Saberon, Zeleen Ann O.

Saberon BSN 4 - ND

From Medscape Emergency Medicine > Ask the Experts

Should Emergency Department Nurses Initiate Intravenous Opioids at Triage?
Sergey M. Motov, MD
12/31/2009

Question
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.[1]
In the era of overcrowding, EDs are faced with an even bigger challenge: providing
timely and efficient analgesia.[2,3] 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[4] 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%.[4]

Kelly and colleagues[5] 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,[6] 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.[6]

In evaluating the delivery of analgesia to trauma patients, Curtis and colleagues[7]

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%.[7]

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.