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.

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).

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).

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).

• 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

  
  

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.

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.