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.

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.

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.

Nursing praxis, compassionate caring and interpersonal relations: an observational study.

BACKGROUND: The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests, treat and manage a range of patient conditions. The CIN role is focused on the waiting room and to 'communicate the wait', initiate diagnostics or treatment and follow-up for waiting room patients. We aim to explore what emergency nurses' do in their extended practice role in observable everyday life in the emergency department (ED). The paper argues that compassionate caring is a core nursing skill that supports CIN interpersonal relations, despite the role's highly clinical nature. METHOD: Sixteen non-participant observations were undertaken in three EDs in New South Wales, Australia. Nurses were eligible for inclusion if they had two years of emergency experience and had worked in the CIN role for more than one year. All CIN's that were observed were highly experienced with a minimum three year ED experience. RESULTS: The CIN observations revealed how compassionate caring was utilised by CIN's to quickly build a therapeutic relationship with patients and colleagues, and helped to facilitate core communication and interpersonal skills. While the CIN role was viewed as extended practice, the role relied heavily on compassionate care to support interpersonal relationships and to actualise extended practice care. CONCLUSION: The study supports the contribution made by emergency nurses and demonstrates how compassionate caring is central to nursing praxis. This paper also demonstrates that the CIN role utilises a complex mix between advanced clinical skills and compassion that supports interpersonal and therapeutic relationships. Further research is needed to understand how compassionate care can be optimised within nursing praxis and the duty of care between nurses and patients, nurses and other health care professionals so that future healthcare goals can be realised.

Managing the wait: clinical initiative nurses' perceptions of an extended practice role.

INTRODUCTION: The Clinical Initiative Nurse (CIN) is a role that requires experienced emergency nurses to assess, initiate diagnostic tests and treat and manage a range of patient conditions. In 2010, the New South Wales Ministry of Health redefined the focus of the CIN role to be on waiting room patients. The new CIN role was now focused on the waiting room and to 'communicate the wait', initiate diagnostics and or treatment and follow-up for waiting room patients. While new models of care are often introduced the perceptions of those undertaking the roles are often absent from evaluation. We aimed to explore emergency nurses' perceptions of the extended practice role known as the Clinical Initiative Nurse. METHOD: This was a multicentre study and formed part of a larger qualitative exploratory study of the CIN role. RESULTS: Thirty-six interviews were conducted across the three sites. There was no statistical difference between groups for hospital site, ED experience or Clinical Nurse Specialist grade. Three main themes were identified from the data and included (i) managing the waiting room patient; (ii) benefits of being the CIN; and (iii) situational barriers impacting on the CIN role. CONCLUSION: We have provided a deeper understanding of the CIN role and of contextual factors operating in everyday practice. Further research is needed to determine how nursing roles can be sustained, learned, enjoyed and optimised to meet future healthcare goals.

A 12 month retrospective study of airway management practices.

INTRODUCTION: Australian emergency nurses have a primary role in advanced airway management. Consequently, they need to be competent in, and have a systematic approach to, airway preparation, management and rescue. AIM: The aims of the study were to (i) identify all patients undergoing endotracheal intubations in the emergency department; (ii) describe patient characteristics, diagnosis and disposition; and, (iii) review the introduction of an advanced airway management algorithm and difficult airway equipment tray. METHODS: A 12 month retrospective study was undertaken (1/1/2006 to 31/12/2006) of all patients requiring oral endotracheal intubation. A survey was conducted to determine nursing confidence and practice with intubation and the benefit of introducing an advanced airway management algorithm and a preassembled difficult airway equipment tray. RESULTS: Two hundred and fifty three patients required intubation during the study. The age ranged from neonates/infants to 98 years. Emergency nurses felt confident in assisting with endotracheal intubation and regularly encountered airway rescue situations. The pre-assembled difficult airway equipment and airway management algorithm led to improved confidence and practice. CONCLUSION: Endotracheal intubation is a regular ED intervention. Emergency nurses need to have knowledge of airway management and rescue. A developed airway management algorithm and difficult airway equipment tray improved nursing confidence, expertise and response time in advanced airway interventions.