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What is the problem?

Overcrowding and patient boarding in the emergency department (ED) have been ongoing issues that were first identified as a concern in the 1980s. This issue has been identified to cause increased nurse turnover, burnout, treatment delays, greater patient mortality, and an increased risk of violence towards staff (Locklear, 2022).

How, where, when, and why?

Worldwide the demand for ED services has only increased each year, and thus with it so has overcrowding. Due to this, patients are waiting longer to be assessed and treated. The focus of care in the ED is to identify life-threatening conditions and stabilize patients, however, this population is not the only one presenting to the ED for treatment. Unmet community care needs, the aging population, patients with chronic conditions, repeated access patients, patients seeking primary care needs, and an increase in seasonal conditions such as flu and heat or cold exposures have increased the demand (Sartini et al., 2022).

Addressing these issues is complex, but nurse-initiated protocols can help reduce overcrowding, length of stay, and improve patient outcomes.

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

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

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Nurse-initiated interventions allow nurses to initiate care via standing orders of protocol-based care pathways prior to the patient seeing a provider. This allows patients who meet pre-defined criteria to receive care more quickly. Examples of this include ordering radiology tests and administering medications such as pain medications, anti-emetics, and intravenous fluids. Studies have found nurse-initiated interventions to be safe and effective. In the case of analgesics, the time to medication administration was found to be improved. Additionally, nurse-initiated interventions were found to be associated with increased patient satisfaction.

This review looked at studies evaluating nurse-initiated interventions in the ED, including all patients accessing treatment in this setting, to evaluate effectiveness. 26 studies were included in the review, looking at a variety of interventions including pain management, management of traumatic injury, ultrasound-guided intravenous catheter insertion, respiratory distress management, stroke treatment, treatment of neonatal jaundice, and nasogastric tube reinsertion.

Outcomes

Time to treatment

Of the nine studies that evaluated time to analgesia, eight showed a statistically significant reduction in the time it took patients to receive pain medication when initiated by nurses.

Studies assessing time to treatment for asthma noted a mean reduction of 44 minutes with nurse-initiated steroids at triage. In patients whose nasogastric tubes had dislodged, nurse-initiated reinsertion improved treatment times by a median of 78.5 minutes. With neonatal jaundice patients time to bilirubin sampling was reduced from 36 minutes to 28 minutes.

Patient reported pain relief

Of the eight studies looking at nurse-initiated analgesia, four showed statistically significant improvement in pain medication administration. Studies showed that when nurse-initiated, patients were more likely to receive pain medication. Additionally, ten studies found a significant reduction in patient-reported pain levels.

Symptom relief

Two studies assessed the effectiveness of nurse-initiated interventions for patients with symptoms of respiratory distress. These studies found improvements in oxygen saturations, peak flow rate measurements, and patients’ reports of dyspnea. Date showed that the achived time of improveming patients to mild respiratoru distress status was reduced by 24 minutes when nurse-initiated interventions were present.

Another study found that when oral rehydration was initiated by nurses for children with gastroenteritis that children were 14% less likely to need intravenous fluids. Additionally, this study found that these children ere 31% more likely to receive anti-emetic medications.

Admission to the hospital

Four studies looking at admission rates to the hospital found that when nurse-initiated protocols were present, patients were less likely to be admitted.

Overall, this systematic review found nurse-initiated interventions to improve patient outcomes in the ED (Burgess et al., 2021).

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Nurse-Driven Protocols for Abdominal Pain in the Emergency Department

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Nurse-Driven Protocols for Abdominal Pain in the Emergency Department

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Overcrowding in the ED can hinder care for patients and have an effect on patient outcomes. Nurse driven protocols can reduce patient length of stay as well as the rate of patients who leave prior to being seen by a provider. The chief complaint of abdominal pain makes up 7-10% of all patient encounters in the ED. This study looked at if a nurse-driven protocol for adult patients with abdominal pain was effective in reducing length of stay and percentage of patients who left without being seen over ten weeks.

The nurse driven protocol in this study consisted of obtaining lab work, starting a peripheral intravenous line, and placing the patient on nothing by mouth (NPO) status. The lab work order set under this protocol consisted of a complete blood count, comprehensive metabolic panel, lipase, and coagulation studies. Additionally, for patients complaining of upper abdominal pain, nurses could initiate obtaining an electrocardiogram and troponin levels. This nurse-driven protocol could be implemented by an ED nurse either in triage or the primary treatment area for cases of patients arriving via ambulance.

The time of length of stay and percentage of patients who left prior to seeing a provider was compared was compared from after ten weeks of the protocol to prior to protocol implementation. Results showed that after ten weeks of the nurse-driven protocol the length of stay was reduced from over 4 hours to under 240 minutes. The study concluded that not only was the nurse-driven protocol implemented effective in reducing the length of stay in the ED, but nurses also reported feeling empowered (Schmidt & University of St. Augustine for Health Sciences, 2022).

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Nurse-Initiated Protocols for Chest Pain in the Emergency Department

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Nurse-Initiated Protocols for Chest Pain in the Emergency Department

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This study identifies that Ed crowding has a negative impact on patient outcomes in chest pain patients. It seeks to evaluate the effectiveness of nurse driven protocols on chest for chest pain by implementing and assessing a nurse-initiated protocol for chest pain and impact on length of stay over 8 weeks. A variety of conditions can cause chest pain, such as acute coronary syndrome and acute myocardial infractions. In these cases, identification and treatment is time sensitive in order to reduce the odds of patient mortality. Each year, chest pain patients make up approximately 10 million ED visits. Nurse-initiated protocols are shown to be able to expedite diagnostic care for patients prior to the patient seeing a provider, in instances of myocardial infarctions this can be lifesaving.

In this study a nurse-initiated protocol was formed for chest pain patients in collaboration with ED providers and approval from the ED medical director in which it was implemented. Nurses were also required to complete a course in order to be familiar with the protocol order set. Interventions in this order set included obtaining a 12 lead electrocardiogram (EKG) in under 10 minutes, I-Stat troponin, complete blood count (CBC), comprehensive metabolic panel (CMP), creatine kinase-myocardial band (CKMB/CK), urine human chorionic gonadotropin (hCG) for female patients of childbearing age, supplemental oxygen, inserting a peripheral intravenous line, and obtaining a chest X-Ray. This study did not show a significant reduction in length of stay for patient with chest pain as a result of the nurse-initiated protocol. However, this the protocol resulted in the time taken to obtain a 12 lead EKG to have reduced in comparison to before the protocol was implemented The mean time taken to obtain a 12 lead EKG prior to protocol implementation was 39.4 minutes. After protocol implementation the mean time was identified to be 9.3 minutes. Obtaining a 12 lead EKG quickly upon a patient presenting with chest pain is essential in timely identification of ST-Elevation myocardial infarctions (STEMI). This decrease in time taken to obtain the 12 lead EKG shows effectiveness of the protocol in improving patient outcomes (Hodges & University of St. Augustine for Health Sciences, 2020).

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Nurses’ play a key role in patient care in the ED. Overcrowding and increased lengths of stay in the ED are identified issues that research has shown nurse-initiated protocols through standing orders have a positive impact on. Through this, nurse-initiated protocols improve patients outcomes in the ED. Currently, many hospital systems EDs have standing orders nurses can act on when patients present with certain chief complaints or meeting certain criteria. All studies presented in the literature review presented evidence that nurse-initiated protocols are safe and effective in improving patient outcomes.

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Nurse involvement is essential for nurse-initiated protocols to be successful. In the study examining a nurse-initiated protocol for chest pain, only 17 out of the 35 nurses trained on the protocol used them. Additionally, newer ED providers were noted to be resistant towards the use of the nurse-driven protocol. While this study did present evidence that the protocol improved patient outcomes by showing a reduction in time taken to obtain a 12 lead EKG, it did not show a statistically significant improvement in length of stay time (Hodges & University of St. Augustine for Health Sciences, 2020). Other studies have presented evidence on nurse-initiated protocols having a significant reduction in length of stay, indicating that involvement is essential in successful implementation and usage of nurse-initiate protocols.

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Challenges or barriers to nurse involvement 

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Challenges or barriers to nurse involvement 

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A mixed methods survey study aiming to identify barriers and enablers to nurse-initiated care identified several potential barriers to nurse involvement. Some nurse perceived barriers consisted of protocols being too difficult to find, vagueness of protocols, uncertainty on when to use the protocols, limitations on interventions nurses can initiate, difficulties in documenting care given, and not every ED nurse being able to use the protocols. Difficulties in using the electronic medical record to place orders in accordance to the protocol and document was stated to be a reason for nurse reluctance to utilize the protocols (Gawthorne et al., 2025). Confidence is another barrier to nurse involvement in implementing and utilizing nurse-initiated protocols. Lack of confidence in skill, knowledge, or understanding of protocols was identified as a reason for nurses not wanting to use protocols as they felt concerned about patient safety. Additionally in this study, only 46% of nurses felt junior staff should use nurse-initiated protocols. Perceived workload was another barrier identified. Some nurses felt that utilizing nurse-initiated protocols would increase their workload and responsibilities and that they would not have the time to do so (Gawthorne et al., 2025). In order for nurse-initiated protocols to be successful, interprofessional collaboration and support is vital. Resistance from physicians in the ED in the usage of these protocols is an identified barrier to nurse involvement (Hodges & University of St. Augustine for Health Sciences, 2020).

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Sentara Advanced Triage Protocols in the Emergency Department

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Sentara Advanced Triage Protocols in the Emergency Department

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Currently, Sentara emergency departments have standing orders that allow nurses to initiate care. Following these nurse-initiated protocols, interventions nurses may perform prior to physician orders include the following:

Obtaining an electrocardiogram (EKG/ECG)

Initiating a peripheral intravenous line with a saline lock

Placing a patient on cardiac monitoring and pulse oximetry

Obtaining a urinalysis and or urine pregnancy test

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How can we promote participation and success?

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How can we promote participation and success?

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1. Encourage interprofessional collaboration in the development of nurse-initiated protocols

Nurse-initiated protocols should be developed in collaboration between nurse managers, physicians, medical directors, and nurses. By doing this, order sets can be formulated and revised in accordance with evidence based practice, patient safety, and staff comfort in mind. While these order sets will be approved by a medical director, involving nurses is key as nurses will be the ones implementing the protocols. In working together in the development of these protocols and standing orders, increased support can be obtained (Leubner & Wild, 2018).

2. Face to face training regarding nurse-initiated protocols

In order for nurse-initiated protocols to be successful, nurses must feel confident in their understanding of the protocols and ability to utilize them. A study in Australia identified that 95% of nurses who participates wanted increased education prior to implementing nurse-initiated analgesia (Gawthorne et al., 2025). In a mixed methods survey it was identified that nurses expressed concerns in when to start protocols and worries of using the wrong protocol. In this study, nurses expressed confidence in initiating simple pain medications, giving bronchodilators, and in giving intravenous fluids. However, nurses expressed lack of confidence in initialing opioids and antihistamines (Gawthorne et al., 2025). For these reasons, providing adequate face to face training for nurses is key in order to foster understanding and confidence of the protocols. This allows nurses to spend time going over the protocols, learning the indications and contraindications for each one, and to ask questions. Additionally, nurses would be able to express any concerns they may have regarding the protocols.

3. Implement a mentorship program

Studies expressed concerns regarding newer nurses having confidence in utilizing nurse-initiated protocols. A mentorship program, similar to new hire preceptorships, can help foster understanding and confidence in nurse-initiated protocols. Paring new nurses, or nurses new to the ED with senior nurses who feel confident in their understanding and ability to utilize nurse-initiated protocols can help ensure success.

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1. Providing safe, competent, and effective nursing care for patients of all ages.

Safe and competent care for patients of all ages and essential to providing effective nursing care. Safety should always be at the forefront of a nurse's thoughts when providing care to any patient, regardless of age. Safety is something that is each and every person's responsibility, including doctors, nurses, and nurse care partners. Nurse-initiated protocols should be formed with patient safety in mind, with prompt recognition of needs and initiation of needed essential interventions. Nurse-initiated protocols are shown to be safe and effective in reducing length of stay and time taken for care. In instances such as respiratory and cardiac emergencies, these actions can help save lives.

2. Collaborate within interprofessional healthcare teams to effect the highest quality, patient-centered care.

The development of nurse-initiated protocols requires interprofessional collaboration. Physicians and nurses should be involved in formulating these protocols. Additionally, physician support is essential in the successful implementation. Utilizing these protocols is patient-centered, as the patient’s needs and presentation are what drives which protocol needs to be followed. For instance, with the Sentara Advanced Triage protocol included in this presentation, nurses must assess the patient and perform or delegate interventions such as EKGs , IV access, and placing the patient on a cardiac monitor in accordance with assessment findings and patient needs.

Leadership

I believe that I have developed an understanding of these concepts during my time at Sentara College of Health Sciences, which will help me be able to take on a leadership role following my transition to professional practice. Nurse-initiated protocols in the emergency department are incredibly patient-centered and require safety and critical thinking about the patient’s condition to be in mind. I believe my time at the college has helped me develop a questioning attitude towards patient safety and to recognize patient needs. Additionally, my time at the college has taught me the importance of interprofessional communication in order for high-quality patient-centered care to be given. My time in my preceptorship has allowed me to see nurse-initiated protocols in action and the collaboration needed in order for them to be implemented safely and effectively. I believe that my experiences at the college have prepared me to take on a leadership role after transition by setting an example to follow protocols and policies. Additionally, by cultivating my own understanding and confidence during my transition to practice on nurse-initiated protocols, I will be prepared to take a leadership role in teaching and mentoring new nurses after me on how to utilize these protocols safely and effectively, as well as develop their own confidence.

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Nurse-initiated protocols allow nurses to initiate diagnostic tests for investigation, provide care, and give medications following standing orders or protocols (Gawthorne et al., 2025). This allows nurses to enact care in accordance with evidence-based practices that have been formulated in collaboration with physicians. These protocols are associated with improved safety, improved job satisfaction, and efficiency in the delivery of care (Lockhart, 2020). One systematic review found that nurse-initiated protocols, or nurse-driven protocols, are effective in reducing time to pain medication administration, time to treatment, improving pain relief, and decreasing hospital admission rates (Agency for Clinical Innovation, 2023). Examples of nurse-initiated protocol interventions include administering pain medications, administering corticosteroids for asthma, initiating x-rays, and initiating intravenous fluids (Agency for Clinical Innovation, 2023).

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Nurse-initiated protocols in the emergency department have been shown to be safe and effective. These protocols can improve patient outcomes as well as improve patient satisfaction and job satisfaction among nurses. These protocols allow for quicker treatment of patients, which can be life-saving (Gawthorne et al., 2025). Additionally, nurse-initiated protocols decrease admission rates and reduce patient length of stay in the ED (Burgess et al., 2021). As evidenced by outcomes in emergency departments with nurse-initiated protocols, these protocols can help address overarching issues in the ED, such as overcrowding and nurse burnout, by reducing length of stay time and increasing job satisfaction.