Should Emergency Department Nurses Initiate Intravenous Opioids at Triage?
Should Emergency Department Nurses Initiate Intravenous Opioids at Triage?
Should ED nurses initiate intravenous opioid analgesia at triage?
The undertreatment of pain, or "oligoanalgesia," remains a pressing issue in the emergency department (ED) despite more than 2 decades of extensive research. In the era of overcrowding, EDs are faced with an even bigger challenge: providing timely and efficient analgesia. The concept of nurse-initiated intravenous opioid analgesia at triage is a great solution to this problem; it promotes efficient delivery of pain medications in the ED, and the current literature supports it.
Fosnocht and Swanson attempted to evaluate the value of a triage pain protocol by using intravenous morphine for patients with severe musculoskeletal pain. The results showed a significant reduction in time to medication administration from 76 minutes to 40 minutes. Intravenous analgesia at triage also contributed to an increase in the number of patients receiving pain medications from 45% to 70%.
Kelly and colleagues conducted a retrospective chart analysis evaluating the impact of nurse-initiated opioid analgesia on patients presenting to the ED with renal or biliary colic. The results showed that nurse-initiated parenteral analgesia reduced the median time to first medication dose from 57 minutes to 31 minutes, curbing delays in providing opioid analgesia.
In a prospective study conducted by Fry and Holdgate, attempts were made to measure the analgesic efficacy and time to analgesia after administration of intravenous morphine by the ED nurses. The results showed that an initial pain score of 8.5 cm on a numerical analog scale was significantly reduced to 4 cm after triage-initiated opioid analgesia. Moreover, the median time to intravenous medications was 18 minutes, compared with the national average of 78 minutes.
In evaluating the delivery of analgesia to trauma patients, Curtis and colleagues designed a before and after study by implementing a fentanyl-based protocol at triage in a level I trauma center. After enrolling 243 patients who were assigned to pre- and post-protocol groups and divided into 3 treatment arms, the study authors showed a significant decrease in time to medication administration from 54 minutes to 28 minutes, once triage protocols were initiated. The nurse-initiated opioid analgesia also increased the number of patients receiving pain medication during the first 30 minutes after arrival from 44% to 75%.
EDs across the country are faced with unacceptably long delays in providing analgesia to their patients. The implementation of nurse-initiated parenteral opioid analgesia at triage has great potential for timely, efficient, and effective pain management in EDs. Despite regulatory and licensing concerns and the issue of patients with drug-seeking behaviors, the nurse-driven pain protocol at triage should be an integral part of patient care.
Question
Should ED nurses initiate intravenous opioid analgesia at triage?
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Response from Sergey M. Motov, MD Assistant Program Director, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York |
The undertreatment of pain, or "oligoanalgesia," remains a pressing issue in the emergency department (ED) despite more than 2 decades of extensive research. In the era of overcrowding, EDs are faced with an even bigger challenge: providing timely and efficient analgesia. The concept of nurse-initiated intravenous opioid analgesia at triage is a great solution to this problem; it promotes efficient delivery of pain medications in the ED, and the current literature supports it.
Fosnocht and Swanson attempted to evaluate the value of a triage pain protocol by using intravenous morphine for patients with severe musculoskeletal pain. The results showed a significant reduction in time to medication administration from 76 minutes to 40 minutes. Intravenous analgesia at triage also contributed to an increase in the number of patients receiving pain medications from 45% to 70%.
Kelly and colleagues conducted a retrospective chart analysis evaluating the impact of nurse-initiated opioid analgesia on patients presenting to the ED with renal or biliary colic. The results showed that nurse-initiated parenteral analgesia reduced the median time to first medication dose from 57 minutes to 31 minutes, curbing delays in providing opioid analgesia.
In a prospective study conducted by Fry and Holdgate, attempts were made to measure the analgesic efficacy and time to analgesia after administration of intravenous morphine by the ED nurses. The results showed that an initial pain score of 8.5 cm on a numerical analog scale was significantly reduced to 4 cm after triage-initiated opioid analgesia. Moreover, the median time to intravenous medications was 18 minutes, compared with the national average of 78 minutes.
In evaluating the delivery of analgesia to trauma patients, Curtis and colleagues designed a before and after study by implementing a fentanyl-based protocol at triage in a level I trauma center. After enrolling 243 patients who were assigned to pre- and post-protocol groups and divided into 3 treatment arms, the study authors showed a significant decrease in time to medication administration from 54 minutes to 28 minutes, once triage protocols were initiated. The nurse-initiated opioid analgesia also increased the number of patients receiving pain medication during the first 30 minutes after arrival from 44% to 75%.
Conclusion
EDs across the country are faced with unacceptably long delays in providing analgesia to their patients. The implementation of nurse-initiated parenteral opioid analgesia at triage has great potential for timely, efficient, and effective pain management in EDs. Despite regulatory and licensing concerns and the issue of patients with drug-seeking behaviors, the nurse-driven pain protocol at triage should be an integral part of patient care.
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