Copyright eContent Management Pty Ltd. Contemporary Nurse (2012) 43(1): 2937.

Reducing time to analgesia in the emergency department using a

nurse-initiated pain protocol: A before-and-after study

JUDITH C FINN*,+,!,#, AMANDA RAE**, NICK GIBSON*, ROGER SWIFT++, TAMARA WATTERS!!
AND IAN G JACOBS*,#
*Discipline of Emergency Medicine (M516), The University of Western Australia, Crawley, WA,
Australia; +School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC,
Australia; !Centre for Nursing Research, Innovation and Quality, Sir Charles Gairdner Hospital,
Nedlands, WA, Australia; #St John Ambulance (Western Australia), Belmont, WA, Australia; **Nickol
Bay Hospital, Karratha, WA, Australia; ++Emergency Department, Sir Charles Gairdner Hospital,
Nedlands, WA, Australia; !!Fremantle Hospital and Health Service, Fremantle, WA, Australia
Abstract: Suboptimal management of pain in emergency departments (EDs) remains a problem, despite having been
rst described over two decades ago. A before-and-after intervention study (with a historical control) was undertaken in
one Western Australian tertiary hospital ED to test the effect of a nurse-initiated pain protocol (NIPP) intervention. A
total of 889 adult patients were included: 144 in the control group and 745 in the intervention group. Patients in the
intervention group were: More likely to have a pain score recorded than those in the control group; have reduced median
time to the rst pain score; and reduced time to analgesia. The statistically signicant reduction in both time to pain score
and time to analgesia remained, even when adjusted by age and sex. Whilst we demonstrated the safety and efcacy of a
NIPP in ED, an unacceptable proportion of patients continued to have inadequate pain relief.

Keywords: emergency nursing, pain relief

T here are over six million patient presenta-

tions to emergency departments (EDs)
in Australia each year (Australian Institute of
Health and Welfare, 2006) of which pain is the
most frequent symptom; occurring in up to
80% of all presentations (National Institute of
Clinical Studies, 2004). For several decades there
has been evidence of the physiological and psy-
chological adverse effects of acute (and chronic)
pain (Macintyre et al., 2010) and yet subopti-
mal management of pain remains a problem in
EDs (Arendts & Fry, 2006; Karwowski-Soulie
et al., 2006; Rupp & Delaney, 2004; Todd et al.,
2007). A number of strategies have been pro-
posed to increase the timely administration of
analgesic medications for ED patients, includ-
ing nurse-initiated (NI) analgesia (Fosnocht &
Swanson, 2007; Fry, Ryan, & Alexander, 2004;
Kelly, Brumby, & Barnes, 2005; Sando, Usher,
& Buettner, 2009).
Nurse-initiated analgesia is dened as the ini-
tiation of analgesia by nursing staff, using a pre-
dened protocol, prior to the patient being seen
by a medical ofcer (Kelly et al., 2005, p. 151).
In Australia, all patients presenting to an ED
are assessed and triaged by an experienced ED
nurse, who allocates the patient to one of ve
Australasian triage scale (ATS) codes, reect-
ing that patients clinical urgency (Australasian
College for Emergency Medicine, 2006). The tri-
age nurse is also in a position to initiate appropriate
investigations or initial management, according
to organisational guidelines (Australasian College
for Emergency Medicine, 2006), although this
is less commonly undertaken. Despite the triage
nurse assessing pain, ED nurses do not routinely
administer any analgesic medications until the
patient has been assessed by the medical ofcer.
Depending on the workload of the ED, there can
be considerable delay between the patients pre-
sentation at ED and being seen by a doctor; and
even longer until pain relief is actually adminis-
tered (Hoot & Aronsky, 2008).
We sought to introduce and evaluate the prac-
tice of nurse-initiated analgesia in the ED of
a busy tertiary hospital, whereby the ED triage
nurse (or other specically trained ED nurse)
administered analgesic medications according to
a pre-dened protocol, without the patient being
rst assessed by a medical ofcer.

Volume 43, Issue 1, December 2012 CN 29

CN Judith C Finn et al.
METHODS
A before-and-after study with a historical control
(National Health and Medical Research Council,
2009) was undertaken to test the null hypothesis
that the nurse-initiated pain protocol (NIPP)
intervention had no effect on either the time to
pain assessment or the time to analgesia.
The study was undertaken in the ED of an
urban tertiary teaching hospital, in Perth, Western
Australia. In 2009, a total of 417,259 patients
attended Perth metropolitan EDs, of which
54,740 attended the study hospital ED. The
ED is medically staffed by a mix of consultant
emergency physicians, senior registrars, resident
medical ofcers and interns. The ED nurses are
predominantly registered nurses, some of whom
have completed a 12-month postgraduate emer-
gency nursing certicate. The triage nurse posi-
tion is lled on a shift-by-shift basis by a senior
registered nurse.
All adult patients (18 years) presenting to
the ED with pain, during the study period from
4 April 2009 to 25 June 2009, were eligible for
recruitment into the intervention arm of the
study. Patients meeting the following conditions
were excluded: presented with chest pain of pre-
sumed cardiac origin or with headache; were tri-
aged as emergency or urgent (Australasian Triage
Score 1 and 2; Australasian College for Emergency
Medicine, 2006); exhibited unstable vital signs;
were pregnant or lactating; had known contra-
indications to one of the study drugs; declined
analgesia; or already had an analgesia related man-
agement plan in place.
Over the 12 months prior to the introduc-
tion of the NIPP, baseline data about initial pain
management in the ED had been collected as part
of the (Australian) National Institute of Clinical
Studies (NICS) National Emergency Care Pain
Management Initiative (Yeoh & Huckson, 2007).
These data were used as the convenience sample
for the historical cohort, for comparison with the
prospectively collected intervention data.
Intervention
The ED NIPP was developed in consultation
with hospital medical, nursing and pharmacy
staff, resulting in guideline instructions, a ow
30 CN Volume 43, Issue 1, December 2012
chart depicting the decision path to be followed
and single page information sheets for each of the
protocol medications. These information sheets
described the drug, dosage, route of administra-
tion, indications, contraindications, potential
adverse effects, required documentation and
patient follow-up. Table 1 shows which medica-
tions were to be administered depending on the
patients initial pain score. The opioid analgesics
[oral oxycodone and intravenous (IV) morphine]
required medical approval prior to administration,
whereas the other listed medications were nurse-
initiated. The NIPP emphasised the importance
of pain assessment using the PAINED acronym,
i.e., place, amount, intensiers, nulliers, effects
of analgesics and description. Pain scores were to
be recorded as soon as possible at triage, and again
60 minutes after oral analgesia or 30 minutes after
oral oxycodone or IV morphine. Nurses were also
advised to consider non-pharmacological meth-
ods of pain relief, such as splinting, support or
cold packs.
Education
Prior to implementation of the NIPP, medical
and nursing staff were encouraged to attend infor-
mation sessions about the NIPP. Nurses were not
permitted to administer analgesia per the NIPP
until they had undertaken specic training and
had demonstrated competence. In addition, all
medical staff were advised of their responsibilities
regarding the administration of Schedule 8 drugs
by nurses (Department of Health and Ageing,
2010), phone ordering and written prescriptions.
Hard copies of the summary protocol guidelines
were laminated and displayed in strategic areas
such as the triage desk, transit area and other
common areas in the ED and complete protocol
details were led in the nursing practice guide-
lines sited in the general ED area and the clinical
nurse educators ofce.
Outcomes
The primary outcomes were: (a) time to rst pain
score recorded; and (b) time to rst analgesia
administered. These were, respectively, dened as
the time interval difference between the patient
arrival in the ED; and (a) the time of the rst pain
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 Reducing time to analgesia in the emergency department CN
TABLE 1: ED NURSE-INITIATED ANALGESIA PROTOCOL ACCORDING TO INITIAL Any adverse events in the inter-
PAIN SCORE vention group were recorded.
Pain score Action
Data collection
Mild 2 paracetamol 500 mg (=1 g) Data were initially extracted from
13 or clinical records on a study-specic
3 paracetamol 500 mg tabs if patients estimated weight form and then entered into an Excel
is more than 100 kg
database that had been specically
or
developed for the project by one
2 ibuprofen 200 mg (=400 mg) if paracetamol is
contraindicated of the three study research nurses.
For further analgesia discuss with senior registrar Data collected included: patient
Moderate 2 paracetamol 500 mg/codeine 30 mg (Panadeine Forte) age, gender, data and time of ED
36 or presentation; triage category using
PO 3 ibuprofen 200 mg/codeine 12.8 mg (Nurofen Plus) the ATS (Australasian College for
For further analgesia discuss with senior registrar Emergency Medicine, 2006); time
Severe Patient to go through to ED assessment area ASAP, then and value of rst pain score; type
710 2 paracetamol 500 mg (=1 g) of analgesia self-administered by
PLUS 3 ibuprofen 200 mg (=600 mg) patient prior to ED presentation;
PLUS IV morphine 2.5 mg boluses up to 10 mg time and type of rst analgesic
or medication administered in ED;
If patient cannot proceed through to ED assessment area, and non-pharmacological pain
then management strategies used. ED
2 paracetamol 500 mg (=1 g) diagnosis was manually catego-
PLUS 3 ibuprofen 200 mg (=600 mg) rised into one of the International
PLUS 12 Endone 5 mg tabs (max 10 mg) Classication of Diseases (ICD-
For further analgesia discuss with senior registrar and get 10) Chapters (World Health
script for schedule 8 drugs
Organisation, 2007).

score recorded, and (b) the rst analgesic medica-
tion administered.
A verbal numeric rating scale (VNRS) from
010 was used to assess (and re-assess) pain,
where 0 represents no pain and 10 represents
worst pain imaginable. The VNRS has been
shown to be a sensitive (and practical) measure
of acute pain in EDs (Holdgate, Asha, Craig, &
Thompson, 2003). Pain scores of 06 were con-
sidered to be mild/moderate pain and pain scores
of 710 were classed as severe pain.
For the initial severe pain cases who had both
an initial and post-analgesia pain score recorded,
adequacy of analgesic effect was calculated as per
Jao, McD Taylor, Taylor, Khan, and Chae (2011)
namely a reduction in the triage pain score of 2
and to a level <4. The NICS denition of effec-
tive pain management, i.e., three-point or better
reduction in severe pain scores, was also calculated
(National Institute of Clinical Studies, 2008).
Sample size and power
A sample size calculation was performed prior
to the implementation phase of the NIPP using
information gleaned from the N = 144 historical
control group. With a baseline mean time to pain
score of 61.5 minutes and a standard deviation
(SD) of 56.3 minutes, a total of 144 cases in the
intervention group would provide a power of 0.99
to detect a 50% relative difference in mean time
to pain score between the experimental and con-
trol arms of the study with a type 1 error of 0.05
(Dupont & Plummer, 1990). However, the intent
of the study was to trial the implementation of the
NIPP intervention for up to 3 months and hence
the actual number of cases in the experimental
group was much larger than the 144 required.
Statistical analysis
Descriptive statistics were used to summarise the
data, including means with SD and medians with

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CN Judith C Finn et al.

interquartile range (IQR) for continuous variables. RESULTS

Denominators for the calculation of percentages The study cohort comprised 889 patients (51%
varied because of missing values for some vari- males), with 144 in the pre-intervention (his-
ables, and in such cases the denominators used are torical sample) group and 745 post-intervention
reported. Comparisons between the before and group. Overall, most of the patients fell within
after groups were made using Pearsons Chi-squared ATS category 3 or 4 (see Table 2; ATS category
test for nominal/ordinal data and the t-test or the 1 and 2 were excluded) and two-thirds had an
non-parametric MannWhitney U-test for con- initial pain score of 06.Overall, 88.8% of
tinuous variables (depending on whether the data all cases attending ED for pain fell into four
met the assumptions of normality). Multivariable main diagnostic categories (based on ICD-10
regression (logistic/multiple regression depending Chapters; World Health Organisation, 2007),
on level of measurement of the outcome variable) namely: (1) disorders of the musculoskeletal sys-
was performed to adjust for potential confound- tem and connective tissue (60.4%); (2) disorders
ers, with results reported as odds ratios (OR) and of the digestive system (13.4%); (3) infectious
95% condence intervals (CI). Sub-group analysis and parasitic diseases (9.7%); and (4) disorders
by pain severity, i.e., mild/moderate pain (pain of the genitourinary system (5.3%). Of those
score 06) and severe
pain (pain score 710),
was dened a priori. For TABLE 2: DIFFERENCES IN BASELINE CHARACTERISTICS OF THE PRE- AND
POST-INTERVENTION GROUPS
the analysis of time to
analgesia, only patients N PRE N = 144 N POST (N = 745) Difference
with a recorded initial
pain score of at least 1 Gender: male (%) 144 78 (54.2%) 745 380 (51%) 0.49a
b
were included. All analy- Age 144 740 0.38
ses were performed using Mean (SD) 38.9 (20.0) 41.9 (19.7)
IBM SPSS Statistics v19.0 Median 32.1 37.5
and statistical signicance ATS 144 744
was accepted as p < 0.05. 3 75 (52.1%) 349 (46.9%) 0.48a
4 66 (45.8%) 382 (51.3%)
Ethics approval 5 3 (2.1%) 13 (1.7%)
Ethics approval for this Musculoskeletal 144 103 (71.5%) 745 434 (58.3%) 0.003a
system related ED
study was obtained from diagnosis
the Hospitals Human Analgesia prior to 74 36 (48%) 745 180 (24.3%) <0.001a
Research Ethics Commit- ED presentation
tee, QIA#2226. Given yes (%)
that the intervention was Pain score 144 83 (57.6%) 745 708 (95%) <0.001a
recorded yes (%)
deemed to be a quality
Initial pain score 83 708 0.03b
improvement activity and
Mean (SD) 4.75 (3.2) 5.67 (2.4)
the data required for the
Median 5.00 6.00
study was already col-
Initial pain score 83 708 0.82b
lected as part of normal category N (%)
clinical practice, a waiver Mildmoderate 53 (63.9%) 443 (62.6%)
of consent was granted. (06)
The data collected were Severe (710) 30 (36.1%) 265 (37.4%)
initially identiable, but Non- 144 41 (28.5%) 745 90 (12.1%) <0.001a
only de-identied data pharmacological
pain interventions
were used for data manip-
ulation and analysis. a
Pearsons Chi-squared test; bMannWhitney U-test.

32 CN Volume 43, Issue 1, December 2012 eContent Management Pty Ltd

 Reducing time to analgesia in the emergency department
patients in the diagnostic category of the mus-
culoskeletal system and connective tissue, 81%
(435/537) were related to injury. The majority
of cases (76%) were recruited during the morn-
ing and afternoon nursing shifts at ED, which
corresponded to the period when the research
nurses were present.
As shown in Table 2, the two groups did not
differ with respect to age, gender, ATS category
or initial pain score category. However, the his-
torical control group had a lower proportion
of patients with a pain score recorded; a lower
median initial pain score; and a higher propor-
tion of patients who received non-pharmacolog-
ical pain relieving interventions. Patients in the
intervention group were much more likely to
have a pain score recorded than those in the con-
trol group (95 vs. 58%, p < 0.001), even when
adjusted for age and sex (OR = 13.9, 95% CI
8.6, 22.4).
Primary outcomes
The time to the rst pain score was reduced from
a median of 47 (IQR 2093) minutes in the
control group to a median of less than 1 minute
(IQR 026) in the NIPP intervention group
(p < 0.001). The comparison of time to analgesia
administration only included patients who had an
initial pain score of greater than or equal to 1,
i.e., N = 67 in the control group and N = 689 in
the intervention group. The time to analgesia in
the intervention group was signicantly reduced
from a median of 98 (IQR 44137) minutes to
28 (IQR 858) minutes (p < 0.001). The statisti-
cally signicant reduction in both median time to
pain score and median time to analgesia remained,
even when adjusted for age and sex.
Both the time to initial pain score and the
time to analgesia administration were reduced in
the NIPP intervention group compared to the
pre-intervention group in both the mild/mod-
erate and severe pain sub-groups, as shown in
Table 3. Patients in the NIPP group with severe
pain were more likely to receive analgesia within
30 minutes, as per the NICS recommendations
(National Institute of Clinical Studies, 2008),
than patients in the control group (47.3% vs.
20%, p = 0.009).
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CN
Adequacy of analgesic effect
Only around 50% of patients overall had their
second pain score within 1 hour of administra-
tion of analgesia and this was no different when
only the severe pain group was considered. For
patients with an initial pain score of 710 (i.e.,
severe pain), and both an initial and post-anal-
gesia pain score recorded (N = 238), a three-point
or better reduction in pain score was achieved for
a signicantly higher proportion of patients in
the post-intervention group (115/216 = 53.2%)
compared to the baseline period (4/22 = 18.2%;
2 = 9.82, 1df, p = 0.003). Using the Jao et al.
(2011) denition of adequate analgesia pro-
duced similar (but not identical results), with
2/22(9.1%) in the pre-intervention group and
70/216 (32.4%) in the post-intervention group
achieving adequate analgesia (2 = 5.44, 1df,
p = 0.03).
Adverse events (NIPP group only)
Of the 548 (74%) of the NIPP patients who
received an analgesic medication in ED, 22 (4%)
had an adverse event agged; 10 (45.5%) in the
patients with mild/moderate pain (PS 06) and
12 (54.5%) in the severe pain group (PS 710).
Only 15 of these events were described of
these half as nausea and the other half as feel-
ing light headed/dizzy. The medications that
had been given in these 22 cases were as follows:
paracetamol (N = 7); paracetamol + codeine
(N = 5); morphine (N = 4); ibuprofen (N = 3);
oxycodone (N = 3). There were no serious adverse
events recorded.
DISCUSSION
We demonstrated that a NIPP resulted in dra-
matic improvements in each of the indicators
commonly used to gauge the quality of pain man-
agement in EDs. When compared to a historical
control group, the NIPP patients were more likely
to have an initial pain score recorded (95% vs.
58%, p < 0.001); have a reduced median time to
initial pain score (<1 min vs. 47 min, p < 0.001)
and a reduced median time to rst analgesia (28
min vs. 98 min, p < 0.001). Whilst the adequacy
of analgesic effect for patients with severe pain, as
dened by Jao et al. (2011), substantially increased
Volume 43, Issue 1, December 2012 CN 33
CN Judith C Finn et al.

TABLE 3: DIFFERENCES IN PRIMARY AND SECONDARY OUTCOMES PRE- AND POST-INTERVENTION, BY SEVERITY OF PAIN

N PRE (N = 53) N POST (N = 443) Difference

Initial pain score = 06 (N = 496)

Time to 1st pain score (min) 53 443 <0.001a

Range 0197 0289
Mean (SD) 55.6 (50.5) 20.9 (39.6)
Median (IQR) 43 (1488) 0 (027)
Time to analgesia (min)c 21 283 <0.001a
Range 0366 0315
Mean (SD) 108.4 (90) 44.2 (57.5)
Median (IQR) 88 (48.5152) 22 (564)
Initial pain score = 710 (N = 295)
PRE (N = 30) POST (N = 265) Difference
Time to 1st pain score (min) 30 <0.001a
Range 0259 264 0284
Mean (SD) 73.5 (65.0) 17.3 (35.9)
Median (IQR) 49 (25126) 0 (022)
Time to analgesia (min)c 25 <0.001a
Range 2386 220 0284
Mean (SD) 105.4 (85.9) 44.6 (46.4)
Median (IQR) 105 (43134) 32 (1356)
Analgesia within 30 min 25 5 (20.0%) 220 104 (47.4%) 0.009b
Three-point reduction 22 4(18.2%) 216 115 (53.2%) 0.003b
in pain scored
Adequate analgesic effectd,e 22 2(9.1%) 216 70 (32.4%) 0.02b
a
MannWhitney U-test; bPearsons Chi-squared test; cOnly patients with initial pain scores > 0; dOnly patients with initial
and post-analgesia pain scores; eAs dened by Jao et al. (2011)

in the NIPP group, there were still two-thirds of
patients with inadequate pain relief. Thus we have
shown that whilst NIPP can improve pain man-
agement in EDs, there is still scope for further
improvement.
Provision of effective pain management in
EDs requires systems to ensure adequate assess-
ment of pain, provision of timely and appro-
priate analgesia, with frequent monitoring and
reassessment of pain (Macintyre et al., 2010).
Enabling an ED nurse to assess a patients pain
at the point of presentation to ED and then
administer analgesia according to a pre-approved
protocol simply makes sense, given the goal to
reduce time to analgesia. The evidence for the
efcacy of NI analgesia in EDs is persuasive,
albeit mostly based on before and after studies,
in single centres.
For example, a beforeafter study conducted
in an urban university ED in Utah (USA;
Fosnocht & Swanson, 2007), showed a reduction
in the mean time to pain medication administra-
tion from 76 to 40 minutes (p < 0.001) after the
introduction of a triage pain protocol initiated
by nurses, for patients presenting with isolated
extremity or back pain. However, individual ED
nurse compliance with the pain protocol varied
between 896% and the protocol was not used
in 30% of the eligible 800 patients (Fosnocht &
Swanson, 2007). At a Swedish university hos-
pital ED, Muntlin, Carlsson, Sfwenberg, and
Gunningberg (2011) implemented a NI intra-
venous analgesic protocol (IV morphine) for
abdominal pain, and measured time to analge-
sia at three time points: before (A1); during (B);
and after (A2) the intervention. The mean time

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 Reducing time to analgesia in the emergency department
to analgesia was reduced from 2.5 hours (A1)
to 1.3 hours (B), but reverted back to 2.1 hours
during the A2 phase, highlighting the challenges
in sustaining changes in clinical practice.
In Australia, it has been shown that NI anal-
gesia is safe and efcacious (Fry & Holdgate,
2002; Kelly et al., 2005). A decade ago, at a uni-
versity teaching hospital in Sydney (Australia),
Fry and Holdgate (2002) demonstrated that an
IV morphine pain protocol could be safely and
effectively implemented in the ED for patients
with acute severe pain. The median time from
triage to administration of NI morphine (time
to narcotic) was 18 minutes. Whilst there was
no concurrent comparison group, a previous
audit at the same hospital had found median
time of 58 minutes between triage and admin-
istration of analgesia (Fry, Holdgate, Baird, Silk,
& Ahern, 1999). Similarly, Kelly et al. (2005) in
an urban public teaching hospital in Melbourne
(Australia), showed that specially trained and cre-
dentialed ED nurses could safely and effectively
initiate and manage titrated IV opioid analgesia
for selected painful conditions. Unfortunately
the study was suspended early when an exter-
nal government body apparently challenged the
legality of what they perceived to be nurse pre-
scribing (Kelly et al., 2005). That this should
occur is fascinating, given that out-of-hospital
paramedic practice around the world relies on
non-physicians administering analgesia (and a
suite of other medications) on the basis of pre-
approved protocols.
Because medication dosage was not reliably
entered into the study database, our capacity to
ascertain compliance with the protocol was lim-
ited. However we were able to report that the type
of analgesic medication(s) administered was con-
sistent with the NIPP for the specic pain score
in 61.1% of patients who received an analgesic
agent. This congruence with the protocol was
higher for patients with mildmoderate pain than
for patients with severe pain (83.4 vs. 30.6%).
One might assume that patients with severe pain
were more likely to have been assessed by an ED
physician and have had their pain management
individually adjusted, although this was not cap-
tured in the database.
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These crude estimates of protocol adherence
are consistent with results reported elsewhere. In
a recent study (Stephan et al., 2010) conducted
in a university hospital in Switzerland it was
found that their locally developed pain manage-
ment protocol for ED was only correctly applied
in 42% of patients, with the protocol incorrectly
or only partially applied in 30% of patients and
28% of patients refused any analgesia at the
time of presentation. Similarly, in a study of
NI oral paracetamol for ED patients present-
ing with minor musculoskeletal injury at a uni-
versity hospital in Hong Kong, whilst the mean
time to analgesia in the NI-Paracetamol group
was dramatically reduced compared to the non
NI-Paracetamol groups (9 min vs. 93 min) and
pain scores were signicantly lower at 60 minutes,
only 22% of eligible patients actually received
paracetamol by the triage nurse (Wong, Chan,
Rainer, & Ying, 2007). As astutely concluded by
the authors protocols and standing orders offer
options for nurses, however, the translation of the
concept into clinical reality is multidimensional
and highly complex (Wong et al., 2007, p. 69).
In our study, anecdotal feedback indicated
that NIPP implementation was less likely when
the ED was busy or when no research nurse was
present in ED. Moreover, we were aware that
there were some triage nurses who refused to par-
ticipate in the study. We did not formally survey
the staff (or patients) re their experiences/attitudes
about NIPP, which on reection was an unfortu-
nate omission. As identied by Fry, Bennetts, and
Huckson (2011, p. 273), further investigation is
needed into emergency nurses attitudes towards
the enablers and barriers to NI policies.
LIMITATIONS
This was a single centre study, based on a non-
consecutive convenience sample of patients. As
such the results may not be generalisable to other
EDs with different stafng proles and/or case-
mix. The data for the pre-intervention historical
cohort that was used as the comparison group
were collected as part of an audit process, up to
1 year prior to the intervention study. It is there-
fore not surprising that differences between the
groups were identied, thereby increasing the risk
Volume 43, Issue 1, December 2012 CN 35
CN Judith C Finn et al.
of confounding of the result. However, adjust-
ment for potential confounders through the use
of multivariable statistics did not alter the strong
effect of the NIPP on time to initial pain score
and time to analgesia.
Despite the study inclusion criteria being
patients presenting to ED with pain, a small
number of patients (3.9% overall) had an ini-
tial pain score recorded as 0. This could mean
that these patients were incorrectly included in
the study, or it could indicate that patients can
still nominate their initial pain score as 0 even
if their reason for presenting to ED is related to
pain (for instance, patients with pain on move-
ment but no pain at rest). We were not able to
discern which of these alternatives applied. There
were also 11% (N = 98/889) of cases without a
recorded initial pain score. It cannot be certain
whether this reects pain not being assessed or
simply not recorded.
CONCLUSION
This study has demonstrated that a NIPP in the
ED increased the likelihood of pain scores being
recorded, reduced the time from ED presen-
tation to the initial pain score and reduced the
time to analgesia. Whilst the adequacy of analge-
sic effect more than tripled, almost two-thirds of
all patients still had inadequate pain relief. Thus
whilst we have demonstrated the potential ef-
cacy of a NIPP, a system-wide multidisciplinary
approach is likely to be required to address the
persistent problem of oligoanalgesia (Wilson &
Pendleton, 1989) in the ED.
ACKNOWLEDGEMENTS
This study was funded by a research grant from
The Sir Charles Gairdner Hospital Research
Advisory Committee. The research team
acknowledges this nancial and other support
provided by the nursing and medical staff of
the emergency department. In particular, we
acknowledge and thank the following research
nurses for their assistance with implementation of
the protocol and data collection: Grainne Mallen,
Susan Greyling and Michelle Lucking. Australian
New Zealand Clinical Trials Registry number:
ACTRN12611000953932.
36 CN Volume 43, Issue 1, December 2012
REFERENCES
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Received 09 April 2012 Accepted 17 August 2012

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Cross-cultural pedagogies and teaching focusing on Islamic pedagogies and epistemologies in a western context and
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