A Pragmatic Randomized Evaluation of a Nurse-Initiated Protocol to Improve Timeliness of Care in an Urban Emergency Department Matthew J. Douma, RN, BSN*; Claire A. Drake, RN, MPH; Domhnall O’Dochartaigh, RN, MSc; Katherine E. Smith, MD, BSc *Corresponding Author. E-mail: matthew.douma@albertahealthservices.ca, Twitter: @matthewjdouma. Study objective: Emergency department (ED) crowding is a common and complicated problem challenging EDs worldwide. Nurse-initiated protocols, diagnostics, or treatments implemented by nurses before patients are treated by a physician or nurse practitioner have been suggested as a potential strategy to improve patient flow. Methods: This is a computer-randomized, pragmatic, controlled evaluation of 6 nurse-initiated protocols in a busy, crowded, inner-city ED. The primary outcomes included time to diagnostic test, time to treatment, time to consultation, or ED length of stay. Results: Protocols decreased the median time to acetaminophen for patients presenting with pain or fever by 186 minutes (95% confidence interval [CI] 76 to 296 minutes) and the median time to troponin for patients presenting with suspected ischemic chest pain by 79 minutes (95% CI 21 to 179 minutes). Median ED length of stay was reduced by 224 minutes (95% CI –19 to 467 minutes) by implementing a suspected fractured hip protocol. A vaginal bleeding during pregnancy protocol reduced median ED length of stay by 232 minutes (95% CI 26 to 438 minutes). Conclusion: Targeting specific patient groups with carefully written protocols can result in improved time to test or medication and, in some cases, reduce ED length of stay. A cooperative and collaborative interdisciplinary group is essential to success. [Ann Emerg Med. 2016;-:1-7.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2016.06.019 INTRODUCTION Background Emergency department (ED) crowding has required broad and creative strategies to ensure timely care provision. 1 A diverse range of approaches has been undertaken early in the patients’ stay, such as diagnosis- specific nurse-initiated protocols that direct evidence-based care for sepsis, 2 corticosteroids for asthma, 3,4 sickle cell crisis, 5 chest radiograph in pneumonia, 6 and thrombolysis for myocardial infarction. 7 The purpose of these protocols is to make consecutive processes simultaneous and to improve departmental performance. Alternatively, protocols can target presenting complaints, such as chest pain 8 and abdominal pain, 9,10 and direct both diagnostics and treatments. Two of the most common nurse-initiated protocols in the literature are the facilitation of radiographic examinations of orthopedic injuries 11-14 and analgesia provision. 9,15-20 The potential benefit of protocols is reductions in length of stay, especially after the patient is treated by a physician or nurse practitioner, because diagnostics are available during initial assessment, allowing disposition decisionmaking to occur. 10 One such study determined that the time saving in patient length of stay for 4 different presenting complaint protocols resulted in a 16% reduction in length of stay regardless of protocol deployed. 21 Deforest and Thompson 8 described combining nurse-initiated protocols with clinical scoring systems to create advanced nursing directives to have the best available evidence guide care. Unfortunately, the legality and acceptance of complaint-specific protocols are often unclear. 22 Alternative “up-front” interventions include geographically anchoring nurse practitioners 23 or physicians 24 at triage to initiate care. The department being evaluated once had a triage physician, but the position’s funding was discontinued before the evaluation. Triage nurses in a 2012 study demonstrated a 76% sensitivity and Volume -, no. - : - 2016 Annals of Emergency Medicine 1 THE PRACTICE OF EMERGENCY MEDICINE/ORIGINAL RESEARCH