Could Nurse-Driven Protocols Cut ER Crowding?

Among the many challenges in U.S. healthcare are the ridiculously extended wait times endured by patients in need of emergency care. Patients have no option but to wait it out, oftentimes for hours, until they can be seen and even longer before they can receive treatment.

According to the Centers for Disease Control and Prevention emergency department visit statistics, the number of visits in the U.S. for 2016 have totalled 136.3 million so far, of which only 27 percent were seen in fewer than 15 minutes.

The Annals of Emergency Medicine recently published a new Canadian study that details how nurse-driven protocols cut ER wait times before treatment as well as the lengths of stay for patients who suffer from fever, chest pain, hip fractures, and vaginal bleeding during pregnancy.

"Nurse-driven protocols are not an ideal solution, but a stop-gap measure to deal with the enormous problem of long wait times in emergency departments especially for patients with complex problems." says lead author of the study, Matthew Douma, clinical nurse educator at Royal Alexandra Hospital in Edmonton, Alberta.

The study authors aim to support a potential strategy to improve patient flow through nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner.

"Given the long waits many emergency patients endure prior to treatment of pain," says Douma, "the acetaminophen protocol was a quick win."

Researchers evaluated a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. The results were just shy of astonishing:

  • Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes)

  • Median time to troponin for patients presenting with suspected ischemic chest pain was decreased by 79 minutes (95% CI 21 to 179 minutes)

  • Median ED length of stay was reduced by 224 minutes (95% CI –19 to 467 minutes) by implementing a suspected fractured hip protocol

  • A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes).

Researchers contend that a cooperative and collaborative interdisciplinary group is essential to success, however by targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce emergency room patients’ length of stay.