Abstract：
BACKGROUND: Australian literature supports nurse-initiated opioid analgesia protocols may be effective, but this practice is not yet widely adopted in Canada.
OBJECTIVE: Previous quality audits of Emergency Departments (EDs) in Victoria (Canada) indicate long delays to administration of analgesia.
METHODS: Two tertiary care hospitals in a Canadian city of approximately 400,000 people were chosen for a quality improvement initiative. A manual retrospective chart review was conducted on a total of 122 patients which was compared to data from 125 patients from a previous audit in 2019.
METHODS: ED nursing staff both hospitals were provided education and daily reminders to document pain score at triage, and to flag an acute analgesia opioid order set on the charts of patients with moderate or severe pain (greater than 4 out of 10 in the Numerical Rating Scale (NRS) or by triage nurse\'s clinical judgment). At Victoria General Hospital (VGH), nurses had the option of finding an emergency physician (EP) to sign the acute analgesia opioid order set, or independently administer IV opioids from a presigned order set without consulting an EP. At Royal Jubilee Hospital (RJH), nursing staff could only administer IV opioids from the order set after an EP was consulted. Median time to opioid analgesia after the intervention was compared to 2019 data for each hospital.
RESULTS: Each hospital significantly reduced median time to administration of opioids: VGH achieved 45.6 % reduction (1 h 8 min improvement, p = 0.001) and RJH achieved a 62.5 % reduction (2 h 11 min improvement, p < 0.001). Secondary outcomes indicated patients may receive analgesia faster when the opioid protocol was nurse initiated (median 43 minutes) vs physician initiated (median 1 h 1 min) at VGH. Pain score documentation at triage improved from <10 % in 2019 to >50 % in 2020 at both sites. Approximately 95 % of EP and nursing staff thought nurse-initiated opioids are safe, effective, and should be supported by regulatory boards.
CONCLUSIONS: Implementing a new triage protocol to expedite initiation of an analgesic protocol was associated with significantly reduced time to analgesia for patients with moderate to severe pain. Time reductions may be greater with nurse-initiated analgesia before physician assessment.
OBJECTIVE: Previous quality audits of Emergency Departments (EDs) in Victoria (Canada) indicate long delays to administration of analgesia.
METHODS: Two tertiary care hospitals in a Canadian city of approximately 400,000 people were chosen for a quality improvement initiative. A manual retrospective chart review was conducted on a total of 122 patients which was compared to data from 125 patients from a previous audit in 2019.
METHODS: ED nursing staff both hospitals were provided education and daily reminders to document pain score at triage, and to flag an acute analgesia opioid order set on the charts of patients with moderate or severe pain (greater than 4 out of 10 in the Numerical Rating Scale (NRS) or by triage nurse\'s clinical judgment). At Victoria General Hospital (VGH), nurses had the option of finding an emergency physician (EP) to sign the acute analgesia opioid order set, or independently administer IV opioids from a presigned order set without consulting an EP. At Royal Jubilee Hospital (RJH), nursing staff could only administer IV opioids from the order set after an EP was consulted. Median time to opioid analgesia after the intervention was compared to 2019 data for each hospital.
RESULTS: Each hospital significantly reduced median time to administration of opioids: VGH achieved 45.6 % reduction (1 h 8 min improvement, p = 0.001) and RJH achieved a 62.5 % reduction (2 h 11 min improvement, p < 0.001). Secondary outcomes indicated patients may receive analgesia faster when the opioid protocol was nurse initiated (median 43 minutes) vs physician initiated (median 1 h 1 min) at VGH. Pain score documentation at triage improved from <10 % in 2019 to >50 % in 2020 at both sites. Approximately 95 % of EP and nursing staff thought nurse-initiated opioids are safe, effective, and should be supported by regulatory boards.
CONCLUSIONS: Implementing a new triage protocol to expedite initiation of an analgesic protocol was associated with significantly reduced time to analgesia for patients with moderate to severe pain. Time reductions may be greater with nurse-initiated analgesia before physician assessment.
摘要：
背景：澳大利亚文献支持护士发起的阿片类镇痛方案可能是有效的，但这种做法在加拿大尚未被广泛采用。
目的：先前对维多利亚州（加拿大）急诊科（ED）进行的质量审核表明，镇痛的使用时间较长。
方法：选择了加拿大城市的两家三甲医院，该医院约有40万人，以实施质量改进计划。对总共122名患者进行了手动回顾性图表审查，并将其与2019年上一次审计的125名患者的数据进行了比较。
方法：为两家医院的ED护理人员提供教育和每日提醒，以记录分诊时的疼痛评分，并在中度或重度疼痛患者的图表上标记急性镇痛阿片类药物顺序（在数字评定量表（NRS）或分诊护士的临床判断中，大于10分之4）。在维多利亚综合医院（VGH），护士可以选择找急诊医师（EP）签署急性镇痛阿片类药物医嘱集，或在不咨询EP的情况下从预先签署的订单集中独立施用IV阿片类药物。在皇家禧年医院（RJH），在咨询EP后,护理人员只能从医嘱集中给予静脉阿片类药物.将干预后阿片类药物镇痛的中位时间与每家医院的2019年数据进行比较。
结果：每家医院均显着减少了阿片类药物的中位给药时间：VGH减少了45.6％（1小时8分钟改善，p=0.001)，RJH降低了62.5%(2小时11分钟改善，p<0.001)。次要结果表明，在VGH时，当护士开始使用阿片类药物方案（中位数43分钟）时，患者可能会更快地接受镇痛（中位数1小时1分钟）。分诊时的疼痛评分记录从2019年的<10%提高到2020年的>50%。大约95％的EP和护理人员认为护士启动的阿片类药物是安全的，有效,并应得到监管委员会的支持。
结论：实施新的分诊方案以加快启动镇痛方案与中度至重度疼痛患者的镇痛时间显著缩短相关。在医生评估之前，护士开始镇痛的时间减少可能更大。
目的：先前对维多利亚州（加拿大）急诊科（ED）进行的质量审核表明，镇痛的使用时间较长。
方法：选择了加拿大城市的两家三甲医院，该医院约有40万人，以实施质量改进计划。对总共122名患者进行了手动回顾性图表审查，并将其与2019年上一次审计的125名患者的数据进行了比较。
方法：为两家医院的ED护理人员提供教育和每日提醒，以记录分诊时的疼痛评分，并在中度或重度疼痛患者的图表上标记急性镇痛阿片类药物顺序（在数字评定量表（NRS）或分诊护士的临床判断中，大于10分之4）。在维多利亚综合医院（VGH），护士可以选择找急诊医师（EP）签署急性镇痛阿片类药物医嘱集，或在不咨询EP的情况下从预先签署的订单集中独立施用IV阿片类药物。在皇家禧年医院（RJH），在咨询EP后,护理人员只能从医嘱集中给予静脉阿片类药物.将干预后阿片类药物镇痛的中位时间与每家医院的2019年数据进行比较。
结果：每家医院均显着减少了阿片类药物的中位给药时间：VGH减少了45.6％（1小时8分钟改善，p=0.001)，RJH降低了62.5%(2小时11分钟改善，p<0.001)。次要结果表明，在VGH时，当护士开始使用阿片类药物方案（中位数43分钟）时，患者可能会更快地接受镇痛（中位数1小时1分钟）。分诊时的疼痛评分记录从2019年的<10%提高到2020年的>50%。大约95％的EP和护理人员认为护士启动的阿片类药物是安全的，有效,并应得到监管委员会的支持。
结论：实施新的分诊方案以加快启动镇痛方案与中度至重度疼痛患者的镇痛时间显著缩短相关。在医生评估之前，护士开始镇痛的时间减少可能更大。
