Australasian Emergency Nursing Journal 20 (2017) 53–62

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Australasian Emergency Nursing Journal

journal homepage: www.elsevier.com/locate/aenj

Systematic Review

A systematic review of the impact of nurse-initiated medications in

the emergency department
C.J. Cabilan a,∗ , Mary Boyde a,b
a
Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Australia
b
School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Nurse-initiated medications are one of the most important strategies used to facilitate
Received 30 January 2017 timely care for people who present to Emergency Departments (EDs). The purpose of this paper was to
Received in revised form 16 March 2017 systematically review the evidence of nurse-initiated medications to guide future practice and research.
Accepted 3 April 2017
Methods: A systematic review of the literature was conducted to locate published studies and Grey liter-
ature. All studies were assessed independently by two independent reviewers for relevance using titles
Keywords:
and abstracts, eligibility dictated by the inclusion criteria, and methodological quality.
Nurse-initiated
Results: Five experimental studies were included in this review: one randomised controlled trial and
Emergency nursing
Emergency department
four quasi-experimental studies conducted in paediatric and adult EDs. The nurse-initiated medications
Overcrowding were salbutamol for respiratory conditions and analgesia for painful conditions, which enabled patients
to receive the medications quicker by half-an-hour compared to those who did not have nurse-initiated
medications. The intervention had no effect on adverse events, doctor wait time and length of stay. Nurse-
initiated analgesia was associated with increased likelihood of receiving analgesia, achieving clinically-
relevant pain reduction, and better patient satisfaction.
Conclusion: Nurse-initiated medications are safe and beneficial for ED patients. However, randomised
controlled studies are required to strengthen the validity of results.
© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Introduction late initiation of thrombolytic therapy for patients with myocardial

Emergency departments (EDs) provide care for people who
require urgent medical attention. These departments are a critical
component of our health-care system with 7.5 million presen-
tations to Australian public hospital EDs in 2015–16 [1]. People
presenting with an acute medical event may need timely treatment,
frequently requiring administration of medications to relieve their
symptoms. The time to administration of medications is often seen
as a quality of care indicator [2] and contributes to patients’ per-
ceptions of the care they receive in the ED [3]. However, timely
administration of medications in the ED environment continues
to provide a challenge for clinical staff working in busy and often
overcrowded EDs [4]. A literature review by Bernstein et al. [5]
revealed some of the known effects of overcrowding, which were
delayed administration of antibiotics for patients with pneumonia,
∗ Corresponding author at: Department of Emergency Medicine, Princess Alexan-
dra Hospital, 199 Ipswich Road, Woolloongabba, 4102, Queensland, Australia.
E-mail address: carajoyce.cabilan@health.qld.gov.au (C.J. Cabilan).
infarction, and longer time-to-analgesia.
Nurse-initiated medications have been one of the most impor-
tant strategies implemented in EDs to facilitate timely care [6]. The
process involves giving nurses the autonomy to administer med-
ications to patients as guided by their medical condition prior to
them being seen by an ED doctor [7].
Evidence from the literature shows that analgesia [8–19],
bronchodilators [20–22], and thrombolytics [23–25] have been
nurse-initiated in EDs. The practice has been utilised in several
countries such as Australia [8,10,11,13,16–19,26], United States
[12,14,21], Sweden [27,28], Canada [20], Hong Kong [22], and
United Kingdom [23–25]. The uptake of nurse-initiated medica-
tions in the ED is increasing; therefore it is pertinent to evaluate
the impact of this practice on important quality of care indicators,
which are safety, timeliness, effectiveness, equitability, patient-
centred care, and efficiency [29]. The findings of this review have
the potential to, influence further up-take of nurse-initiated medi-
cation administration and direct future research.

http://dx.doi.org/10.1016/j.aenj.2017.04.001
1574-6267/© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
54 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

Table 1 Table 2
The six quality of care domains proposed by the Institute of Medicine. Search strategy for published studies.

Safety avoiding injuries to patients from the care that is Database CINAHL via Ebsco
intended to help them. Example outcome measures
Dates Inception to July 5,
are adverse events, left without being seen, morbidity,
2016
or mortality.
Keywords:
Timeliness defined as reducing waits and sometimes harmful
1. TX emergency department OR TX (accident 85,176
delays for both those who receive and those who give
and emergency)
care. Timeliness is measured using time-based
2. TX medication$ OR TX drug$ OR TX 695,708
outcomes such as time to first medication
“medication protocol” OR TX “drug protocol”
administration.
OR TX protocol
Effectiveness defined as providing services based on scientific
3. TX “nurse initiated” OR TX “nurse managed” 9564
knowledge to all who could benefit, and refraining
OR TX “nurse prescribing” OR TX “non medical
from providing services to those not likely to benefit,
prescribing”
for example clinical improvement.
4. TX nurse OR TX nursing 1,211,525
Equitability refers to providing care that does not vary in quality
5. 1 AND 2 AND 3 AND 4 869
because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic
status. Outcome measures include accessibility or Database PubMed
availability of medications. Dates Inception to July 5,
Patient-centeredness providing care that is respectful of and responsive to 2016
individual patient preferences, needs, and values, and Keywords:
ensuring that patient values guide all clinical decisions. 1. emergency department OR TX (accident and 186,325
Outcomes can include patient satisfaction or patient emergency)
perceptions of the care received in ED. 2. medication* OR drug* OR “medication 5,330,388
Efficiency focuses on avoiding waste, including waste of protocol” OR “drug protocol” OR protocol
equipment, supplies. Outcome measures that fall 3. “nurse initiated” OR “nurse managed” OR 1208
under efficiency are length of ED stay or the rate of “nurse prescribing” OR “non medical
inpatient admission. prescribing”
4. nurse OR nursing 740,859
5. 1 AND 2 AND 3 AND 4 39

Objectives Database EMBASE

Dates Inception to July 5,

The objectives of this review were to: systematically review
2016
the literature evaluating the effects of nurse-initiated medications Keywords:
in the emergency department; and to quantify the impact of the 1. ‘emergency’/exp OR emergency AND 278,464
practice on quality of care indicators (i.e. safety, timeliness, effec- department OR ‘accident’/exp OR accident
AND (’emergency’/exp OR emergency)
tiveness, equitability, patient-centred care, and efficiency).
2. medication* OR drug* OR ‘medication 9,934,833
protocol’ OR ‘drug protocol’ OR protocol
3. ‘nurse initiated’ OR ‘nurse managed’ OR 1475
Methods ‘nurse prescribing’ OR ‘non medical
prescribing’
Inclusion criteria for this review 4. ‘nurse’ OR ‘nursing’ 853,533
5. 1 AND 2 AND 3 AND 4 72
Types of studies
The review included experimental studies, such as randomised
controlled trials (RCT), quasi-experimental or controlled before-
and-after studies that evaluated the effectiveness of nurse-initiated Search methods
medications in the ED. Observational studies were not included
in this effectiveness review [30] due to the inherent bias and The search strategy, as shown in Table 2, was used to yield
confounding factors that could obscure the true effect of nurse- published studies and the grey literature from the start of the
initiated medications [31,32]. database until July 5, 2016 and in any language. Published stud-
ies were obtained from CINAHL, CENTRAL, PubMed, and EMBASE,
while Grey literature were sourced from Web of Science, Open-
Types of participants Grey, and ProQuest Dissertations and Theses. Additional studies
Participants were paediatric and adult patients who sought care were also located in clinical trials registries and hand-searching in
in the ED. the references of relevant studies.

Types of interventions
Nurse-initiated medications is a component of non-medical pre-
scribing, where a list of medications is pre-approved (such as in
a formulary or protocol), can be given according to the patient’s
condition, and signs and symptoms, and administered without a
medical order [7]. The nurse-initiated medication must be given in
ED and by ED nurses.
Types of outcome measures
The outcomes were categorised according to the quality of
care domains in ED, safety, timeliness, effectiveness, equitability,
patient-centeredness, and efficiency (Table 1) [29].
Data collection and analysis
Selection of studies
Selection of studies was done independently by two indepen-
dent reviewers. Any disagreements between Reviewer 1 (CJC) and
2 (MB) were discussed and resolved. All citations from the final
search strategy were imported into referencing software and sub-
sequently screened for relevance using title and abstract. Then, the
full-text of relevant citations were retrieved and assessed for eligi-
bility based on the inclusion criteria. Lastly, all eligible studies were
appraised for methodological quality using the Effective Practice
and Organisation of Care Group risk of bias criteria [33].
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62
Data synthesis
Data (e.g. study characteristics, intervention, population demo-
graphics) were extracted independently by two independent
reviewers to prevent error. Outcomes of interest were entered into
Review Manager 5.3.5 software [34]. Meta-analysis was conducted
where possible, otherwise, findings were presented in a narrative
form. For example, studies that reported time-to-analgesia were
pooled because regardless of the type of analgesia, analgesia was
given for a pain score of ≥4. However, studies that reported time-
to-bronchodilator had varying indication for the administration of
salbutamol; thus could not be pooled.
Continuous data, such as time and length of ED stay, were ana-
lysed using random effects inverse variance and presented as mean
difference (MD).Event variables (i.e. adverse events, provision of
analgesia) were analysed using Mantel-Haenszel method under the
random effects model and presented as risk ratio (RR) [35]. A RR
of >1 was interpreted as increased likelihood of the event, while
decreased chance of the event occurring had a corresponding value
of <1. A RR with a 95% confidence internal (CI) that does not include
the value of 1 was considered statistically significant [36].
Assessment of heterogeneity
Sometimes studies in the meta-analysis can differ (heterogene-
ity) and this may be due to clinical characteristics of the population,
methodological diversity, intervention and the magnitude of effect
of the intervention. In this context, testing for heterogeneity is
important to determine the similarity or dissimilarity of studies
[35]. Heterogeneity was assessed statistically using the standard I2
statistic, where (approximately) 1%–25%, 26%–75%, 76%–100% was
interpreted as low, moderate, and high respectively [37]. The chi-
squared statistic was also used to determine heterogeneity, where
a p value of less than 0.1 indicated statistically significant het-
erogeneity. If present, heterogeneity was explored in a sensitivity
analysis using population characteristics and sample size.
Results
The structured search generated a total of 1064 studies: 980
published studies, 72 from the grey literature, and 12 from clini-
cal trials registries. After removal of duplicates 1026 studies were
screened for relevance using titles and abstracts, from which 53
full-text articles were retrieved. These studies were assessed for
eligibility using the inclusion criteria, which yielded 12 additional
studies from the reference lists. Of the 67 studies, 37 were described
as nurse-initiated medications. From these 37 studies 31 were
excluded: 11 conference abstracts excluded because their full-text
were unable to be retrieved or received from authors, 2 were nurse-
initiated thrombolysis excluded because the interventions were
not delivered in ED [23,25], 2 were descriptive research [38–41],
5 were cross-sectional studies [16–18,42,43], 2 had cohort design
[20,44], and 9 were retrospective chart audits [8–15,21]. Ultimately,
6 experimental studies were appraised for methodological quality.
Methodological quality
Of the six studies, one was a RCT design [22]. Five had before-
and-after design [19,27,45–47], with a high-risk of selection bias
and performance bias. Attrition bias and selective reporting were
only evident in a study by Wong et al. [45] where a number of
participants did not receive the intervention and their results were
excluded in the analysis. Detection bias was low in three studies
[19,22,45], but unclear in the other three papers [27,46,47]. The
55
study by Wong et al. [45] was excluded from the systematic review
analysis due to methodological flaws (Fig. 1).
Description of included studies
The characteristics of the included studies are summarised in
Table 3. Studies were conducted in Australia [19], Hong Kong [22],
Netherlands [47], Saudi Arabia [46], and Sweden [27]. There were
1272 participants in five studies. Of the five studies, two stud-
ies recruited paediatric populations (n = 352) [19,46] and three
included adult populations (n = 920) [22,27,47]. The nurse-initiated
medications differed among studies. Two studies investigated
salbutamol administration for asthma exacerbation in children [46]
and exacerbation of chronic obstructive pulmonary disease (COPD)
in adults [22]; while the remaining studies investigated a range of
analgesia that included opioids for adult patients with abdominal
pain [27] and musculoskeletal injury [47], as well as children who
presented with painful conditions [19]. Mandatory education and
training of nurses before the intervention were explicitly described
in four studies [19,27,46,47] except the nurse-initiated salbutamol
for COPD patients [22].
Main findings
The available evidence for nurse-initiated salbutamol were
safety (nausea and vomiting, medication errors, perception of
tremors and palpitation, and ED representations), timeliness
(time-to-bronchodilators), effectiveness (clinical improvement)
and efficiency (ED LOS, doctor wait time). On the other hand, nurse-
initiated analgesia had evidence for safety (deviation of vital signs),
timeliness (time-to-analgesia), effectiveness (clinically-relevant
pain relief), equitability (access to analgesia), patient-centeredness
(patient satisfaction) and efficiency (ED LOS).
Safety
Three studies evaluated the safety aspects of nurse-initiated
medications. Muntlin et al. [27] reported no adverse events related
to nurse-initiated analgesia, which was defined as oxygen satu-
ration below 90%, pulse rate below 60 beats/min, systolic blood
pressure below 100mmHg, respiratory rate below 12 breaths/min,
or incidence of nausea and vomiting. Qazi et al. [46] evaluated the
incidence of medication errors, vomiting, and ED representation
within three days in children with asthma. There were no reported
medication errors; and there was no statistically significant differ-
ence in vomiting (RR 2, 95% CI 0.37–10.72) and in representations
(RR 4, 95% CI 0.45–35.29). The perception of tremors and pal-
pitations after nurse-initiated salbutamol was evaluated by Ho
et al. [22]. The perception of tremors was similar in patients who
received nurse-initiated and non-nurse-initiated salbutamol, but
patients who received a nurse-initiated dose were more likely to
report palpitations (RR 1.39, 95% CI 1.02–1.9).
Timeliness
Time-to-analgesia was reported in three studies, and was mea-
sured from triage time (approximately arrival time) to time of first
analgesic [19,27,47]. The studies were pooled in a meta-analysis
because In the nurse-initiated group, time-to-analgesia was sig-
nificantly shorter with a mean of 30 min (MD −30.61 min, 95% CI
−50.58 to −10.64 min, p = 0.003) (Fig. 2). However, this must be
interpreted with caution due to substantial heterogeneity (97%,
p = <0.01). The sensitivity analyses did not yield lower heterogene-
ity.
Time-to-bronchodilator was assessed in two studies [22,46],
which was measured from the time of arrival to ED to the time
 56
Table 3
Characteristics of included studies

Study Study Design Location Patient Intervention Type of No. of Age (mean %Male Summary of primary
population Nurse-initiated participants ± standard findings
Medication deviation)

Qazi et al. [46] Prospective Saudi Arabia 1–12 year-olds Asthma Salbutamol Pre, n = 125; Pre = 3.3 ± 2.6; Pre = 63.2%; Time-to-first
Pretest- who presented training nebulizer Post, n = 125 Post = 4.2 ± 3 Post = 68% bronchodilator
posttest for program on decreased from
design exacerbation of pathophysiol- 59.8 min ± 38.8 to
asthma ogy, 28.5 min ± 26.6
pharmacology, (p < 0.001).
and

C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

management of
asthma;
Nurse-initiated
salbutamol
nebulization
Muntlin et al. [27] Prospective Sweden ≥18 years old; Education IV morphine Pre, n = 50; Not provided Pre = 32%; Time to analgesia
Pretest- Ongoing session on with a starting Post, n = 100 per group Post = 47% significantly decreased
posttest atraumatic acute bolus of 2 mg from 2.5 ± 1.7 h(pre-
design abdominal pain abdominal and after 3 min intervention) to
no more than symptoms, the 1mg could be 1.3 ± 1 h(intervention)
2 days; character, repeated every (p = 0.001);
Orientated to quality and second minute ED length of stay was
person, place, location of not significantly
time; and pain, how to different; and
Pain score of measure pain Patients’ perceptions of
4–8. intensity, pain the quality of care in
medication ED improved with the
alternatives intervention.
and differential
diagnoses; and
nurse-initiated
IV morphine

Ho and Yau [22] Randomised Hong Kong ≥18 years old; Nurse-initiated Salbutamol Control, n = 55; Control = 74.3 ± 7.8; Control = 69.1%; Time-to-first
controlled trial Dyspnea; salbutamol metred dose Intervention, Interven- Interven- bronchodilator
History of inhaler n = 55 tion = 76.4 ± 8.0 tion = 74.5% decreased to
chronic 7.6 ± 1.1 min from
obstructive 45.6 ± 19.6 (p < 0.001);
pulmonary Peak flow rate, ED
disease; length of stay, and
Triage Category doctor wait time were
of 4–5; not significantly
Experience different.
using albuterol
metered dose
inhaler; and
Competent to
blow a peak
flow meter.
Table 3 (Continued)

Study Study Design Location Patient Intervention Type of No. of Age (mean %Male Summary of primary
population Nurse-initiated participants ± standard findings
Medication deviation)

Taylor et al. [19] Prospective Australia 5–17 years old; Education; Oral paraceta- Pre, n = 51; Pre = 11.0 ± 3.3; Pre = 64.7%; Time to analgesia
Pretest- Pain score ≥4; Nurse-initiated mol ± codeine; Post, n = 51 Post = 10.1 ± 3.4 Post = 60.8% significantly reduced to
posttest Triage Category medications Oral ibuprofen; 24.8 ± 12.4 min in the

C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

design 4–5; Topical local intervention period
Patient or anaesthet- from 55.1 ± 14.7 min
guardian able ics(lignocaine, (p = 0.003);
to amethocaine, There were more
communicate epinephrine), patients who received
pain score amethocaine, adequate analgesia in
eutectic the intervention period
mixture of local (Pre = 21%,
anaesthetics; Post = 37%,p = 0.001);
and
Patient/guardian
satisfaction was
similar.
Pierik et al. [47] Prospective Netherlands 18–70 years Active and Oral/IV Pre, n = 504; Pre = 43.4 ± 8.08; Pre = 45.2%; There were
Pretest- old; passive (e.g. paracetamol; Post, n = 156 Post = 49.9 Post = 44.2% significantly more
posttest Musculo- posters, Oral diclofenac; ± 6.57 patients in the
design skeletal leaflets) Oral ibuprofen intervention group
isolated education; Oral tramadol; who received adequate
extremity nurse initiated IV morphine; analgesia (Pre = 21.1%,
injury caused analgesia IV fentanyl; Post = 31.3%,p < 0.05);
by blunt IV esketamin More patients in the
trauma; with intervention period
Must be able to midazolam were offered analgesics
communicate; (Pre = 46.8%,
No cognitive Post = 68%,p < 0.05);
disability; ED length of stay was
Pain score ≥4 shorter in the
intervention period but
was not significantly
different;
Time-to-analgesia was
reduced to 8.3 ± 4.3
from 17.9 ± 13.2 min
(p = <0.05)

Legend: IV = intravenous, ED = emergency department.

57
58 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

Identification
Number of citations identified
through a systematic search Duplicates

n = 1,084 n = 58

Number of citations screened

using title and abstract Number of citations excluded
Screening

n = 1,026 n = 973

Additional studies identified

from reference lists
Number of full-text articles n = 12
Eligibility

assessed for eligibility

n = 65
Did not meet inclusion criteria

n = 59

Studies for critical appraisal

n=6 Did not meet quality criteria

n=1
Included

Studies included in this review

n=5

Fig. 1. Study flow diagram [48].

Fig. 2. Mean difference of time-to-analgesia between nurse-initiated and non-nurse-initiated patients in the emergency department.

of first salbutamol administration. In children with asthma exac-
erbation, nurse-initiated salbutamol significantly decreased time-
to-bronchodilator (MD −31.3 min, 95% CI −39.55 to −23.05 min,
p = <0.01), and time-to-corticosteroids (MD −22.9, 95%CI −36.83
to −8.97, p = <0.01) [46]. In adults with chronic obstructive pul-
monary disease, time-to-bronchodilator significantly reduced by
38 min (MD −38 min, 95% CI −43.19 to −32.81 min, p = <0.01) [22].
Effectiveness
Two studies [19,47] measured effectiveness based on the pro-
portion of patients who had clinically-relevant reduction of pain
amongst patients with moderate to severe pain (≥4 score in a 0–10
scale). Adequate pain relief was defined in the studies [19,47] as
a 2-point reduction or more of initial pain score and to a mild
intensity (<4) at discharge. Pooled results showed that nurse-
initiated analgesia increased the likelihood of achieving adequate
pain relief compared to non-nurse-initiated analgesia (RR 1.58, 95%
CI 1.24–2.01) (Fig. 3).
Ho et al. [22] reported the differences in peak flow rate, oxygen
saturation, respiratory rate, heart rate, and perception of dysp-
noea. Peak flow rate, oxygen saturation, and respiratory rate were
not significantly different between nurse-initiated and non-nurse-
initiated salbutamol. However, heart rate was significantly higher
in nurse-initiated patients (MD 6.9, 95% CI 1.54–12.26). Dyspnoea
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62
Fig. 3. Comparison of the proportion of patients who received adequate analgesia between nurse-initiated and non-nurse-initiated period.
was less likely to be perceived by patients who did not receive
nurse-initiated salbutamol (RR 0.53, 95% CI 0.33–0.86).
Equitability
Results from three studies [19,27,47] showed patients with
moderate to severe pain were more likely to receive analgesia with
nurse-initiated analgesia (RR 1.23, 95% CI 1.06–1.43) (Fig. 4).
Pierek et al. [47], added that more patients were offered anal-
gesia when nurses were allowed to nurse-initiate (RR 1.45, 95% CI
1.24–1.7).
Patient-centeredness
Satisfaction with treatment received in the ED was reported
in two studies [19,27]. In one study, although the proportion of
parents who were either satisfied or very satisfied with the man-
agement of their child’s pain was higher in the nurse-initiated
group, the difference was not statistically significant [19]. In the
other study [27], satisfaction was assessed using a 10-item ques-
tionnaire with each item rated on a 5-point Likert scale. Patients
in the nurse-initiated analgesia group were more satisfied with
how their pain was managed compared to those who did not have
nurse-initiated analgesia.
Efficiency
Pooled results from four studies [22,27,46,47] showed that
length of ED stay was not significantly different between nurse-
initiated and non-nurse- initiated patients (Fig. 5).
Doctor wait time amongst children with asthma was not signif-
icantly different (MD −4.4 min, 95% CI −13.76 to 4.96 min, p = 0.36),
but they were attended to by the primary nurse quicker (MD
−15.6 min, 95% CI −23.67 to −7.53) [46].
Discussion
This systematic review focused on experimental studies which
evaluated the practice of nurse–initiated medications including
analgesia and salbutamol in ED. In comparison to non-nurse-
initiated analgesia, patients who received nurse-initiated analgesic
medication received their medication a mean of 30 min earlier.
This intervention also improved the likelihood of achieving clin-
ically relevant pain relief by 58% and showed patients were 23%
more likely to receive analgesia. Additionally patients receiving
nurse-initiated analgesics showed higher satisfaction with their
care in ED. Nurse-initiated salbutamol enabled adult and paediatric
patients to receive their bronchodilators therapy more than 30 min
earlier and to achieve improved clinical outcomes. Nurse-initiated
medications appear to be a safe intervention, evidenced by the lack
of adverse events reported.
The available evidence from the medical literature suggests that
nurse-initiated medications can be administered without com-
promising safety. While it is difficult to identify the key factors
that contributed to this positive outcome, standardised protocols
59
with pre-implementation training for the nurses have most likely
been critical elements [19,27,46,47]. As well, the accountability
and responsibility associated with nurse-initiated medications may
influence nurses to apply more caution within their practice [49].
Nurse-initiated analgesia, particularly for patients with abdominal
pain, has been met with significant challenges due to the belief
that it would impede diagnosis and management [50]. However,
there is little evidence to support this belief, and research has sug-
gested that administration of early analgesia assists diagnosis with
a more co-operative patient being able to tolerate a comprehensive
assessment [51,52].
Timely access to medication is an important aspect of patient
care in ED. Nurse-initiated medication protocols promote a more
efficient process for medication administration by allowing nurses
to administer analgesia autonomously, thus leading to timely
administration of pain relief to patients with moderate to severe
pain. The findings of this review have implications for pain treat-
ment delays contributed to by overcrowding [53]. Overcrowding
limits the resources that can be allocated to new patients, because
the available resources are utilised by patients who are already
in the ED [54,55]. For example, without nurse-initiated analge-
sia, patients have to wait for the doctor’s availability to prescribe
analgesia before they can receive pain relief. Additionally, the
ability of the emergency staff to deliver immediate treatment to
children with asthma exacerbation has also been a significant
issue [56]. Although empiric evidence is limited to one study [46],
nurse-initiated salbutamol has the ability to shorten the time-to-
first bronchodilator. Evidence from observational studies suggested
that nurse-initiated corticosteroids for asthma exacerbation led
to quicker administration of the drug, increased the likelihood
of receiving the treatment within 60 min, reduced ED LOS, and
decreased the risk of hospitalisation [20,21]. Moreover, nurse-
initiated medications benefit patients with COPD [22]. However,
generalisability is limited due to the lack of studies. The evidence
from this review and from other studies [20,21] indicate that fur-
ther research is required to evaluate the impact of nurse-initiated
salbutamol and/or corticosteroids in patients with asthma and
COPD.
The findings of this review demonstrate that nurse-initiated
analgesia not only facilitates timely analgesia but also increases
the likelihood of attaining clinically-relevant pain relief, which has
been defined as a ≥2-point reduction in pain score [19,47]. This
measure has been used in pain management research [13,57–59].
Taylor et al. hypothesised that this effect could be related to the
timeliness of and access to analgesia [19]. This is supported by find-
ings from one study, which showed that adequate pain relief was
associated with the availability of analgesics [60].
Access to analgesia was an important outcome that was evalu-
ated, because in overcrowded EDs not all patients receive analgesia
in spite of their pain severity [57,61]. As previously highlighted,
overcrowded conditions limits doctors’ availability to prescribe
analgesia for patients [54,55]. This review provides evidence that
patients are more like to receive analgesia when nurse-initiated
protocols are implemented.
60 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62
Fig. 4. Comparison of analgesia provision between nurse-initiated and non-nurse-initiated period.
Fig. 5. Mean difference of length of stay between nurse-initiated and non-nurse-initiated patients in the emergency department.
Inadequate pain management is a source of frustration and dis-
satisfaction among patients [62]. Two studies [19,27] included in
this review showed that patients who had nurse-initiated analgesia
tend to have higher levels of pain management satisfaction com-
pared to those who did not. Patient satisfaction is multifactorial and
can be influenced by staff communication, general experience of
care in ED, timeliness of treatment, and quality of care [62]. Perhaps
an important factor contributing to patient satisfaction was timely
analgesia and the clinically significant pain reduction achieved with
the intervention [58,59,63,64].
Although the implementation of nurse-initiated medications
led to quicker access to medications and effective symptom relief,
the intervention did not reduce the LOS in ED and doctor wait-
ing time [22,27,46,47]. There are two plausible reasons for this.
First, unlike nurse-initiated blood tests and x-rays [65,66], nurse-
initiated medications do not guide the diagnosis and direct patient
treatment. Second, analgesics and bronchodilators mainly target
the immediate relief of symptoms and patient comfort. Therefore,
patient flow is unlikely to be influenced by nurse-initiated medica-
tions.
There are limitations to this systematic review. First, experi-
mental studies were exclusively selected as they were considered
to provide the highest level of evidence. This limited the available
research to one RCT and four quasi-experimental studies which met
the inclusion criteria. Quasi experimental designs do not include
randomisation so there is a selection and performance bias and
the reported outcomes may be impacted on by unknown variables.
Second, the included studies did not all report the same outcomes
which decreased the quality and availability of data for the analysis.
Third, the mean difference was used widely in the results because
the available data preclude the computation of median difference.
The mean difference can either overestimate or underestimate the
effect depending on the direction of the skew. The time-based out-
comes (e.g. time-to-analgesia) in this review were almost positively
skewed; therefore the time reductions reported could be greater
than the actual time.
Findings from this review support the practice of nurse-initiated
medications in ED. There is a potential for the practice to expand
beyond analgesia and salbutamol, and benefit other patient cohorts.
However further high level evidence is required to confirm these
initial findings. While RCTs may be more challenging to conduct in
the ED, the study by Ho et al. [22] is proof that this can be accom-
plished. There is an urgent need for further RCTs to strengthen the
validity of the results from this systematic review.
Conclusion
The systematic review holds clinical and research implications.
Findings from this review support the practice of nurse-initiated
medications in the ED, particularly nurse-initiated analgesia.
Nurse-initiated analgesia increases the accessibility of analgesia,
and facilitates the administration of timely and effective pain relief.
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62
The practice is safe and may increase patients’ satisfaction with
pain management. However, RCTs are required to strengthen the
validity of practice implications.
Funding
The authors do not have any funding sources to declare for this
systematic review.
Provenance and conflicts of interest
This systematic review was not commissioned. The authors have
no conflicts of interest to declare.
References
[1] Australian Institute of Health and Welfare Emergency department care
2015–16: Australian hospital statistics. Canberra: AIHW; 2016.
[2] National Institute of Clinical Studies National emergency department
collaborative report. Melbourne: NICS; 2004.
[3] Johnson KD, Winkelman C. The effect of emergency department crowding on
patient outcomes: a literature review. Adv Emerg Nurs J 2011;33(1):39–54.
[4] Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M.
Overcrowding in emergency department: an international issue. Intern
Emerg Med 2015;10(2):171–5.
[5] Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The
effect of emergency department crowding on clinically oriented outcomes.
Acad Emerg Med 2009;16(1):1–10.
[6] Elder E, Johnston AN, Crilly J. Review article: systematic review of three key
strategies designed to improve patient flow through the emergency
department. Emerg Med Aust 2015;27(5):394–404.
[7] National Health Workforce Planning and Research Collaboration.
Non-medical prescribing: an exploration of likely nature of, and
contingencies for, developing a nationally consistent approach to prescribing
by non-medical health professionals; 2010.
[8] Coman M, Kelly AM. Safety of a nurse-managed, titrated analgesia protocol
for the management of severe pain in the emergency department. Emerg Med
1999;11(3):128–32.
[9] Kelly AM. A process approach to improving pain management in the
emergency department: development and evaluation. J Accid Emerg Med
2000;17(3):185–7.
[10] Kelly AM. Nurse-managed analgesia for renal colic pain in the emergency
department. Aust Health Rev 2000;23(2):185–9.
[11] Kelly A, Brumby C, Barnes C. Nurse-initiated, titrated intravenous opioid
analgesia reduces time to analgesia for selected painful conditions. CJEM
2005;7(3):149–54.
[12] Fosnocht DE, Swanson ER. Use of a triage pain protocol in the ED. Am J Emerg
Med 2007;25(7):791–3.
[13] Finn JC, Rae A, Gibson N, Swift R, Watters T, Jacobs IG. Reducing time to
analgesia in the emergency department using a nurse-initiated pain protocol:
a before-and-after study. Contemp Nurse 2012;43(1):29–37.
[14] Tanabe P, Hafner JW, Martinovich Z, Artz N. Adult emergency department
patients with sickle cell pain crisis: results from a quality improvement
learning collaborative model to improve analgesic management. Acad Emerg
Med 2012;19(4):430–8.
[15] Tanabe P, Martinovich Z, Buckley B, Schmelzer A, Paice JA. Safety of an ED
high-dose opioid protocol for sickle cell disease pain. J Emerg Nurs
2015;41(May(3)):227–35.
[16] Fry M, Hearn J, Alexander N. A prospective study of nurse initiated panadeine
forte: expanding the pain management in the ED. Australas Emerg Nurs J
2005;8(3):90.
[17] Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency
department: efficacy, rate of adverse events and impact on time to analgesia.
Emerg Med 2002;14(3):249–54.
[18] Fry M, Ryan J, Alexander N. A prospective study of nurse initiated panadeine
forte: expanding pain management in the ED. Accid Emerg Nurs
2004;12(3):136–40.
[19] Taylor SE, Taylor DM, Jao K, Goh S, Ward M. Nurse-initiated analgesia
pathway for paediatric patients in the emergency department: a clinical
intervention trial. Emerg Med Aust 2013;25(4):316–23.
[20] Zemek R, Plint A, Osmond MH, Kovesi T, Correll R, Perri N, et al. Triage nurse
initiation of corticosteroids in pediatric asthma is associated with improved
emergency department efficiency. Pediatrics 2012;129(4):671–80.
[21] Miller AG, Breslin ME, Pineda LC, Fox JW. An asthma protocol improved
adherence to evidence-based guidelines for pediatric subjects with status
asthmaticus in the emergency department. Respir Care 2015;60(12):1759–64.
[22] Ho JKM, Yau WH. 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 Med
2012;19(3):162–70.
61
[23] Wilmshurst P, Purchase A, Webb C, Jowett C, Quinn T. Improving door to
needle times with nurse initiated thrombolysis. Heart 2000;84(3):262–6.
[24] Heath SM, Bain RJI, Andrews A, Chida S, Kitchen SI, Walters MI. Nurse initiated
thrombolysis in the accident and emergency department: safe, accurate, and
faster than fast track. Emerg Med J 2003;41:8–20.
[25] Qasim A, Malpass K, O’Gorman DJ, Heber ME. Safety and efficacy of nurse
initiated thrombolysis in patients with acute myocardial infarction. Br Med J
2002;324(7349):1328–31.
[26] Shaban RZ, Holzhauser K, Gillespie K, Huckson S, Bennetts S. Characteristics of
effective interventions supporting quality pain management in Australian
emergency departments: an exploratory study. Aust Emerg Nurs J
2012;15(1):23–30.
[27] Muntlin A, Carlsson M, Safwenberg 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
Jan;48(1):13–23.
[28] Muntlin Athlin A, Carlsson M, Gunningberg L. To receive or not to receive
analgesics in the emergency department: the importance of the pain intensity
assessment and initial nursing assessment. Pain Manag Nurs 2015
Oct;16(5):743–50.
[29] Institute of Medicine. Crossing the quality chasm: a new health system for the
21st century. Washington, DC: Institute of Medicine; 2001.
[30] Norris S, Atkins D, Bruening W, Fox S, Johnson E, Kane R, et al. Selecting
observational studies for comparing medical interventions. Rockville, MD:
Agency for Healthcare Research and Quality; 2010 [cited 2016 September]
Available from: https://www.effectivehealthcare.ahrq.gov/ehc/products/196/
454/MethodsGuideNorris 06042010.pdf.
[31] Hammer GP, du Prel J-B, Blettner M. Avoiding bias in observational studies.
Dtsch Arzteblatt Int 2009;106:664–8.
[32] Jepsen P, Johnsen SP, Gillman M, Sørensen HT. Interpretation of observational
studies. Heart 2004;90(8):956–60.
[33] Cochrane Collaboration. Suggested risk of bias criteria for EPOC reviews.
Oxford: Cochrane Collaboration; 2013.
[34] The Nordic Cochrane Centre TCC. Review Manager (RevMan) [Computer
program]. Version 5.35 ed. Copenhagen: The Nordic Cochrane Centre,
Cochrane Collaboration; 2011.
[35] Deeks J, Higgins J, Altman D, Green S. Cochrane handbook for systematic
reviews of interventions version 5.1.0 [updated March 2011]. Cochrane
Collaboration; 2011.
[36] Scott I. Interpreting risks and ratios in therapy trials. Aust Prescr 2008;31(1).
[37] Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
meta-analyses. Br Med J 2003;327(7414):557–60.
[38] Miller JH, Griffin E. Methotrexate administration for ectopic pregnancy in the
emergency department – one hospital’s protocol/competencies. J Emerg Nurs
2003;29(3):240–4.
[39] Campbell P, Dennie M, Dougherty K, Iwaskiw O, Rollo K. Implementation of an
ED protocol for pain management at triage at a busy level I trauma center. J
Emerg Nurs 2004;30(5):431–522.
[40] Seguin D. A nurse-initiated pain management advanced triage protocol for ED
patients with an extremity injury at a level I trauma center. J Emerg Nurs
2004;30(4):330–5.
[41] Ballejos-Campos C. Pain management in triage and reducing percentage of
left without being seen in an overcrowded ED [Ph.D.]. Ann Arbor: University
of San Diego; 2012.
[42] Goh HK, Choo SE, Lee I, Tham KY. Emergency department triage nurse
initiated pain management. Hong Kong J Emerg Med 2007;14(1):16–21.
[43] Givens M, Rutherford C, Joshi G, Delaney K. Impact of an emergency
department pain management protocol on the pattern of visits by patients
with sickle cell disease. J Emerg Med 2007;32(3):239–43.
[44] Boyd RJ, Stuart P. The efficacy of structured assessment and analgesia
provision in the paediatric emergency department. Emerg Med J
2005;3:30–2, 3p.
[45] Wong EM, Chan HM, Rainer TH, Ying CS. The effect of a triage pain
management protocol for minor musculoskeletal injury patients in a Hong
Kong emergency department. Aust Emerg Nurs J 2007;10(2):64–72.
[46] Qazi K, Altamimi SA, 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(5):428–33.
[47] Pierik JG, Berben SA, IJzerman MJ, Gaakeer MI, van Eenennaam FL, van Vugt
AB, et al. A nurse-initiated pain protocol in the ED improves pain treatment in
patients with acute musculoskeletal pain. Int Emerg Nurs 2016;(March).
[48] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for
systematic reviews and meta-analyses: the PRISMA statement. PLoS Med
2009;6(July (7)):e1000097.
[49] Cabilan C, Eley R, Hughes JA, Sinnott M. Medication knowledge and
willingness to nurse-initiate medications in an emergency department: a
mixed-methods study. J Adv Nurs 2016;72(2):396–408.
[50] Yealy DM, O’Toole KS. Challenging dogma: analgesia in abdominal pain. Acad
Emerg Med 1996;3(December (12)):1081–2.
[51] Amoli HA, Golozar A, Keshavarzi S, Tavakoli H, Yaghoobi A. Morphine
analgesia in patients with acute appendicitis: a randomised double-blind
clinical trial. Emerg Med J 2008;25(9):586.
[52] Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for
undifferentiated abdominal pain. Br J Surg 2003;90(January (1)):5–9.
62 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62
[53] Collis J. Adverse effects of overcrowding on patient experience and care: John
Collis presents the findings of a systematic literature review of how the
number of people in emergency departments affects service delivery. Emerg
Nurse 2010;18(8):34–9.
[54] Henneman PL, Nathanson BH, Li H, Smithline HA, Blank FSJ, Santoro JP, et al.
Emergency department patients who stay more than 6 hours contribute to
crowding. J Emerg Med 2010;39(1):105–12.
[55] Dunn R. Reduced access block causes shorter emergency department waiting
times: an historical control observational study. Emerg Med
2003;15(3):232–8.
[56] Bekmezian A, Fee C, Bekmezian S, Maselli JH, Weber E. Emergency
department crowding and younger age are associated with delayed
corticosteroid administration to children with acute asthma. Pediatr Emerg
Care 2013;29(10), http://dx.doi.org/10.1097/PEC.0b013e3182a5cbde.
[57] Todd KH, Ducharme J, Choiniere M, Crandall CS, Fosnocht DE, Homel P, et al.
Pain in the emergency department: results of the pain and emergency
medicine initiative (PEMI) multicenter study. J Pain 2007;8(6):460–6.
[58] Jao K, McD Taylor D, Taylor SE, Khan M, Chae J. Simple clinical targets
associated with a high level of patient satisfaction with their pain
management. Emerg Med Aust 2011;23(2):195–201.
[59] Shill J, Taylor DM, Ngui B, Taylor SE, Ugoni AM, Yeoh M, et al. Factors
associated with high levels of patient satisfaction with pain management.
Acad Emerg Med 2012;19(10):1212–5.
[60] Pierik JG, IJzerman MJ, Gaakeer MI, Berben SA, van Eenennaam FL, van Vugt
AB, et al. Pain management in the emergency chain: the use and effectiveness
of pain management in patients with acute musculoskeletal pain. Pain Med
2015;16(5):970–84.
[61] Fry M, Bennetts S, Huckson S. An Australian audit of ED pain management
patterns. J Emerg Nurs 2011;37(3):269–74.
[62] Marco CA, Davis A, Chang S, Mann D, Olson JE. ED patient satisfaction: factors
associated with satisfaction with care. Am J Emerg Med 2015;33(11):1708–9.
[63] Taylor DM, Fatovich DM, Finucci DP, Furyk J, Sw Jin, Keijzers G, et al.
Best-practice pain management in the emergency department: a
cluster-randomised, controlled, intervention trial. Emerg Med Aust
2015;27(6):549–57.
[64] Bhakta HC, Marco CA. Pain management: association with patient satisfaction
among emergency department patients. J Emerg Med 2014;46(4):456–64.
[65] 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):1.
[66] Rowe BH, Villa-Roel C, Guo X, Bullard MJ, Ospina M, Vandermeer B, et al. The
role of triage nurse ordering on mitigating overcrowding in emergency
departments: a systematic review. Acad Emerg Med 2011;18(12):1349–57.