUSION: A small proportion of children arriving in the ED post-major trauma have deranged clinical observations and receive critical interventions. The limited exposure in the management of trauma in paediatric patients requires measures to ensure clinicians have adequate training, skills and confidence to manage these clinical presentations in all EDs.

Prehospital care and transport costs of severely injured children in NSW Australia.

BACKGROUND: Injury is the leading cause of childhood death and disability in Australia. Prehospital emergency services in New South Wales (NSW) are provided by NSW Ambulance. The incidence, pre-hospital care provided and outcomes of children suffering major injury in NSW has not previously been described. METHODS: This retrospective study was conducted between July 2015 and September 2016 and included children <16 years with an injury severity score (ISS) >9, or requiring intensive care admission, or deceased following injury and treated in NSW. Children were identified through the three NSW Paediatric Trauma Centres, the NSW Trauma Registry, NSW Medical Retrieval Registry (AirMaestro, Avinet, Australia). RESULTS: There were 359 majorly injured children treated by NSW-based emergency service providers, the majority were male (73.3%) with a mean (SD) age of 8.0 (5.2) years. The median (IQR) injury severity score (ISS) for those transported via NSW emergency medical services was 10 (9-17), with almost half (44.1%) treated prehospital having an ISS >12. The most common documented interventions were intravenous access (44.1%) and oxygen therapy (39.6%). Intubation and chest decompression were recorded in 15.3% and 3.1% of cases respectively. The calculated median (IQR) transport charges for NSW Emergency Services was AUD $942 ($841.3-$1184.6). CONCLUSION: Critical interventions are performed infrequently in children with major injuries in the pre-hospital environment. The monitoring of the incidence and success rates for staff performing these interventions is not readily available from all prehospital emergency medical services operating in NSW. The capacity and processes to monitor and audit all critical interventions in the paediatric population should be resourced and clearly defined.

Cause, treatment costs and 12-month functional outcomes of children with major injury in NSW, Australia.

BACKGROUND: Information about children treated in New South Wales (NSW), Australia following major injury has been limited to those treated at trauma centres using mortality as the main outcome measure, restricting assessment of the effectiveness of the Trauma System. This study sought to describe the detailed characteristics as well as functional and psychosocial health outcomes of all children suffering major injury in NSW. METHODS: A longitudinal study was conducted between July 2015 and November 2017 and included children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW or who died following injury. Children were identified through the three NSW Paediatric Trauma Centres (PTC), the NSW Trauma Registry, NSW Aeromedical Retrieval Registry (AirMaestro) and the National Coronial Information System (NCIS). Health-related quality of life (HRQoL) outcomes for children treated at the three PTCs were collected at baseline, 6 and 12 months using the Paediatric Quality of Life inventory (PedsQL 4.0) and EuroQol five-dimensional EQ-5D-Y. RESULTS: There were 625 children, with a median (interquartile range) age of 7 (2-13) years and 71.7% were male. Around half were injured in major cities (51.2%). The median (IQR) injury severity score (ISS) was 10 (9-17). Twelve-month HRQoL measured by PedsQL remained below baseline for psychosocial health. Treatment costs increased with injury severity (p=<0.001) and polytrauma (p=<0.001). No survival benefit was demonstrated between PTC versus non-PTC definitive care. Injured females and children from rural / remote NSW were overrepresented in the deceased. CONCLUSION: Children treated in NSW following major injury have reduced quality of life and in particular, reduced emotional well-being at 12 months post-injury. Improved psychosocial care and outpatient follow-up is required to minimise the long-term emotional impact of injury on the child.

Determining the priorities for change in paediatric trauma care delivery in NSW, Australia.

BACKGROUND: Injury remains the leading cause of death and disability for Australian children. There is known variability in the quality of care delivered to injured children in Australia. This study prioritises recommendations developed from an expert review of paediatric trauma cases, for implementation with the aim of improving health service delivery to children sustaining severe injury. METHODS: A modified-Delphi study was conducted between October 2018 and February 2019. Two rounds of an online survey to rank the suitability and importance of each of the 26 recommendations was conducted. Final decisions on the priorities for change in the paediatric trauma system was determined by a consensus of ≥80% for importance and/or suitability. RESULTS: One hundred and one participants completed Round 1, and 60 participants completed Round 2 of the modified-Delphi. In Round 1, 13 recommendations reached ≥80% and in round 2, 11 recommendations reached ≥80%. Those ranked highest focussed on pre-hospital airway management, streamlining retrieval and transfer processes, improving hospital nursing ratios and radiology reporting. CONCLUSION: This modified-Delphi study identified the priority areas for recommended change to the NSW paediatric trauma system. Work to address these areas has the potential to provide more coordinated and timely care to children sustaining severe injury.

Identifying areas for improvement in paediatric trauma care in NSW Australia using a clinical, system and human factors peer-review tool.

BACKGROUND: There is known variability in the quality of care delivered to injured children. Identifying where care improvement can be made is critical. This study aimed to review paediatric trauma cases across the most populous Australian State to identify factors contributing to clinical incidents. METHODS: Medical records from three New South Wales Paediatric Trauma Centres were reviewed for children <16 years requiring intensive care; with an injury severity score of ≥9, or who died following injury between July 2015 and September 2016. Records were peer-reviewed by nurse surveyors who identified cases that might not meet the expected standard of care or where the child died following the injury. A multidisciplinary panel conducted the peer-review using a major trauma peer-review tool. Records were reviewed independently, then discussed to establish consensus. RESULTS: A total 535 records were reviewed and 41 cases were peer-reviewed. The median (IQR) age was 7 (2-12) years, the median ISS was 25 (IQR 16-30). The peer-review identified a combination of clinical (85%), systems (51%) and communication (12%) problems that contributed to difficulties in care delivery. In 85% of records, staff actions were identified to contribute to events; with medical task failure the most frequently identified cause (89%). CONCLUSION: The peer-review of paediatric trauma cases assisted in the identification of contributing factors to clinical incidents in trauma care resulting in 26 recommendations for change. The prioritisation and implementation of these recommendations, alongside a uniform State-wide trauma case review process with consistent criteria (definitions), performance indicators, monitoring and reporting would facilitate improvement in health service delivery to children sustaining severe injury.

Development of the major trauma case review tool.

BACKGROUND: As many as half of all patients with major traumatic injuries do not receive the recommended care, with variance in preventable mortality reported across the globe. This variance highlights the need for a comprehensive process for monitoring and reviewing patient care, central to which is a consistent peer-review process that includes trauma system safety and human factors. There is no published, evidence-informed standardised tool that considers these factors for use in adult or paediatric trauma case peer-review. The aim of this research was to develop and validate a trauma case review tool to facilitate clinical review of paediatric trauma patient care in extracting information to facilitate monitoring, inform change and enable loop closure. METHODS: Development of the trauma case review tool was multi-faceted, beginning with a review of the trauma audit tool literature. Data were extracted from the literature to inform iterative tool development using a consensus approach. Inter-rater agreement was assessed for both the pilot and finalised versions of the tool. RESULTS: The final trauma case review tool contained ten sections, including patient factors (such as pre-existing conditions), presenting problem, a timeline of events, factors contributing to the care delivery problem (including equipment, work environment, staff action, organizational factors), positive aspects of care and the outcome of panel discussion. After refinement, the inter-rater reliability of the human factors and outcome components of the tool improved with an average 86% agreement between raters. DISCUSSION: This research developed an evidence-informed tool for use in paediatric trauma case review that considers both system safety and human factors to facilitate clinical review of trauma patient care. CONCLUSIONS: This tool can be used to identify opportunities for improvement in trauma care and guide quality assurance activities. Validation is required in the adult population.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: protocol for a mixed methods cohort study.

BACKGROUND: Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear. The objective of this study is to review the processes of care and describe the impacts of a regionalised trauma system on the outcomes of severely injured children. METHODS: This article describes the design of a mixed methods cohort study evaluating the paediatric trauma system in New South Wales (NSW), the most populous state in Australia. Recommendations and an implementation strategy will be developed for aspects of the paediatric trauma care system that require change. All injured children (aged <16 years) requiring intensive care, or with an Injury Severity Score (ISS) ≥ 9 treated in NSW, or who died following injury in NSW in the 2015-16 financial year, will be eligible for participation. Injury treatment and processes will be examined via retrospective medical record review. Quality of care will be measured via peer review and staff interviews, utilising a human factors framework. Health service and cost outcomes will be calculated using activity based funding data provided by the Ministry of Health. Health-related quality of life (HRQoL) proxy measures will occur at baseline, 6 and 12 months to measure child HRQoL and functional outcomes. DISCUSSION: This will be the first comprehensive analysis undertaken in Australia of the processes and systems of care for severe paediatric injury. The collaborative research method will encourage clinician, consumer and clinical networks to lead the clinical reform process and will ultimately enable policy makers and service providers to ensure that children seriously injured in Australia have the best opportunity for survival, improved functional outcome and long-term quality of life.

Implementation and Evaluation of a Ward-Based eLearning Program for Trauma Patient Management.

The majority of trauma nursing education is focused on the emergency phases of care. We describe the development and evaluation of a trauma eLearning module for the ward environment. The module was developed using adult learning principles and implemented in 2 surgical wards. There were 3 phases of evaluation: (1) self-efficacy of nurses; (2) relevance and usability of the module and; (3) application of knowledge learnt. The majority indicated they had applied new knowledge, particularly when performing a physical assessment (85.7%), communicating (91.4%), and identifying risk of serious illness (90.4%). Self-efficacy relating to confidence in caring for patients, communication, and escalating clinical deterioration improved (p = .023). An eLearning trauma patient assessment module for ward nursing staff improves nursing knowledge and self-efficacy.

Is there a relationship between personality and choice of nursing specialty: an integrative literature review.

BACKGROUND: Personality is deemed to play a part in an individual's choice of work, with individuals' preferencing a profession or field of work that will satisfy their personal needs. There is limited research exploring the personality characteristics of nurses within clearly defined nursing specialty areas. Retaining nurses within specialty areas has workforce implications when vacancies are unable to be filled by appropriately experienced staff. The aim of the review was to determine the current state of knowledge regarding the personality profiles of nurses in specialty areas of nursing practice. METHODS: An integrative literature review was undertaken. Five electronic databases were searched using personality and nursing based keywords. No date limit or research design restriction was applied. Rigorous screening and quality appraisal was undertaken considering the research design, methods and limitations of each manuscript. RESULTS: A review of the 13 included articles demonstrated some variability in the personality characteristics of the nursing specialty groups studied. A relationship was identified between personality characteristics and levels of nursing stress and burnout. CONCLUSION: There is some evidence to suggest a relationship between personality characteristics and nursing specialty choice, burnout and job satisfaction. The published literature is limited and the effect of personality on retention is not well established.

The personality of emergency nurses: is it unique?

BACKGROUND: With ever increasing demands on emergency services it is necessary to consider how to enhance the recruitment and retention of emergency nurses in public hospitals. Personality is known to influence occupational choice, yet there is a lack of research exploring how personality may influence the workforce decisions of emergency nurses. METHODS: A standardised personality test instrument, the NEO™-PI-3, was used in a survey design inclusive of demographic questions to measure personality characteristics. Data were collected from 72 emergency nurses working at an Australian Emergency Department between July and October 2012. The personality scores of emergency nurses were compared against general population norms in each of five personality domains and their 30 associated facets. RESULTS: Participants scored higher than population norms in the domains of Extraversion (p < .001), Openness to experience (p < .001) and Agreeableness (p = .001), and in twelve facets, including excitement-seeking (p < .001) and competence (p = .003). CONCLUSION: The personality profile of this sample of emergency nurses is different to the population norm. Assessment of personality and knowledge of its influence on specialty selection may assist in improving retention and recruitment in emergency nursing.