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The effectiveness of nurse-initiated interventions in the Emergency Department: A systematic review

  • Luke Burgess
    Correspondence
    Corresponding author at: School of Nursing, Queensland University of Technology, Australia.
    Affiliations
    School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia

    Emergency Department, Mater Health Services, Brisbane, QLD, Australia
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  • Kathryn Kynoch
    Affiliations
    Evidence in Practice Unit and The Queensland Centre for Evidence Based Nursing and Midwifery, A JBI Centre of Excellence, Mater Health, Brisbane, Australia
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  • Karen Theobald
    Affiliations
    School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia
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  • Samantha Keogh
    Affiliations
    School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia
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Published:March 13, 2021DOI:https://doi.org/10.1016/j.auec.2021.01.003

      Abstract

      Background

      Nurse-initiated interventions potentially provide an opportunity for earlier response for time sensitive presentations to the Emergency Department, and may improve time-to-treatment, symptomatic relief and patient flow through the department.

      Objective

      To determine the effectiveness of nurse-initiated interventions on patient outcomes in the Emergency Department.

      Method

      The review followed the JBI methodology for reviews of quantitative evidence. Each study was assessed by two independent reviewers and data were extracted from included papers using standardized data extraction tools. Outcomes of interest included time-to-treatment, relief of acute symptoms, waiting times and admission rates.

      Results

      Twenty-six studies were included in the final review, with a total of 9144 participants. Nine were randomized control trials, 17 had a quasi-experimental design. Twelve of the studies involved pediatric patients only and 14 included adult patients only. Interventions, protocols and outcomes were heterogeneous across studies. Overall, nurse-initiated interventions were effective in reducing time-to-analgesia, time-to-treatment for acute respiratory distress as well as improved pain relief and decreased admission rates.

      Conclusion

      To achieve early intervention and timely relief of acute symptoms, nurses should seek to consistently implement nurse-initiated interventions into their care of patients in the Emergency Department. Several findings are made to inform practice, however future high-quality research with locally specific strategies is required to improve certainty and quality of findings.

      Keywords

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      References

        • Forero R.
        • Nugus P.
        Australasian College for Emergency Medicine (ACEM) Literature review on the Australasian triage scale (ATS).
        2012
      1. Australian Institute of Health and Welfare. Emergency department care 2016-2017. Australian hospital statistics, 2017
        • Streppa J.
        • Schneidman V.
        • Biron A.
        Requesting wrist radiographs in emergency department triage. Developing a training program and diagnostic algorithm.
        Adv Emerg Nurs J. 2014; 36: 62-77
        • Muntlin
        • Carlsson M.
        • Säfwenberg U.
        • Gunningberg L.
        Outcomes of a nurse-initiated intravenous analgesic protocol for abdominal pain in an emergency department: a quasi-experimental study.
        Int J Nurs Stud. 2011; 48: 13-23
        • Taylor D.
        • Taylor S.
        • Jao K.
        • Goh S.
        A clinical intervention trial of nurse-initiated analgesia for paediatric patients in the emergency department.
        Emerg Med Australas. 2013; 25: 14
        • Goh H.
        • Choo S.
        • Lee I.
        • Tham K.
        Emergency department triage nurse initiated pain management.
        Hong Kong J Emerg Me. 2007; 14: 16-21
        • Charney R.L.
        • Yan Y.
        • Schootman M.
        • Kennedy R.M.
        • Luhmann J.D.
        Oxycodone versus codeine for triage pain in children with suspected forearm fracture: a randomized controlled trial.
        Pediatr Emerg Care [Internet]. 2008; : 595-600
        • Taylor D.
        • Liversidge X.
        • Liu B.
        • Ling S.
        • Taylor S.
        Variables associated with a high level of parent satisfaction with their child’s pain management in the emergency department.
        Emerg Med Australas. 2015; 27: 24
        • Varndell W.
        • Fry M.
        • Elliott D.J.I.
        Quality and impact of nurse-initiated analgesia in the emergency department: a systematic review. 2018; 40: 46-53
        • Cabilan C.
        • Boyde M.
        A systematic review of the impact of nurse-initiated medications in the emergency department.
        Australas Emerg Nurs J. 2017;
        • Considine J.
        • Shaban R.Z.
        • Curtis K.
        • Fry M.
        Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review.
        Eur J Emerg Med. 2019; 26: 314-322
        • Burgess L.
        • Kynoch K.
        Effectiveness of nurse-initiated interventions on patient outcomes in the emergency department: a systematic review protocol.
        JBI Database System Rev Implement Rep. 2017; 15: 873-881
        • Tufanaru C.
        • Munn Z.
        • Aromataris E.
        • Campbell J.
        • Hopp L.
        Chapter 3: systematic reviews of effectiveness.
        in: Aromataris E. Munn Z. JBI manual for evidence synthesis. 2020
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        • Group P.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Considine J.
        • Shaban R.Z.
        • Curtis K.
        • MJE Fry
        Effectiveness of nurse-initiated X-ray for emergency department patients with distal limb injuries: a systematic review. 2019; 26: 314-322
        • Oredsson S.
        • Jonsson H.
        • Rognes J.
        • Lind L.
        • Göransson Ke
        • Ehrenberg A.
        • et al.
        A systematic review of triage-related interventions to improve patient flow in emergency departments.
        Scand J Trauma Resusc Emerg Med. 2011; 19: 1
        • Jones P.
        • Schimanski K.
        The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes.
        Emerg Med Australas. 2010; 22: 391-398
      2. Higgins J. Green S.E. Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. 2011
        • Waddington H.
        • Aloe A.M.
        • Becker B.J.
        • Djimeu E.W.
        • Hombrados J.G.
        • Tugwell P.
        • et al.
        Quasi-experimental study designs series—paper 6: risk of bias assessment.
        J Clin Epidemiol. 2017; 89: 43-52
        • Goodacre S.
        Uncontrolled before-after studies: discouraged by Cochrane and the EMJ.
        BMJ Publishing Group Ltd and the British Association for Accident & Emergency Medicine, 2015
        • Boyd R.J.
        • Stuart P.
        The efficacy of structured assessment and analgesia provision in the paediatric emergency department.
        Emerg Med J. 2005; 22: 30-32
        • Fosnocht D.E.
        • Swanson E.R.
        Use of a triage pain protocol in the ED.
        Am J Emerg Med. 2007; 25: 791-793
        • Pierik J.G.J.
        • Berben S.A.
        • Ijzerman M.J.
        • Gaakeer M.I.
        • van Eenennaam F.L.
        • van Vugt A.B.
        • et al.
        A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain.
        Int Emerg Nurs. 2016; 27: 3-10
        • Dewhirst S.
        • Zhao Y.
        • MacKenzie T.
        • Cwinn A.
        • Vaillancourt C.
        Evaluating a medical directive for nurse-initiated analgesia in the Emergency Department.
        Int Emerg Nurs. 2017; 35: 13-18
        • Schoolman-Anderson K.
        • Lane R.D.
        • Schunk J.E.
        • Mecham N.
        • Thomas R.
        • Adelgais K.
        Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: effect of implementation.
        Am J Emerg Med. 2018;
        • Wong E.M.L.
        • Chan H.M.S.
        • Rainer T.H.
        • Ying C.S.
        The effect of a triage pain management protocol for minor musculoskeletal injury patients in a Hong Kong emergency department.
        Australas Emerg Nurs J. 2007; 10: 64-72
        • Caspi S.
        • Meidan R.
        • Peless E.
        • Raizman E.J.I.
        Nurse-initiated oral opioid pain protocol improves the quality of musculoskeletal pain management in the emergency department. 2019; 43: 29-33
        • Brown K.
        • Iqbal S.
        • Sun S.-L.
        • Fritzeen J.
        • Chamberlain J.
        • Mullan P.C.
        Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis.
        BMJ Qual Improv Rep. 2016; 5 (u216506. w5621)
        • Ho J.
        • Yau W.
        Nurse-initiated albuterol metered-dose inhaler for acute exacerbations of chronic obstructive pulmonary disease in an emergency department: a randomised controlled trial.
        Hong Kong J Emerg Me. 2012; 19: 162
        • Qazi K.
        • Altamimi S.A.
        • Tamim H.
        • Serrano K.
        Impact of an emergency nurse-initiated asthma management protocol on door-to-first-salbutamol-nebulization-time in a Pediatric Emergency Department.
        J Emerg Nurs. 2010; 36: 428-433
        • Zemek R.
        • Plint A.
        • Osmond M.H.
        • Kovesi T.
        • Correll R.
        • Perri N.
        • et al.
        Triage nurse initiation of corticosteroids in pediatric asthma is associated with improved emergency department efficiency.
        Pediatrics [Internet]. 2012; : 671-680
        • Brown K.
        • Iqbal S.
        • Sun S.-L.
        • Fritzeen J.
        • Chamberlain J.
        • Mullan P.C.
        Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis.
        BMJ Qual Improv Rep. 2016; 5
        • Ho C.
        • Rainer T.H.
        • Graham C.A.
        Nurse initiated reinsertion of nasogastric tubes in the Emergency Department: a randomised control trial.
        Australas Emerg Nurs J. 2013; 16: 136-143
        • Long M.
        • Farion K.J.
        • Zemek R.
        • Voskamp D.
        • Barrowman N.
        • Akiki S.
        • et al.
        A nurse-initiated jaundice management protocol improves quality of care in the paediatric emergency department.
        Paediatr Child Health. 2017; 22: 259-263
        • Darvish A.H.
        • Shroff S.D.
        • Mostofi M.B.
        • Weiner S.
        • Sarff A.R.
        Single-operator ultrasound-guided IV placement by emergency nurses.
        Eur J Emerg Med [Internet]. 2011; : 298-299
        • Ridderikhof M.L.
        • Schyns F.J.
        • Schep N.W.
        • Lirk P.
        • Hollmann M.W.
        • Goslings J.C.
        Emergency department pain management in adult patients with traumatic injuries before and after implementation of a nurse-initiated pain treatment protocol utilizing fentanyl for severe pain.
        J Emerg Med. 2017; 52: 417-425
        • Farion K.J.
        • Splinter K.L.
        • Newhook K.
        • Gaboury I.
        • Splinter W.M.
        The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial.
        CMAJ [Internet]. 2008; : 31-36
        • Singer A.J.
        • Stark M.J.
        Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized double-blind trial.
        Acad Emerg Med [Internet]. 2000; : 751-756
        • Wilson J.G.
        The effect of nurse initiated paracetamol on emergency department patients with pain from low acuity injury.
        Edith Cowan University, Churchlands, Western Australia2008
        • Yau C.
        • Ho S.
        • Chan C.
        A nurse-initiated early pain management program (NIEPMP) for the management of acute low back pain in Emergency Medicine Ward: a randomized controlled pilot study.
        J Pain. 2012; 13: S61
        • Sepahvand M.
        • Gholami M.
        • Hosseinabadi R.
        • Beiranvand A.J.P.M.N.
        The use of a nurse-initiated pain protocol in the Emergency Department for patients with musculoskeletal injury: a pre-post intervention study. 2019; 20: 639-648
        • Dixon A.
        • Clarkin C.
        • Barrowman N.
        • Correll R.
        • Osmond M.H.
        • Plint A.C.
        Reduction of radial-head subluxation in children by triage nurses in the emergency department: a cluster-randomized controlled trial.
        CMAJ. 2014; 186: E317-E323
        • Hendrickson M.A.
        • Zaremba J.
        • Wey A.R.
        • Gaillard P.R.
        • Kharbanda A.B.
        The use of a triage-based protocol for oral rehydration in a pediatric emergency department.
        Pediatr Emerg Care. 2017;
        • Middleton S.
        • Dale S.
        • Cheung N.W.
        • Cadilhac D.A.
        • Grimshaw J.M.
        • Levi C.
        • et al.
        Nurse-initiated acute stroke care in emergency departments: the triage, treatment, and transfer implementation cluster randomized controlled trial. 2019; 50: 1346-1355
        • Doherty S.
        • Knott J.
        • Bennetts S.
        • Jazayeri M.
        • Huckson S.
        National project seeking to improve pain management in the emergency department setting: findings from the NHMRC‐NICS National Pain Management Initiative.
        Emerg Med Australas. 2013; 25: 120-126
        • Hatherley C.
        • Jennings N.
        • Cross R.
        Time to analgesia and pain score documentation best practice standards for the Emergency Department–a literature review.
        Australas Emerg Nurs J. 2016; 19: 26-36
        • Todd K.H.
        • Ducharme J.
        • Choiniere M.
        • Crandall C.S.
        • Fosnocht D.E.
        • Homel P.
        • et al.
        Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study.
        J Pain. 2007; 8: 460-466
        • Schug S.A.
        • Palmer G.M.
        • Scott D.A.
        • Halliwell R.
        • Trinca J.
        Acute pain management: scientific evidence.
        Acute Pain Management: Scientific Evidence. 2015; (lxiv)
        • Gerdtz M.
        • Considine J.
        • Sands N.
        • Stewart C.
        • Crellin D.
        • Pollock W.
        • et al.
        Emergency triage education kit.
        Department of Health and Ageing, Canberra2007: 19
        • Morley C.
        • Unwin M.
        • Peterson G.M.
        • Stankovich J.
        • Kinsman L.J.Po
        Emergency department crowding: a systematic review of causes, consequences and solutions. 2018; 13e0203316