Nurse-Initiated Protocols Can Improve Timeliness of Care in an Urban Emergency Department Interview with
Mathew Douma, RN BSN ENC(C) CNCC(C)
Emergency Department, Royal Alexandra Hospital
Edmonton, Alberta, Canada; Masters of Nursing Student
University of Toronto, Toronto What is the background for this study?

Response: Many emergency departments experience crowding, which is typically defined as a situation where demands for service exceed the ability of the emergency department to provide quality care in a timely fashion. Typically when patients are waiting in a waiting room they do not undergo diagnostics or treatments. In an effort to speed the process up and reduce the amount of time the patient spends in the emergency department, some facilities have created protocols for diagnostics or treatments typically outside the traditional scope of practice of nursing staff.

Our emergency department had protocols like this for almost 15 years, though we had never evaluated their effectiveness. So an interdisciplinary group in our emergency department updated them and then we set out to evaluate them. What are the main findings?

Response: Our main findings are that for specific well defined patient population with predictable conditions, protocols appear to reduce their emergency department length of stay.

One hundred and forty three patients were randomized, over 43 days, 76 in the protocol and 67 in the control group. Most patients (n=126) were enrolled from triage. Having nurses administer acetaminophen prior to patient being seen by a physician reduced the median time-to-analgesia/antipyretic by 186 minutes. When nurses suspected that patients had a fractured hip, our protocol reduced the median time to x-ray by 257 minutes and reduced the median patient length of stay in the emergency department by 224 minutes.

When our nurses suspected a patient might be experiencing ischemic chest the use of a protocol to test for myocardial infarction using a blood test resulted in a reduction to reporting of this test by a median time of 79 minutes. This was especially useful in identifying patients actually having a myocardial infarction who would have waited for a care space become available. This additional information allowed triage nurses to get them in front of a physician faster. One of our most effective protocols was for vaginal bleeding during pregnancy which reduced the median ED length of stay by 232 minutes.

Ninety-seven percent (29/30) of nurses were “confident” the protocols represent the diagnostics the physicians send “most” or “all of the time.”

Of the 33 physician satisfaction responses with the nurse-implemented protocols: 29 (88%) were “satisfied or assisted,” and the remaining four (12%) were “neutral or unaffected”. What should readers take away from your report?

Response: Targeting specific patient groups with carefully focused protocols can result in improved time to test or medication, and in some cases reduce patient ED length of stay. We believe a cooperative and collaborative interdisciplinary group is essential to nurse implemented protocol success.

In an ideal state the emergency department crowding would be relieved, you would get to the root cause and solve the problem resulting in crowding and delays in quality care. Protocols are a strategy that can improve things while works to solve the underlying problem are undertaken. What recommendations do you have for future research as a result of this study?

Response: Future studies into additional patient presentations that might benefit from using protocols or expansion of nurse scope of practice may be undertaken to expand the knowledge base. What’s really needed is research into what solutions work for preventing the crowding in the first place. Is there anything else you would like to add?

Response: It was interesting combining improvement work and research processes. In reporting this study we combined both the CONSORT guidelines for pragmatic trials and SQUIRE 2.0 for reporting improvement work. We believe we are the first authors to combine the two and we hope it makes for a transparent and rigorous evaluation.

Most importantly however, the staff in our emergency department should really be applauded for all their hard work evaluating our protocols. It was a lot of extra work for the nurses and challenging for them to randomize patients and rigorously evaluate the protocols. I’m especially grateful for our physician group’s collaboration and support as well. Thank you for your contribution to the community.


Ann Emerg Med. 2016 Jul 25. pii: S0196-0644(16)30297-9.
doi: 10.1016/j.annemergmed.2016.06.019. [Epub ahead of print]
A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department.
Douma MJ1, Drake CA2, O’Dochartaigh D3, Smith KE4.

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on September 2, 2016 by Marie Benz MD FAAD