Lynchburg Journal of Medical Science

Lynchburg Journal of Medical Science


Emergency Medicine


Dr. Thomas Colletti




Emergency department overcrowding and CMS reimbursement measures have brought increased attention to exploring effective process improvements. The use of front-end models which apply providers in triage has been well researched and increasingly popular. For small emergency departments, the financial expenditures associated with implementing this type of front-end model may not be feasible. Strategies to improve patient flow using the available department resources should be explored. By having nurses initiate specific orders following evidence-based protocols, certain segments of a patient's throughput can be altered such as time waiting for re-evaluation after a provider orders imaging, or early relief of symptoms. Having each member of the healthcare team work at their full scope can maximize efficiency with the same amount of resources.

Objectives were to explore the benefits and outcomes of implementing nurse-initiated protocols in the emergency department.



A systematic review of published literature was conducted using the online databases PubMed and Cochrane Library to identify relevant studies of nurse-initiated triage diagnostic and treatment protocols that have been published in the English language between January 1, 2013, and November 25th, 2018. Boolean Operators were used in making the following specific search phrase: (nurse AND initiated) AND (orders OR x-rays OR imaging OR medications OR labs OR protocols) AND ((emergency AND department) OR triage) AND (time OR throughput OR los OR (length AND of AND stay)) NOT (team OR pediatric).

Selection. Two independent reviewers identified articles for this review, and the search results are outlined in figure 1. If there were discrepancies in the selection, the articles were discussed, and a third reviewer was consulted to give majority consensus. After removal of duplicates, articles, which were relevant to the objective of this review and contained keywords in their titles or abstracts, were selected to proceed to a full-text eligibility determination using pre-priori inclusion and exclusion criteria and were assessed for quality. Full-text articles, which qualified for final selection were only selected if their study was performed in the ED setting, was relevant to assessing the impact of nurse-initiated protocols (NIPs) for imaging, medication, or laboratory studies on ED patient throughput and Presented ED length of stay (LOS) as a study outcome.


From 97 identified records, a total of 13 full-text articles advanced to the evaluation of eligibility and methodological quality review. This process rendered five eligible articles, two systematic reviews, and three randomized control studies (RCT’s). Nurse-initiated radiological studies were most prevalent. There was only one study on nurse-initiated medications that met eligibility, and only one relevant to nurse-initiated diagnostic laboratory tests. Use of the Ottawa ankle criteria was a well-studied protocol and proved to decrease ED length of stay amongst other secondary outcomes such as the decreased un-necessary ordering of x-rays and promoted use of clinical practice guidelines.1–3 Another study on a nurse-initiated throat pain protocol also used clinical practice guidelines in the assessment and decision to initiate early diagnostic testing in patients who presented with chief complaint of sore throat. The decision process was guided by the Centor and McIsaac criteria.4 In this study patients in the nurse intervention group experienced a 19-minute decrease in mean LOS compared to the control group.4 This study also gave a comparison to provider-initiated intervention and resulted in a 6-minute decrease in mean LOS when compared to that of providers.4 Nurse-initiated medication studies were evaluated in a systematic review and did not provide a statistically significant decrease in comparison with provider initiation.4,5 Most studies presented in the nurse-initiated medication systematic review were shown to be useful in creating early access to symptomatic improvement and in some analgesic studies even increasing patient likelihood of receiving medication for analgesia during ED visit.5 While important to other quality care metrics such as timely care, evidence of these nurse-initiated medication studies were not impactful for ED LOS.


Some nurse-initiated protocols, especially those involving radiological studies, are supported by evidence to improve patient throughput by reducing the length of stay. Careful consideration as to which protocols will have the greatest impact is necessary because not all interventions have a substantial effect on the overall length of stay. More studies on various protocols and types of interventions are necessary to support future adoption of these methods to improve patient throughput in emergency departments with limited resources. Additional studies are also needed to increase the generalizability of results to emergency departments with a variety of average daily census statistics.


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