From the emergency room to aged care: the potential of HIRAID

To many in health care, ‘ABC’ in emergency care (Airways, Breathing, Circulation) is as familiar as the alphabet itself, but registered nurse Professor Kate Curtis discovered there needed to be a more comprehensive way for nurses to assess patients when they arrived in the emergency department (ED).

Professor Curtis found there was no structured approach that helped nurses gather patient information easily. When developing the University of Sydney teaching curriculum with Dr Margaret Murphy (Westmead ED), she wanted to create a simple and efficient system that would guide how nurses assess and triage patients quickly and efficiently after they were triaged at the emergency department.

“Emergency nursing practice is a highly complex situation. When a patient first presents to the emergency department, the triage nurse needs to not only assess the patient, but also determine the clinical urgency,” said Professor Curtis from the University of Sydney and Wollongong Emergency Department.

“Emergency nurses are the first clinicians that patients have contact with. They are responsible for the initial and ongoing assessment, management and safety of patients of all ages with varying degrees of severity and urgency of illness or injury.

“Those are all essential elements of safe, quality nursing care and ultimately the patient’s safety — and this needs to be done accurately and efficiently.”

Professor Curtis says emergency nurses assess and manage patients of all ages, with varying degrees of clinical urgency and severity.

The quality of nurses’ initial and ongoing assessment is also crucial as emergency department patients often have extended wait times. The patients may also be in pain, or have undiagnosed conditions or unstable conditions that carry risk of deterioration.

Across Australia in 2021, only 63% of urgent patients were seen by medical officers within 30 minutes of arriving at the emergency department. During that time, the patients were in the care of emergency nurses.

“However, before there was no standardised structure to guide this, the closest was the ‘ABC’ triage method, which is important but does not cover the complexity of patients presenting to the ED,” Professor Curtis said.

“This has led to unwarranted variation in nursing care, avoidable patient deterioration, poor pain management, poor nursing documentation, human suffering and patient dissatisfaction with emergency care.”

A seven-step model

What Professor Curtis created with Dr Margaret Murphy was HIRAID, a program to triage and care for patients — a seven-step nursing model for emergency department patients.

HIRAID stands for History, Identify Red flags, Assessment, Interventions, Diagnostic, reassessment and communication.

What makes HIRAID stand out is that it is a streamlined system that helps nurses to also gather information about a patient’s medical history and infection risk. This can be used by emergency nurses who need to quickly assess patients and triage for treatment, and have confidence in their findings and interventions, particularly when escalating to medical staff.

But for the benefits of HIRAID to be realised, it must be implemented properly, ensuring nurses are appropriately trained, equipped and enabled to use HIRAID in the real world.  

A trial in the Illawarra Shoalhaven Local Health District showed a 50% reduction in patient deterioration and over $1 million savings per year. While it was developed before the pandemic, the system has proven useful amid high rates of COVID-19 and other respiratory viruses.

Now working with Professor Ramon Shaban, they both want to bring emergency-department-level assessment and infection control to aged care. HIRAID aims to bring emergency room and infection control protocols to aged care.

At the COVID-19 pandemic frontline

Both Professor Curtis and Professor Ramon Shaban were at the frontlines when the COVID-19 pandemic began.

Professor Shaban was present at the aged care outbreaks in Sydney’s western region and saw firsthand the value of healthcare infection control training for residents.

“This pandemic has really emphasised that aged care facilities needed to be treated like healthcare facilities; HIRAID has shown it is an effective method to assess people who need care in the emergency department quickly and efficiently in a resource- and time-limited setting. There is a real potential for HIRAID to be applied in aged care facilities,” said Professor Shaban, clinical chair of communicable diseases and infection prevention at the University of Sydney and director of infection prevention and disease control at Western Sydney Local Health District.

“HIRAID is a way to support and upskill nurses and places patients and residents front and centre.

“HIRAID in aged care will meet the contemporary practice needs of registered nurses who lead and manage the care of older Australians in residential aged care facilities. The system is co-designed and tested by them and the recipients of their care in partnership with leading aged care providers and other agencies that are committed to providing quality care in aged care nationally.”

Currently HIRAID is being used in the Illawarra Shoalhaven, Southern NSW, Northern NSW and Western Sydney Local Health District Emergency Departments. The goal is for aged care facilities to use HIRAID nationwide.  

Scaling up HIRAID meets clinician Australian emergency research priorities and actions of the Australian Commission on Safety and Quality in Health Care. This includes reducing unwarranted clinical variation and to promote more equitable access to better value health care.  It also aligns with actions in the National Safety and Quality Health Service Standards which apply to more than 1300 facilities nationwide.

HIRAID was a recipient of the Australian Council on Healthcare Standards 24th annual quality improvement award in Clinical Excellence and Patient Safety Award for safer, better emergency nursing care and ‘a proven, up-scalable emergency nursing framework’ aimed at ensuring emergency nurses have an evidence base for their initial assessment and management of patients who enter emergency.

Image caption: Dr Margaret Murphy (left) and Professor Kate Curtis. Image: Supplied.

Originally published here.