An interesting question: what do you do with patients in severe pain presenting 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.


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]

I once worked in an Emergency Department where a medical directive* allowed RNs to administer narcotics to suspected hip fractures and kidneys stones. It wasn’t quite at Triage, but close enough. The-then ED medical director was enormously hostile to nurses, and was adamantly opposed to nurses administering narcotics though a medical directive, on the grounds of “patient safety” — though I suspect territoriality was the real problem, as there were no history of adverse incidents.

Practical experience points to a real issue. This is a good idea, the literature supports its practice, it has direct therapeutic benefits to the patient, and has subsidiary benefits in that it will increase overall patient satisfaction. But the chances of this actually being implemented in any hospital in Canada, I would guess, is approximately zero, at least in the near-term. There is nearly always resistance from physicians to new medical directives, especially if it appears nurse-driven, and nursing administration is almost never interested in prologued battles with physicians over practice issues. Getting approval for new medical directives is in any case a notoriously fraught and time-consuming process.

In the end, practically speaking, change will have to led by physicians, and unless you have a particularly enlightened group of physicians working in your local emergency, it isn’t going to happen. It’s a bit sad, really.


*A medical directive is a document which gives nurses and other health care professionals permission under certain circumstances to perform acts normally outside their scope of practice. To administer an opioid analgesic without a physician’s order, for example, requires a medical directive.


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  1. #1 by JennJilks on Saturday 16 January 2010 - 0929

    We know how amenable physicians are to change! (NOT!) They do not understand teamwork.
    It will take nurse managers and case managers, in home care, to make a difference.
    In my hospice work, I am appalled at the myths around pain management.
    Keep up the great posts.

  2. #2 by Matt on Monday 08 August 2011 - 1734

    The problem is just as rampant pre-hospital. Change is needed universally across the patient care spectrum.

  3. #3 by Marcia on Sunday 29 January 2012 - 1810

    We have a DMF (delegated medical function) in my ED where the nurse can initiate IV access and administer Morphine 5mg q5min to a total of 15mg to patients with pain rated 8/10 or greater. The only contraindications are chest pain/dental pain, pregnancy, Age <18yrs and an allergy to Morphine.

    This DMF was spearheaded by our then Clinical Nurse Lead and is supported by most of our ER physicians. Its comforting to know we have the ability to bring comfort to our renal colics/new abd pains while they wait for Dr assessment, especially on busy days, and the patients are beyond grateful.

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