Australasian Emergency Nursing Journal 20 (2017) 53–62

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Australasian Emergency Nursing Journal

journal homepage: www.elsevier.com/locate/aenj

Systematic Review

A systematic review of the impact of nurse-initiated medications in

the emergency department
C.J. Cabilan a,∗ , Mary Boyde a,b
a
Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Australia
b
School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Nurse-initiated medications are one of the most important strategies used to facilitate
Received 30 January 2017 timely care for people who present to Emergency Departments (EDs). The purpose of this paper was to
Received in revised form 16 March 2017 systematically review the evidence of nurse-initiated medications to guide future practice and research.
Accepted 3 April 2017
Methods: A systematic review of the literature was conducted to locate published studies and Grey liter-
ature. All studies were assessed independently by two independent reviewers for relevance using titles
Keywords:
and abstracts, eligibility dictated by the inclusion criteria, and methodological quality.
Nurse-initiated
Results: Five experimental studies were included in this review: one randomised controlled trial and
Emergency nursing
Emergency department
four quasi-experimental studies conducted in paediatric and adult EDs. The nurse-initiated medications
Overcrowding were salbutamol for respiratory conditions and analgesia for painful conditions, which enabled patients
to receive the medications quicker by half-an-hour compared to those who did not have nurse-initiated
medications. The intervention had no effect on adverse events, doctor wait time and length of stay. Nurse-
initiated analgesia was associated with increased likelihood of receiving analgesia, achieving clinically-
relevant pain reduction, and better patient satisfaction.
Conclusion: Nurse-initiated medications are safe and beneficial for ED patients. However, randomised
controlled studies are required to strengthen the validity of results.
© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

Introduction late initiation of thrombolytic therapy for patients with myocardial

infarction, and longer time-to-analgesia.
Emergency departments (EDs) provide care for people who Nurse-initiated medications have been one of the most impor-
require urgent medical attention. These departments are a critical tant strategies implemented in EDs to facilitate timely care [6]. The
component of our health-care system with 7.5 million presen- process involves giving nurses the autonomy to administer med-
tations to Australian public hospital EDs in 2015–16 [1]. People ications to patients as guided by their medical condition prior to
presenting with an acute medical event may need timely treatment, them being seen by an ED doctor [7].
frequently requiring administration of medications to relieve their Evidence from the literature shows that analgesia [8–19],
symptoms. The time to administration of medications is often seen bronchodilators [20–22], and thrombolytics [23–25] have been
as a quality of care indicator [2] and contributes to patients’ per- nurse-initiated in EDs. The practice has been utilised in several
ceptions of the care they receive in the ED [3]. However, timely countries such as Australia [8,10,11,13,16–19,26], United States
administration of medications in the ED environment continues [12,14,21], Sweden [27,28], Canada [20], Hong Kong [22], and
to provide a challenge for clinical staff working in busy and often United Kingdom [23–25]. The uptake of nurse-initiated medica-
overcrowded EDs [4]. A literature review by Bernstein et al. [5] tions in the ED is increasing; therefore it is pertinent to evaluate
revealed some of the known effects of overcrowding, which were the impact of this practice on important quality of care indicators,
delayed administration of antibiotics for patients with pneumonia, which are safety, timeliness, effectiveness, equitability, patient-
centred care, and efficiency [29]. The findings of this review have
the potential to, influence further up-take of nurse-initiated medi-
cation administration and direct future research.
∗ Corresponding author at: Department of Emergency Medicine, Princess Alexan-
dra Hospital, 199 Ipswich Road, Woolloongabba, 4102, Queensland, Australia.
E-mail address: carajoyce.cabilan@health.qld.gov.au (C.J. Cabilan).

http://dx.doi.org/10.1016/j.aenj.2017.04.001
1574-6267/© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
54 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

Table 1 Table 2
The six quality of care domains proposed by the Institute of Medicine. Search strategy for published studies.

Safety avoiding injuries to patients from the care that is Database CINAHL via Ebsco
intended to help them. Example outcome measures
Dates Inception to July 5,
are adverse events, left without being seen, morbidity,
2016
or mortality.
Keywords:
Timeliness defined as reducing waits and sometimes harmful
1. TX emergency department OR TX (accident 85,176
delays for both those who receive and those who give
and emergency)
care. Timeliness is measured using time-based
2. TX medication$ OR TX drug$ OR TX 695,708
outcomes such as time to first medication
“medication protocol” OR TX “drug protocol”
administration.
OR TX protocol
Effectiveness defined as providing services based on scientific
3. TX “nurse initiated” OR TX “nurse managed” 9564
knowledge to all who could benefit, and refraining
OR TX “nurse prescribing” OR TX “non medical
from providing services to those not likely to benefit,
prescribing”
for example clinical improvement.
4. TX nurse OR TX nursing 1,211,525
Equitability refers to providing care that does not vary in quality
5. 1 AND 2 AND 3 AND 4 869
because of personal characteristics such as gender,
ethnicity, geographic location, and socioeconomic
status. Outcome measures include accessibility or Database PubMed
availability of medications. Dates Inception to July 5,
Patient-centeredness providing care that is respectful of and responsive to 2016
individual patient preferences, needs, and values, and Keywords:
ensuring that patient values guide all clinical decisions. 1. emergency department OR TX (accident and 186,325
Outcomes can include patient satisfaction or patient emergency)
perceptions of the care received in ED. 2. medication* OR drug* OR “medication 5,330,388
Efficiency focuses on avoiding waste, including waste of protocol” OR “drug protocol” OR protocol
equipment, supplies. Outcome measures that fall 3. “nurse initiated” OR “nurse managed” OR 1208
under efficiency are length of ED stay or the rate of “nurse prescribing” OR “non medical
inpatient admission. prescribing”
4. nurse OR nursing 740,859
5. 1 AND 2 AND 3 AND 4 39

Objectives Database EMBASE

Dates Inception to July 5,

The objectives of this review were to: systematically review
2016
the literature evaluating the effects of nurse-initiated medications Keywords:
in the emergency department; and to quantify the impact of the 1. ‘emergency’/exp OR emergency AND 278,464
practice on quality of care indicators (i.e. safety, timeliness, effec- department OR ‘accident’/exp OR accident
AND (’emergency’/exp OR emergency)
tiveness, equitability, patient-centred care, and efficiency).
2. medication* OR drug* OR ‘medication 9,934,833
protocol’ OR ‘drug protocol’ OR protocol
3. ‘nurse initiated’ OR ‘nurse managed’ OR 1475
Methods ‘nurse prescribing’ OR ‘non medical
prescribing’
Inclusion criteria for this review 4. ‘nurse’ OR ‘nursing’ 853,533
5. 1 AND 2 AND 3 AND 4 72
Types of studies
The review included experimental studies, such as randomised
controlled trials (RCT), quasi-experimental or controlled before-
and-after studies that evaluated the effectiveness of nurse-initiated Search methods
medications in the ED. Observational studies were not included
in this effectiveness review [30] due to the inherent bias and The search strategy, as shown in Table 2, was used to yield
confounding factors that could obscure the true effect of nurse- published studies and the grey literature from the start of the
initiated medications [31,32]. database until July 5, 2016 and in any language. Published stud-
ies were obtained from CINAHL, CENTRAL, PubMed, and EMBASE,
while Grey literature were sourced from Web of Science, Open-
Types of participants Grey, and ProQuest Dissertations and Theses. Additional studies
Participants were paediatric and adult patients who sought care were also located in clinical trials registries and hand-searching in
in the ED. the references of relevant studies.

Types of interventions
Data collection and analysis
Nurse-initiated medications is a component of non-medical pre-
scribing, where a list of medications is pre-approved (such as in
Selection of studies
a formulary or protocol), can be given according to the patient’s
Selection of studies was done independently by two indepen-
condition, and signs and symptoms, and administered without a
dent reviewers. Any disagreements between Reviewer 1 (CJC) and
medical order [7]. The nurse-initiated medication must be given in
2 (MB) were discussed and resolved. All citations from the final
ED and by ED nurses.
search strategy were imported into referencing software and sub-
sequently screened for relevance using title and abstract. Then, the
Types of outcome measures full-text of relevant citations were retrieved and assessed for eligi-
The outcomes were categorised according to the quality of bility based on the inclusion criteria. Lastly, all eligible studies were
care domains in ED, safety, timeliness, effectiveness, equitability, appraised for methodological quality using the Effective Practice
patient-centeredness, and efficiency (Table 1) [29]. and Organisation of Care Group risk of bias criteria [33].
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62 55

Data synthesis study by Wong et al. [45] was excluded from the systematic review
analysis due to methodological flaws (Fig. 1).
Data (e.g. study characteristics, intervention, population demo-
graphics) were extracted independently by two independent Description of included studies
reviewers to prevent error. Outcomes of interest were entered into
Review Manager 5.3.5 software [34]. Meta-analysis was conducted The characteristics of the included studies are summarised in
where possible, otherwise, findings were presented in a narrative Table 3. Studies were conducted in Australia [19], Hong Kong [22],
form. For example, studies that reported time-to-analgesia were Netherlands [47], Saudi Arabia [46], and Sweden [27]. There were
pooled because regardless of the type of analgesia, analgesia was 1272 participants in five studies. Of the five studies, two stud-
given for a pain score of ≥4. However, studies that reported time- ies recruited paediatric populations (n = 352) [19,46] and three
to-bronchodilator had varying indication for the administration of included adult populations (n = 920) [22,27,47]. The nurse-initiated
salbutamol; thus could not be pooled. medications differed among studies. Two studies investigated
Continuous data, such as time and length of ED stay, were ana- salbutamol administration for asthma exacerbation in children [46]
lysed using random effects inverse variance and presented as mean and exacerbation of chronic obstructive pulmonary disease (COPD)
difference (MD).Event variables (i.e. adverse events, provision of in adults [22]; while the remaining studies investigated a range of
analgesia) were analysed using Mantel-Haenszel method under the analgesia that included opioids for adult patients with abdominal
random effects model and presented as risk ratio (RR) [35]. A RR pain [27] and musculoskeletal injury [47], as well as children who
of >1 was interpreted as increased likelihood of the event, while presented with painful conditions [19]. Mandatory education and
decreased chance of the event occurring had a corresponding value training of nurses before the intervention were explicitly described
of <1. A RR with a 95% confidence internal (CI) that does not include in four studies [19,27,46,47] except the nurse-initiated salbutamol
the value of 1 was considered statistically significant [36]. for COPD patients [22].

Main findings
Assessment of heterogeneity
The available evidence for nurse-initiated salbutamol were
Sometimes studies in the meta-analysis can differ (heterogene- safety (nausea and vomiting, medication errors, perception of
ity) and this may be due to clinical characteristics of the population, tremors and palpitation, and ED representations), timeliness
methodological diversity, intervention and the magnitude of effect (time-to-bronchodilators), effectiveness (clinical improvement)
of the intervention. In this context, testing for heterogeneity is and efficiency (ED LOS, doctor wait time). On the other hand, nurse-
important to determine the similarity or dissimilarity of studies initiated analgesia had evidence for safety (deviation of vital signs),
[35]. Heterogeneity was assessed statistically using the standard I2 timeliness (time-to-analgesia), effectiveness (clinically-relevant
statistic, where (approximately) 1%–25%, 26%–75%, 76%–100% was pain relief), equitability (access to analgesia), patient-centeredness
interpreted as low, moderate, and high respectively [37]. The chi- (patient satisfaction) and efficiency (ED LOS).
squared statistic was also used to determine heterogeneity, where
a p value of less than 0.1 indicated statistically significant het- Safety
erogeneity. If present, heterogeneity was explored in a sensitivity
analysis using population characteristics and sample size. Three studies evaluated the safety aspects of nurse-initiated
medications. Muntlin et al. [27] reported no adverse events related
Results to nurse-initiated analgesia, which was defined as oxygen satu-
ration below 90%, pulse rate below 60 beats/min, systolic blood
The structured search generated a total of 1064 studies: 980 pressure below 100mmHg, respiratory rate below 12 breaths/min,
published studies, 72 from the grey literature, and 12 from clini- or incidence of nausea and vomiting. Qazi et al. [46] evaluated the
cal trials registries. After removal of duplicates 1026 studies were incidence of medication errors, vomiting, and ED representation
screened for relevance using titles and abstracts, from which 53 within three days in children with asthma. There were no reported
full-text articles were retrieved. These studies were assessed for medication errors; and there was no statistically significant differ-
eligibility using the inclusion criteria, which yielded 12 additional ence in vomiting (RR 2, 95% CI 0.37–10.72) and in representations
studies from the reference lists. Of the 67 studies, 37 were described (RR 4, 95% CI 0.45–35.29). The perception of tremors and pal-
as nurse-initiated medications. From these 37 studies 31 were pitations after nurse-initiated salbutamol was evaluated by Ho
excluded: 11 conference abstracts excluded because their full-text et al. [22]. The perception of tremors was similar in patients who
were unable to be retrieved or received from authors, 2 were nurse- received nurse-initiated and non-nurse-initiated salbutamol, but
initiated thrombolysis excluded because the interventions were patients who received a nurse-initiated dose were more likely to
not delivered in ED [23,25], 2 were descriptive research [38–41], report palpitations (RR 1.39, 95% CI 1.02–1.9).
5 were cross-sectional studies [16–18,42,43], 2 had cohort design
[20,44], and 9 were retrospective chart audits [8–15,21]. Ultimately, Timeliness
6 experimental studies were appraised for methodological quality.
Time-to-analgesia was reported in three studies, and was mea-
sured from triage time (approximately arrival time) to time of first
Methodological quality analgesic [19,27,47]. The studies were pooled in a meta-analysis
because In the nurse-initiated group, time-to-analgesia was sig-
Of the six studies, one was a RCT design [22]. Five had before- nificantly shorter with a mean of 30 min (MD −30.61 min, 95% CI
and-after design [19,27,45–47], with a high-risk of selection bias −50.58 to −10.64 min, p = 0.003) (Fig. 2). However, this must be
and performance bias. Attrition bias and selective reporting were interpreted with caution due to substantial heterogeneity (97%,
only evident in a study by Wong et al. [45] where a number of p = <0.01). The sensitivity analyses did not yield lower heterogene-
participants did not receive the intervention and their results were ity.
excluded in the analysis. Detection bias was low in three studies Time-to-bronchodilator was assessed in two studies [22,46],
[19,22,45], but unclear in the other three papers [27,46,47]. The which was measured from the time of arrival to ED to the time
 56
Table 3
Characteristics of included studies

Study Study Design Location Patient Intervention Type of No. of Age (mean %Male Summary of primary
population Nurse-initiated participants ± standard findings
Medication deviation)

Qazi et al. [46] Prospective Saudi Arabia 1–12 year-olds Asthma Salbutamol Pre, n = 125; Pre = 3.3 ± 2.6; Pre = 63.2%; Time-to-first
Pretest- who presented training nebulizer Post, n = 125 Post = 4.2 ± 3 Post = 68% bronchodilator
posttest for program on decreased from
design exacerbation of pathophysiol- 59.8 min ± 38.8 to
asthma ogy, 28.5 min ± 26.6
pharmacology, (p < 0.001).
and

C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

management of
asthma;
Nurse-initiated
salbutamol
nebulization
Muntlin et al. [27] Prospective Sweden ≥18 years old; Education IV morphine Pre, n = 50; Not provided Pre = 32%; Time to analgesia
Pretest- Ongoing session on with a starting Post, n = 100 per group Post = 47% significantly decreased
posttest atraumatic acute bolus of 2 mg from 2.5 ± 1.7 h(pre-
design abdominal pain abdominal and after 3 min intervention) to
no more than symptoms, the 1mg could be 1.3 ± 1 h(intervention)
2 days; character, repeated every (p = 0.001);
Orientated to quality and second minute ED length of stay was
person, place, location of not significantly
time; and pain, how to different; and
Pain score of measure pain Patients’ perceptions of
4–8. intensity, pain the quality of care in
medication ED improved with the
alternatives intervention.
and differential
diagnoses; and
nurse-initiated
IV morphine

Ho and Yau [22] Randomised Hong Kong ≥18 years old; Nurse-initiated Salbutamol Control, n = 55; Control = 74.3 ± 7.8; Control = 69.1%; Time-to-first
controlled trial Dyspnea; salbutamol metred dose Intervention, Interven- Interven- bronchodilator
History of inhaler n = 55 tion = 76.4 ± 8.0 tion = 74.5% decreased to
chronic 7.6 ± 1.1 min from
obstructive 45.6 ± 19.6 (p < 0.001);
pulmonary Peak flow rate, ED
disease; length of stay, and
Triage Category doctor wait time were
of 4–5; not significantly
Experience different.
using albuterol
metered dose
inhaler; and
Competent to
blow a peak
flow meter.
Table 3 (Continued)

Study Study Design Location Patient Intervention Type of No. of Age (mean %Male Summary of primary
population Nurse-initiated participants ± standard findings
Medication deviation)

Taylor et al. [19] Prospective Australia 5–17 years old; Education; Oral paraceta- Pre, n = 51; Pre = 11.0 ± 3.3; Pre = 64.7%; Time to analgesia
Pretest- Pain score ≥4; Nurse-initiated mol ± codeine; Post, n = 51 Post = 10.1 ± 3.4 Post = 60.8% significantly reduced to
posttest Triage Category medications Oral ibuprofen; 24.8 ± 12.4 min in the

C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

design 4–5; Topical local intervention period
Patient or anaesthet- from 55.1 ± 14.7 min
guardian able ics(lignocaine, (p = 0.003);
to amethocaine, There were more
communicate epinephrine), patients who received
pain score amethocaine, adequate analgesia in
eutectic the intervention period
mixture of local (Pre = 21%,
anaesthetics; Post = 37%,p = 0.001);
and
Patient/guardian
satisfaction was
similar.
Pierik et al. [47] Prospective Netherlands 18–70 years Active and Oral/IV Pre, n = 504; Pre = 43.4 ± 8.08; Pre = 45.2%; There were
Pretest- old; passive (e.g. paracetamol; Post, n = 156 Post = 49.9 Post = 44.2% significantly more
posttest Musculo- posters, Oral diclofenac; ± 6.57 patients in the
design skeletal leaflets) Oral ibuprofen intervention group
isolated education; Oral tramadol; who received adequate
extremity nurse initiated IV morphine; analgesia (Pre = 21.1%,
injury caused analgesia IV fentanyl; Post = 31.3%,p < 0.05);
by blunt IV esketamin More patients in the
trauma; with intervention period
Must be able to midazolam were offered analgesics
communicate; (Pre = 46.8%,
No cognitive Post = 68%,p < 0.05);
disability; ED length of stay was
Pain score ≥4 shorter in the
intervention period but
was not significantly
different;
Time-to-analgesia was
reduced to 8.3 ± 4.3
from 17.9 ± 13.2 min
(p = <0.05)

Legend: IV = intravenous, ED = emergency department.

57
58 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

Identification
Number of citations identified
through a systematic search Duplicates

n = 1,084 n = 58

Number of citations screened

using title and abstract Number of citations excluded
Screening

n = 1,026 n = 973

Additional studies identified

from reference lists
Number of full-text articles n = 12
Eligibility

assessed for eligibility

n = 65
Did not meet inclusion criteria

n = 59

Studies for critical appraisal

n=6 Did not meet quality criteria

n=1
Included

Studies included in this review

n=5

Fig. 1. Study flow diagram [48].

Fig. 2. Mean difference of time-to-analgesia between nurse-initiated and non-nurse-initiated patients in the emergency department.

of first salbutamol administration. In children with asthma exac- scale). Adequate pain relief was defined in the studies [19,47] as
erbation, nurse-initiated salbutamol significantly decreased time- a 2-point reduction or more of initial pain score and to a mild
to-bronchodilator (MD −31.3 min, 95% CI −39.55 to −23.05 min, intensity (<4) at discharge. Pooled results showed that nurse-
p = <0.01), and time-to-corticosteroids (MD −22.9, 95%CI −36.83 initiated analgesia increased the likelihood of achieving adequate
to −8.97, p = <0.01) [46]. In adults with chronic obstructive pul- pain relief compared to non-nurse-initiated analgesia (RR 1.58, 95%
monary disease, time-to-bronchodilator significantly reduced by CI 1.24–2.01) (Fig. 3).
38 min (MD −38 min, 95% CI −43.19 to −32.81 min, p = <0.01) [22]. Ho et al. [22] reported the differences in peak flow rate, oxygen
saturation, respiratory rate, heart rate, and perception of dysp-
noea. Peak flow rate, oxygen saturation, and respiratory rate were
Effectiveness not significantly different between nurse-initiated and non-nurse-
initiated salbutamol. However, heart rate was significantly higher
Two studies [19,47] measured effectiveness based on the pro- in nurse-initiated patients (MD 6.9, 95% CI 1.54–12.26). Dyspnoea
portion of patients who had clinically-relevant reduction of pain
amongst patients with moderate to severe pain (≥4 score in a 0–10
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62 59

Fig. 3. Comparison of the proportion of patients who received adequate analgesia between nurse-initiated and non-nurse-initiated period.

was less likely to be perceived by patients who did not receive with pre-implementation training for the nurses have most likely
nurse-initiated salbutamol (RR 0.53, 95% CI 0.33–0.86). been critical elements [19,27,46,47]. As well, the accountability
and responsibility associated with nurse-initiated medications may
Equitability influence nurses to apply more caution within their practice [49].
Nurse-initiated analgesia, particularly for patients with abdominal
Results from three studies [19,27,47] showed patients with pain, has been met with significant challenges due to the belief
moderate to severe pain were more likely to receive analgesia with that it would impede diagnosis and management [50]. However,
nurse-initiated analgesia (RR 1.23, 95% CI 1.06–1.43) (Fig. 4). there is little evidence to support this belief, and research has sug-
Pierek et al. [47], added that more patients were offered anal- gested that administration of early analgesia assists diagnosis with
gesia when nurses were allowed to nurse-initiate (RR 1.45, 95% CI a more co-operative patient being able to tolerate a comprehensive
1.24–1.7). assessment [51,52].
Timely access to medication is an important aspect of patient
Patient-centeredness care in ED. Nurse-initiated medication protocols promote a more
efficient process for medication administration by allowing nurses
Satisfaction with treatment received in the ED was reported to administer analgesia autonomously, thus leading to timely
in two studies [19,27]. In one study, although the proportion of administration of pain relief to patients with moderate to severe
parents who were either satisfied or very satisfied with the man- pain. The findings of this review have implications for pain treat-
agement of their child’s pain was higher in the nurse-initiated ment delays contributed to by overcrowding [53]. Overcrowding
group, the difference was not statistically significant [19]. In the limits the resources that can be allocated to new patients, because
other study [27], satisfaction was assessed using a 10-item ques- the available resources are utilised by patients who are already
tionnaire with each item rated on a 5-point Likert scale. Patients in the ED [54,55]. For example, without nurse-initiated analge-
in the nurse-initiated analgesia group were more satisfied with sia, patients have to wait for the doctor’s availability to prescribe
how their pain was managed compared to those who did not have analgesia before they can receive pain relief. Additionally, the
nurse-initiated analgesia. ability of the emergency staff to deliver immediate treatment to
children with asthma exacerbation has also been a significant
Efficiency issue [56]. Although empiric evidence is limited to one study [46],
nurse-initiated salbutamol has the ability to shorten the time-to-
Pooled results from four studies [22,27,46,47] showed that first bronchodilator. Evidence from observational studies suggested
length of ED stay was not significantly different between nurse- that nurse-initiated corticosteroids for asthma exacerbation led
initiated and non-nurse- initiated patients (Fig. 5). to quicker administration of the drug, increased the likelihood
Doctor wait time amongst children with asthma was not signif- of receiving the treatment within 60 min, reduced ED LOS, and
icantly different (MD −4.4 min, 95% CI −13.76 to 4.96 min, p = 0.36), decreased the risk of hospitalisation [20,21]. Moreover, nurse-
but they were attended to by the primary nurse quicker (MD initiated medications benefit patients with COPD [22]. However,
−15.6 min, 95% CI −23.67 to −7.53) [46]. generalisability is limited due to the lack of studies. The evidence
from this review and from other studies [20,21] indicate that fur-
Discussion ther research is required to evaluate the impact of nurse-initiated
salbutamol and/or corticosteroids in patients with asthma and
This systematic review focused on experimental studies which COPD.
evaluated the practice of nurse–initiated medications including The findings of this review demonstrate that nurse-initiated
analgesia and salbutamol in ED. In comparison to non-nurse- analgesia not only facilitates timely analgesia but also increases
initiated analgesia, patients who received nurse-initiated analgesic the likelihood of attaining clinically-relevant pain relief, which has
medication received their medication a mean of 30 min earlier. been defined as a ≥2-point reduction in pain score [19,47]. This
This intervention also improved the likelihood of achieving clin- measure has been used in pain management research [13,57–59].
ically relevant pain relief by 58% and showed patients were 23% Taylor et al. hypothesised that this effect could be related to the
more likely to receive analgesia. Additionally patients receiving timeliness of and access to analgesia [19]. This is supported by find-
nurse-initiated analgesics showed higher satisfaction with their ings from one study, which showed that adequate pain relief was
care in ED. Nurse-initiated salbutamol enabled adult and paediatric associated with the availability of analgesics [60].
patients to receive their bronchodilators therapy more than 30 min Access to analgesia was an important outcome that was evalu-
earlier and to achieve improved clinical outcomes. Nurse-initiated ated, because in overcrowded EDs not all patients receive analgesia
medications appear to be a safe intervention, evidenced by the lack in spite of their pain severity [57,61]. As previously highlighted,
of adverse events reported. overcrowded conditions limits doctors’ availability to prescribe
The available evidence from the medical literature suggests that analgesia for patients [54,55]. This review provides evidence that
nurse-initiated medications can be administered without com- patients are more like to receive analgesia when nurse-initiated
promising safety. While it is difficult to identify the key factors protocols are implemented.
that contributed to this positive outcome, standardised protocols
60 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62

Fig. 4. Comparison of analgesia provision between nurse-initiated and non-nurse-initiated period.

Fig. 5. Mean difference of length of stay between nurse-initiated and non-nurse-initiated patients in the emergency department.

Inadequate pain management is a source of frustration and dis- the reported outcomes may be impacted on by unknown variables.
satisfaction among patients [62]. Two studies [19,27] included in Second, the included studies did not all report the same outcomes
this review showed that patients who had nurse-initiated analgesia which decreased the quality and availability of data for the analysis.
tend to have higher levels of pain management satisfaction com- Third, the mean difference was used widely in the results because
pared to those who did not. Patient satisfaction is multifactorial and the available data preclude the computation of median difference.
can be influenced by staff communication, general experience of The mean difference can either overestimate or underestimate the
care in ED, timeliness of treatment, and quality of care [62]. Perhaps effect depending on the direction of the skew. The time-based out-
an important factor contributing to patient satisfaction was timely comes (e.g. time-to-analgesia) in this review were almost positively
analgesia and the clinically significant pain reduction achieved with skewed; therefore the time reductions reported could be greater
the intervention [58,59,63,64]. than the actual time.
Although the implementation of nurse-initiated medications Findings from this review support the practice of nurse-initiated
led to quicker access to medications and effective symptom relief, medications in ED. There is a potential for the practice to expand
the intervention did not reduce the LOS in ED and doctor wait- beyond analgesia and salbutamol, and benefit other patient cohorts.
ing time [22,27,46,47]. There are two plausible reasons for this. However further high level evidence is required to confirm these
First, unlike nurse-initiated blood tests and x-rays [65,66], nurse- initial findings. While RCTs may be more challenging to conduct in
initiated medications do not guide the diagnosis and direct patient the ED, the study by Ho et al. [22] is proof that this can be accom-
treatment. Second, analgesics and bronchodilators mainly target plished. There is an urgent need for further RCTs to strengthen the
the immediate relief of symptoms and patient comfort. Therefore, validity of the results from this systematic review.
patient flow is unlikely to be influenced by nurse-initiated medica-
tions.
Conclusion
There are limitations to this systematic review. First, experi-
mental studies were exclusively selected as they were considered
The systematic review holds clinical and research implications.
to provide the highest level of evidence. This limited the available
Findings from this review support the practice of nurse-initiated
research to one RCT and four quasi-experimental studies which met
medications in the ED, particularly nurse-initiated analgesia.
the inclusion criteria. Quasi experimental designs do not include
Nurse-initiated analgesia increases the accessibility of analgesia,
randomisation so there is a selection and performance bias and
and facilitates the administration of timely and effective pain relief.
 C.J. Cabilan, M. Boyde / Australasian Emergency Nursing Journal 20 (2017) 53–62 61

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