Background
Clinical documentation by emergency nurses supports effective communication, improves patient safety and is a professional and legal responsibility, yet documentation is often incomplete, poor quality, or inaccurate.
HIRAID® (History including Infection risk, Red Flags, Assessment, Interventions, Diagnostics, communication and reassessment) is a validated framework that supports nurses in assessment and management of patients in the emergency department. As part of a larger evaluation, HIRAID® was implemented in a large rural health district using an implementation strategy informed by behaviour change theory.
This study aimed to evaluate the quality of initial nursing documentation in the rural context pre-post implementation of the HIRAID® emergency nursing framework.
Methods
A quasi-experimental, pre-post study design was conducted across ten emergency departments in rural NSW during 2020/21. A previously validated modified D-catch instrument was used to evaluate emergency nurses’ initial documentation for a three-month period before and repeated six months after implementation. The instrument assessed the quality and quantity of documentation on a four-point ordinal scale. Following power calculations, records meeting inclusion were randomised for review.
Results
In 222 records (110 pre/112 post) there was significant improvement in initial ED nursing documentation. Post-implementation there was a significant increase in the mean (SD) scores for the quantity of documentation elements for all areas, in particular, structure (1.6(0.9) -3.3(1.1), p<0.0001), history (1.9(1.1) - 3(1.1), p<0.001) and red flags (1.5(0.9) – 2.3(1.3), p<0.0001). The quality of documentation also significantly improved, with the greatest improvement in areas of history (1.5(0.6) – 2.3(0.8), p<0.001) and assessment (1.6(0.7) – 2.3(0.9), p<0.001).
Conclusion
Emergency nursing initial documentation six-months after the implementation of the HIRAID® demonstrated significant improvement across all areas following a behaviour change informed strategy for practice change. Improved documentation is key to informing and evaluating ongoing care, supporting communication and continuity of care, and is essential to patient safety.