Evaluating a medical directive for nurse-initiated analgesia in the Emergency Department
Introduction
Acute pain is the most common primary complaint seen in the emergency department (ED) [1], [2]. Unfortunately, pain is often poorly treated in the ED [2], [3], [4], [5], [6], [7]. In particular, patients expect to receive analgesics more rapidly than routinely occurs. A survey of ED patients revealed they expected to receive analgesics within 30 min of their arrival [5]. Although triage nurses routinely assess patients’ pain, medications are usually not provided prior to being ordered by a physician, which leads to significant delays in analgesia. Nurse-initiated analgesia protocols have been proposed as a potential solution to decrease the time to first dose of analgesics in the ED [2], [8], [9].
In October 2011, The Ottawa Hospital ED introduced a medical directive enabling nurses to provide three classes of oral analgesic medications to a broad spectrum of patients presenting to the ED with pain, prior to the patient being seen by a physician (see Appendix).
This protocol is generally applied by the triage nurse, but can be applied by any ED nurse looking after a patient. Eligible patients under this medical directive may receive any combination of the three medications (Acetaminophen 975 mg, Naproxen 250 mg, Tramadol 50 mg), depending on the severity of pain, and on the presence of pre-specified contraindications to each medication. Thus, for example, a patient who had recently taken Acetaminophen might still be eligible to receive Naproxen and Tramadol.
The objectives of this study were to assess the impact of this medical directive on (i) the proportion of patients receiving analgesics, of any kind, in the ED; (ii) the mean time interval between ED arrival and the administration of the first dose of analgesic, (iii) the proportion of patients receiving analgesics in the first 30 min of their ED arrival, and (iv) the mean total length of stay in the ED. We chose to limit our patient population to patients presenting with musculoskeletal back pain in order to decrease clinical heterogeneity, and because guidelines suggest these patients do not routinely require investigations or management beyond analgesia [10].
Section snippets
Study design and setting
We conducted this before-after health record review at two of the three Ottawa Hospital campuses between September 2010 and December 2012. The Ottawa Hospital is a tertiary care, University affiliated institution with an annual ED census of 160,000 visits. The Civic campus of the Ottawa Hospital is a level one accredited trauma center.
Medical directive development and implementation
The Medical Directive was developed by a team of experienced local emergency physicians and nurses, based on local prescribing patterns, best practices, and local
Characteristics of study subjects
A total of 524 cases were identified for review, of which 401 remained after applying our exclusion criteria (Fig. 1). Inter-rater reliability was very good, with a kappa of 0.92 (95% CI of 0.81–1.0). There were 201, and 200 patients in the pre- and post-implementation groups respectively. We also show the breakdown of patients within the post-implementation phase. There were 50 patients who received the protocol, among which two patients received the protocol incorrectly. In both cases, the
Discussion
In this before-after health record review, a medical directive for nurse-initiated analgesia was associated with significantly decreased time to first dose of analgesic, and an increase in the proportion of patients receiving analgesics within the first 30 min when compared to a historical control group. There was no change in overall proportion of patients receiving analgesics, or the total ED length of stay.
Previous studies have found nurse initiated analgesia protocols to be safe and
Conclusion
In summary, we found that a nurse-initiated analgesia protocol was associated with a decreased time to first dose of analgesia and a higher proportion of patients receiving analgesia within 30 min of their ED arrival, but that it had no effect on the proportion of patients receiving analgesia or their total length of stay in the ED.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of interest
None
Acknowledgements
We would like to thank all the nurses and educators at the Ottawa Hospital Emergency Department for their hard work implementing this protocol, and commitment to excellent patient care. We would also like to thank Angela Marcantonio for her assistance with obtaining ethics approval and preparing this manuscript for submission.
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