Triage Pain Protocols

[jeremyRN]

I work in a large, busy, urban ER where patient's often experience extensive waits before physician evaluation. We are currently working on establishing a protocol that would allow us to administer pain medication in triage before the patient sees the physician. Depending on the patient's stated pain level and symptoms, it would allow us to administer NSAIDs as well as Percocet and Morphine IM.

Does your ER have a triage protocol or standing order for pain management? If so what are the parameters? Has this been successful, or have there been any adverse events related to this practice at your facility? Are the nurses obligated to medicate all patients with pain, or do they retain some discretion on when to enact the protocol?

Some of the concerns that our committee has had regarding this practice have been, safety - what if the patient has and adverse reaction, gets dizzy, falls etc.... What if the patient feels better then leaves the triage area after they are medicated, only to find out they have an appy or an ectopic? Will drug seeking be a problem?

Looking forward to any thoughts and discussion related to this topic.

[Larry77, RN]

I've heard of it working but in a situation where there was a second WR...one where the patients have been treated with protocols and a nurse was assigned to that area to monitor for adverse reactions and changes in s/s. So sort of a step to a room...if they are a level 2 they go to the main but if they are a 3 and need intervention they go to the second WR.

Maybe someone here works at a facility that does this???

[ThrowEdNurse, BSN, RN]

I've heard of it working but in a situation where there was a second WR...one where the patients have been treated with protocols and a nurse was assigned to that area to monitor for adverse reactions and changes in s/s. So sort of a step to a room...if they are a level 2 they go to the main but if they are a 3 and need intervention they go to the second WR.

Maybe someone here works at a facility that does this???

I do, but the assignment is torture and unsafe. I've had as many as 40 pts. No beds or monitors. Just running around, getting tasks done in chairs, small rooms for privacy for IMS, fluids, urine, accuchecks, tx bp, culture, out of what is essentially a WR. Major lawsuit waiting to happen plus the pts never appreciate the reduction in total wait time or the fact they've been tx'd sooner. All they want is a bed.

[canoehead, BSN, RN]

I was in tears and he did not even offer me a tissue. Even with a box right beside him.

I am very grateful to have spent about 20 mins in the ER. It was amazing to see how fast they worked. I was very impressed. I am not angry with that, just the triage system that involves no pain meds.

Were your arms broken? You couldn't say "Could you pass me a tissue?"

I daresay that your wait time in the ER shows that the triage nurse was VERY sympathetic, and did a lot of advocating behind the scenes for you. Triage nurses can't promise that their backstage work will help because the minute they manage to finagle a bed for you an ambulance may rush in, destroying their efforts. You weren't told about his work, but someone was definitely on your side that day.

We have pain protocols, the patient gets relevant teaching like sedation effects, and the fact that they may feel better, but that doesn't mean that the original problem is better. We also have chart flagging if the patient has multiple visits in a short period. If morphine IV is indicated the patient goes to a bed ASAP. Percocet orders are great for musculoskeletal injuries that still need to be Xrayed and wait for a bed. Not many seekers will wait 3-4 hours for one Percocet, but for real ER patients it's a great thing.

[hlgarrett77]

At my facility we give Tylenol for fever, aspirin for chest pain, and Albuterol nebs for asthma at triage. If someone is vomiting and I have a subtriage bed (as well as a few extra minutes) to start an IV and give Zofran I will. I simply do not have the time or space to medicate someone with narcotics or even Phenergan, I can't monitor them for adverse reactions or safety checks while I am running around triaging other patients, starting stroke protocols, and cleaning rooms. I know that patients come in for severe pain, but triage is a place to assign acuity. We also start care protocols (i.e. labs, EKG's, and Xrays). I have been in severe pain myself and I know that it is awful, but my license is important to me and so is patient safety and I will NOT jeopardize that. On a side note, we obtain an order from a provider to medicate patients once they are in a room and under the care of a primary nurse, so at least patients aren't waiting for the provider to see them and a nurse can monitor them. The idea of giving someone IM morphine or Percocet and then basically setting them free to leave or have a reaction in the waiting room sounds crazy to me.