Fry M, Holdgate A

Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia

Emerg Med 2002; 14(3): 249-254

Our Observations

This was a prospective observational case-series in which the authors evaluated the effect of a nurse-initiated pain protocol in which nursing staff could administer opioids autonomously. The protocol allowed triage nurses to initiate and titrate IV morphine in patients with pain due to various causes: 2.5mg IV morphine every 5 minutes until the patient was comfortable or up to a maximum of 0.1mg/kg.

Nursing staff had to have at least 18 months emergency nursing experience, had completed a 3 day course in triage and a detailed education session. There were strict protocol exclusion criteria documented, when nursing staff wanted to initiate analgesia:

- VAS <5

- patients younger than 18 or older than 75 years

- hemodynamic instability (heart rate >110/min; systolic blood pressure <100mmHg)

- altered level of consciousness (EMV <15)

- respiratory rate <12/min

- oxygen saturation <95% on room air

- possible ischemic chest pain

- dyspnea as major presenting complaint

- presenting with headache

- allergy to morphine


This was a prospective study and therefore, data was collected for study purposes directly, which decreases information bias and increases data value.

Moreover, this was the first prospective (observational) study in which the effect of a nurse-managed pain protocol in the Emergency Department was evaluated and the first study to investigate the effects of an IV narcotic nurse-initiated pain protocol.


This was a single-group study without a comparison group, therefore the exact effect of implementation of the pain protocol cannot be determined. Patients were recruited at the moment the triage nurse would use the pain protocol and the study population consisted of a convenience sample with potential selection bias, as patient selection could have been influenced by factors such as overall activity in the department; crowding; work load; level of current staffing; opportunities to acquire morphine and to record data at that specific moments, etcetera.

The authors concluded that patients received analgesia 26 minutes earlier (as time to be seen by a physician was 26 minutes after administration of analgesics in triage). However, it is not unimaginable that a treating physician went to treat other patients first, because pain of study patients was already being treated adequately by protocol (for example in patients with known kidney stones and presenting with renal colic, treating physicians might have waited for lab results and urinalysis before seeing the patient). Therefore the time gain of 26 minutes is too easily concluded. 

The authors mention 15 potentially serious adverse events (4.3%), however they sum up 25 (7.2%).

Clinical applicability

The use of an IV narcotic titrated nurse-initiated pain protocol in triage can assure timely administration of adequate pain treatment and adequate pain relief in patients presenting to the Emergency Department with various painful conditions, however, the use of morphine leads to several adverse events.

Level of evidence 4


Kelly AM, Brumby C, Barnes C

Nurse-initiated, titrated intravenous opioid analgesia reduces time to analgesia for selected painful conditions

CJEM 2005; 7(3): 149-154

Our Observations

This was a retrospective observational cohort study in which the authors evaluated the time to analgesic administration in patients receiving pain medication according to a nurse-initiated IV opioid pain treatment protocol compared to physician-directed analgesic administration.

In previous studies the same research group evaluated a nurse-driven narcotic pain protocol and its effect on several factors. In the current study they evaluated the effect of a novel, nurse-initiated opioid analgesia protocol that was implemented shortly before data collection. This protocol allowed nursing staff (who were specially trained and accredited for this purpose) to initiate and manage titrated IV opioid analgesics for selected patients presenting with certain painful conditions, before physician's assessment. 


Data was collected by 2 reviewers and the authors did their best to minimize selection bias, information bias and differential loss to follow-up by collecting data from several source documents, such as Emergency Department patient records; drug charts; nursing observation charts and a narcotic drugs register, which they used to cross-check if analgesia was nurse-initiated. A sample size calculation was performed in order to detect a reduction in time to analgesia from 45 to 30 minutes.


Unfortunately, the planned sample size of 224 patients was not reached, because their hospital suspended the nurse-initiated narcotic pain protocol as its legality was challenged by an external governmental institution. 

​It was unclear whether the reviewers were blinded for the results of each other / collected data independently. No referee was appointed in case of disagreement and note interpretation could have influenced results, leading to information bias.​

It was a retrospective study with high risk of potential (unknown) confounders.  

The nursing-initiated analgesia group had higher triage acuity category scores, possibly reflecting higher pain scores, which might have influenced results (pain scores were not recorded in the study).

 Finally, the authors mention in the results section that no cases of respiratory depression occurred, however, occurrence of adverse events was not mentioned in the methods section and therefore it is not known whether it was specifically and systematically looked for by the data reviewers.

Clinical applicability

The implementation of an IV narcotic nurse-initiated pain protocol probably shortens time to adequate analgesia in adult patients presenting to the Emergency Department with biliary and renal colic.

Level of evidence 4


Wong EML, Chan HMS, Rainer TH, Sek Ying C

The effect of a triage pain management protocol for minor musculoskeletal injury patients in a Hong Kong emergency department

AENJ 2007; 10: 64-72

Our Observations

This was a prospective, observational study in which the authors evaluated the use of a triage pain protocol in a Hong Kong Emergency Department.

According to the protocol, nursing staff was allowed to administer acetaminophen 1000mg orally to patients with minor musculoskeletal injuries. Moreover, pain assessment was added to standard care using 100mm VAS pain scores and triage nurses received a 2 hour training about pain management concepts, the pain protocol and study logistics. 

Study results showed a significant increase in pain assessment after implementation, however there was a remarkable lack of protocol adherence regarding administration of acetaminophen. Of patients included after implementation, only 22% of patients who would have liked to receive acetaminophen actually received this.



The authors also performed a qualitative study in order to find out beliefs and thoughts of both patients and nursing staff regarding nurse-initiated triage analgesia and desire for pain medication.

Patient beliefs included fear of adverse events of analgesics; analgesics should only be used in severe pain and the belief that pain should be beared as much as possible.

Nurses mainly thought that there was no time when the waiting room was full and they needed to get used to working with the new protocol.



Not all consecutive patients were recruited as patients were only approached for inclusion in the study during office hours. This could have led to selection bias.

When present, a research assistant (not involved in care), approached patients for inclusion. Treating nursing staff could have been influenced by their presence and therefore (unconsciously) changed their behavior, potentially resulting in a Hawthorne effect, (although study results certainly do not point in that direction).

There was a large difference in waiting time before a patient was evaluated by a physician, in favor of the phase before implementation of the pain protocol. The authors explain this because of 'differences in medical staff skill mix' between the 2 periods (more senior staff available in first period). These differences might have influenced other study results as well. Other unknown confounding factors might have been present.

The groups were divided in pre- and post-implementation groups as was to be expected. Additionally, the post-test group (after implementation of the pain protocol) was sub-divided in patients who actually received acetaminophen and patients who did not receive this. This resulted in small study groups. Conclusions drawn from these groups should be approached with caution as the study was probably not powered to detect any meaningful differences. Finally, no sample size calculation was performed.

Clinical applicability

The implementation of a triage pain protocol in which nursing staff can administer oral acetaminophen to adult patients with minor musculoskeletal injuries leads to increased pain assessment. This study failed to show increase in analgesic administration or superior pain treatment. It is worthwhile to evaluate thoughts and beliefs of both patients and health care staff when optimizing pain management in the Emergency Department. 

Level of evidence 4


Fosnocht DE, Swanson ER

Use of a triage pain protocol in the ED

Am J Emerg Med 2007; 25: 791-793

Our Observations

In this Emergency Department observational cohort study, the investigators evaluated the use of a triage pain protocol. Analgesic choices depended on VAS pain scores and consisted of orally administered or IV administered pain medication. 

This meant that patients with a VAS pain score somewhere between 1mm and 33mm (mild pain) could receive ibuprofen 600mg orally.

In case the VAS pain score was between 34mm and 66mm (moderate pain), the triage nurse was allowed to administer ibuprofen 600mg AND hydrocodone 10mg orally, in combination with acetaminophen 1000mg orally.

In case of severe pain (VAS pain score between 67mm and 100mm), the triage nurse had 2 options: the analgesics as described above in case of moderate pain OR 5mg IV morphine. The latter was recommended in case of high suspicion of a fracture or in case of failure of oral opioids prior to arrival in the Emergency Department.


Nurses were educated in a 15-minute session by the study PI at trial start. Moreover, nursing quality assurance audits were performed monthly, including feedback given to nursing staff as a whole and individually regarding enrollment of eligible patients.

They used research associates who were blinded for the study purpose.


It can be assumed that patients were recruited prospectively, however this was not explicitly described.

Patients were not recruited consecutively and selection bias potentially influenced the study results, possibly threatening internal study validity. Performing the study itself might have led to an increased awareness of pain treatment and therefore a Hawthorne effect.

An historical patient group was used as comparison and retrospective data is prone to potential confounding factors, for which no corrective measures were described. 

Clinical applicability

When compared to a historical control group, a triage pain protocol did not improve pain relief at discharge, but it did improve analgesic administration. 

Level of evidence 4


Muntlin Å, Carlsson M, Säffenberg U, Gunningberg L

Outcomes of a nurse-initiated analgesic protocol for abdominal pain in an emergency department: a quasi-experimental study

Int J Nurs Stud 2011; 48(1): 13-23

Our Observations

In this Swedish prospective study the authors examined the effect of an intervention that consisted of two parts:

1. Education session for nursing staff about abdominal pain; pain measurement and analgesics

2. Protocolized pain assessment by nursing staff as well as nurse-initiated IV opioid pain treatment.

In case patients had non-traumatic abdominal pain with an NRS pain score between 4 and 8, 2mg IV morphine could be administered with additional 1mg incremental IV dosages every 3 minutes up to a maximum dose of 10mg. 

Exclusion criteria of this protocol were: hemodynamic or respiratory instability; pain intensity > 8; allergy to morphine or pregnancy. 


Besides implementation there was awareness regarding the value of educational sessions and protocolized pain assessment. Consecutive patients were included with well-defined criteria.

Patients were questioned regarding their experience with pain management in the Emergency Department. 


The study design was quasi-experimental, utilizing a so-called A1BA2-design, in which A1 represented baseline; B implementation and A2 return to baseline (during which the implemented pain protocol was retracted again).


During the study course, there was significant change in staff (continuous consultants present during office hours). These changed could have confounded study results, however this was recognized and might have been corrected by utilizing study phase A2.

Although the implementation of the pain protocol resulted in improved pain assessment and pain score documentation (96%!), pain scores at discharge were not recorded systematically. Therefore, only the least pain that was experienced during the stay in the Emergency Department could be compared between the groups. No formal sample size calculation was performed.

The questionnaire that was utilized was designed for post-operative pain originally. Therefore, it was not validated for use in the Emergency Department to evaluate patients with acute pain. 


Clinical applicability

Implementation of an IV opioid nurse-initiated pain protocol based on morphine, combined with an extensive educational session, resulted in increased pain assessment; increased analgesic administration and decreased time to analgesia in adult patients presenting to the Emergency Department with non-traumatic abdominal pain. 

Level of evidence 2b


Finn JC, Rae A, Gibson N, Swift R, Watters T, Jacobs IG

Reducing time to analgesia in the emergency department using a nurse-initiated pain protocol: a before-and-after study

Contemp Nurse 2012; 43(1): 29-37

Our Observations

The authors of this Australian before- and after observational cohort study evaluated the use of a nurse-initiated pain management protocol. The protocol was NRS-based;

NRS 1-3: APAP 1000mg orally (1500mg in case weight > 100kg) OR ibuprofen 400mg

NRS 4-6: APAP/codeine 1000/60mg orally OR ibuprofen/codeine 600/38,4mg

NRS 7-10: APAP 1000mg AND ibuprofen 600mg orally AND IV morphine 2.5mg bolus titrated up to 10mg OR endone 5-10mg orally.

Additionally, information sessions were held for nursing staff and specific training and demonstrated competence was required for nurses to administer analgesics autonomously. Hard copies of the protocol were displayed.


This resulted in decreased time to initial pain score as well as analgesic administration. In patients with severe pain, 3-points reduction in NRS pain scores occurred more often and adequacy of analgesic effect was significantly improved after implementation, however numbers of these subgroups were small.



Formal sample size calculation was performed.

Patients in the intervention group were recruited by research nurses, not involved in direct clinical care.



The control group was a historical control group, not-consecutively recruited and therefore prone to potential (unknown) confounders and bias. There were several significant baseline differences between the control group and the intervention group.

Moreover, patients in the intervention group were also not included consecutively, as research nurses were not present 24 hours and 7 days per week.

Although the pain protocol was ‘nurse-initiated’, opioid analgesics still had to be signed off and therefore, administration of narcotics was not nurse-initiated.

The group of patients with a second pain score recorded was very small (especially in the pre-intervention group), therefore the study was probably not powered to detect differences regarding the outcomes ‘effective pain management’ (3-point NRS decrease in severe pain) and ‘adequacy of analgesic effect’.

The authors mention that medication dosage was not reliably entered into the study database and therefore protocol adherence cannot be ascertained. This might have confounded results, especially as departmental issues, such as crowding were not accounted for as well.  


Clinical applicability

Implementation of a nurse-initiated protocol in which nursing staff was allowed to administer non-opioids autonomously resulted in decreased times to initial pain score and initial analgesia.

Level of evidence 4


Pierik JGJ, Berben SA, IJzerman MJ, Gaakeer MI, Van Eenennaam FL, Van Vugt AB, Doggen CJM

A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain

Int Emerg Nurs 2016; 27: 3-10

Our Observations

The authors of this prospective, observational, before- and after-implementation study from The Netherlands evaluated the effect of implementing a nurse-initiated pain protocol in patients with acute musculoskeletal injuries. The pain protocol was based on a Dutch national pain treatment guideline, the major change was structural pain measurement. Moreover, nurses were allowed to administer analgesics, including opioids without assessment autonomously. The protocol was NRS based and consisted of acetaminophen as first choice in mild and in moderate pain (oral or IV). NSAIDs or tramadol could be administered as well. 

In severe pain, IV morphine 0.1mg/kg or fentanyl 1-2ug/kg can be administered OR IV esketamine 0.25mg/kg.


The authors found a significant increase in analgesic administration. The proportion of patients to whom pain medication was offered increased significantly from 46.8% to 68%, however 21.9% of patients refused analgesics. Median NRS scores decreased significantly from 1.46 to 2.02 NRS points. This difference was not significant when defined as a 33% proportional decrease patients who actually received pain medication.

There were no differences in length of stay or patient satisfaction.



This was a prospective study in which patients were included consecutively and a formal sample size calculation was performed. Prehospital analgesics were accounted for.

The first study to evaluate a nurse-initiated protocol in which esketamine was allowed (although not reported how often this was administered after implementation).

Besides absolute decreases in pain scores, relative decreases in percentages were reported as well.


Important to mention that at discharge 69.2% still had moderate to severe pain (before this was 77%).


Standardized assessment of NRS pain scores were part of the protocol, however, patients who did not provide pain scores were excluded from the study. It is unclear how many patients were excluded for this reason and whether they were always asked for pain scores, as this might have confounded results. Moreover, treating nurses recruited the patients and this could have influenced selection. Therefore, confounding factors such as crowding or other departmental or staff-related issues might have played a role.

Relatively large proportion of patients had fractures (up to 70%), more than other comparable studies (in which strains and sprains are the largest group of patients with acute musculoskeletal injuries). Therefore, it is unclear whether the study results are representative for all Emergency Departments.

The tool with which patient satisfaction was measured, was not explicitly reported. It could have been that satisfaction with Emergency Department treatment in general was measured. There was no significant difference.


Clinical applicability

Implementation of a nurse-initiated pain protocol including IV opioids and IV esketamine in severe pain arising from acute musculoskeletal injuries results in more adequate and faster pain relief. 

Level of evidence 2b


Van Woerden G, Van den Brand CL, Den Hartog CF, Idenburg FJ, Grootendorst DC, Van der Linden MC

Increased analgesia administration in emergency medicine after implementation of revised guidelines

Int J Emerg Med 2016; 9: 4

Our Observations

The authors of this Dutch prospective observational cohort study evaluated the effect of implementing a nurse-initiated pain protocol in adults presenting with pain of various causes. These causes were not reported, as patients were subdivided into specialties who treated them and not the conditions they presented with.

The pain protocol included the following:

NRS 4-6: acetaminophen orally, and when necessary in combination with NSAIDs and/or tramadol orally administered

NRS 7-10: piritramide IV (in combination with acetaminophen)

Nursing staff was educated face-to-face and pocket-size versions of the protocol were distributed and posters were placed in the Emergency Department.


They found that the rate of analgesic administration increased significantly, but still was very low after implementation: 31.7%. NRS at moment of discharge from the Emergency Department was missing in 46% of patients in total.



It was a comparative study.

The authors analyzed several previously published confounding factors that might influence analgesic administration by performing both univariable and multivariable logistic regression.

The authors recognized some limitations and tried to correct these, such as the administration of prehospital analgesics that was unequally divided over the study groups.



It was not described who performed the data collection.

No sample size calculation was performed.

The authors reported that it was not clear whether analgesics were administered by nurses utilizing the protocol or by treating physicians. There are 2 important things to mention about this limitation. Firstly, the authors describes the study as a prospective study, however the distinction between protocolized pain treatment or physician-driven pain treatment should have been easily made then (moreover, it was described that data collection was conducted from the medical records, fueling the thought patient recruitment might have been retrospective). Secondly, if this distinction cannot be made, we cannot conclude whether the increase in analgesic administration was because of nurse-initiated analgesia or just because of increased pain awareness among all health care staff.


Clinical applicability

After implementation of a nurse-initiated pain protocol utilizing oral analgesics and IV piritramide in severe pain, the analgesic administration increased, but still was suboptimal.

Level of evidence 4


Ridderikhof ML, Schyns F, Schep NW, Lirk P, Hollmann MW, Goslings JC

Emergency Department pain management in adult patients with traumatic injuries before and after implementation of a nurse-initiated pain treatment protocol utilizing fentanyl for severe pain

J Emerg Med 2017; 52(4): 417-425

Our Observations

The authors of this Dutch retrospective observational study evaluated the effect of the implementation of a nurse-initiated pain treatment protocol. According to the protocol, nursing staff was allowed to administer analgesics, including opioids, fully autonomously and based on NRS pain scores.

In case pain was minor (NRS 1-3): oral or IV acetaminophen 1000mg was offered.

When pain was moderate (NRS 4-6): oral diclofenac or tramadol was offered (besides acetaminophen).

In case of severe pain (NRS 7-10), IV fentanyl was administered (besides acetaminophen), initially 1ug/kg (0.5ug/kg >60 years) and subsequent dosages of 0.5ug/kg could be given as well if pain persisted. The goal was to reach an NRS pain score <4. Before nursing staff could use the pain protocol, they had to attend a 1 hour educational session, which was signed off.


This was the first nurse-managed pain protocol study in which IV fentanyl was evaluated. 

The authors tried to minimize selection bias and information bias by utilizing 2 independent reviewers (of whom 1 was blinded to study purpose) and previously proposed chart review criteria. 


Not a single adverse event was recorded, however, as this was a retrospective study, it was prone to information bias, specifically regarding adverse events.  Moreover, the study was probably not powered to detect fentanyl-related adverse events. 

The authors state that frequent audits feedback to staff increased the late implementation results at 18 months, however this was not causally determined and other confounders probably influenced results as this follow-up period was rather long. 

Analgesia that was already taken prehospitally was not accounted for. Even after implementation, pain treatment and assessment was suboptimal and the majority still got no pain medication nor had their pain assessed. Finally, regarding documentation bias, it is well known that pain scores are documented very badly.


Clinical applicability

A nurse-driven pain protocol based on NRS pain scores increases analgesic administration in the long term and not in the short term. Pain assessment and pain awareness increases immediately. Using IV fentanyl in severe pain seems safe. 

Level of evidence 2b


Butti L, Bierti O, Lanfrit R, Bertolini R, Chittaro R, Delli Compagni S, Del Russo D, Mancusi RL, Pertoldi F

Evaluation of the effectiveness and efficiency of the triage emergency department nursing protocol for the management of pain

J Pain Res 2017; 10: 2479-2488

Our Observations

The authors of this Italian prospective case-series evaluated the use of a previously implemented triage pain protocol in use for patients older than 4 years old and presenting with moderate or severe pain caused by various causes. There was an extensive list of exclusion criteria for use of this protocol, that was based on NRS pain scores (and Wong-Baker scale under the age of 8 years old).

NRS 4-6: acetaminophen 1000mg orally (body weight > 40kg)

NRS 7-10: morphine 10mg orally administered (Oramorph)

In case children with bodyweight less than 40 kg: acetaminophen dosed per weight category.


The authors found that with this triage pain protocol in place, mean NRS decrease at 60 minutes was >2 NRS points in 65.9% of 312 patients presenting with a variety of painful conditions. Despite the fact that the majority of patients presented with severe pain (in which morphine was advised by protocol, only 2.6% of patients received this), patient satisfaction regarding analgesic treatment was high (8.73 / 10).



Prospective data collection

As Patient Reported Outcome Measures, not only patient satisfaction in general was measured, but a specific item on analgesic treatment was reported as well.



The inclusion criterion ‘patients whose symptomatology did not suggest surgical intervention’ is a very subjective one and is sensitive to confounding factors, especially of treating staff (both nurses and physicians)

No sample size was performed. The study consisted of only 1 group, without a comparison. Confounding factors, such as crowding or other department- or staff-related factors were not evaluated.

It was not described how long the triage pain protocol had been in place the moment study data was collected.

Regarding the pain protocol, the exclusion list was rather long, raising questions regarding external validity.


Clinical applicability

A NRS based triage protocol in place utilizing orally administered analgesia and morphine in severe pain decreases pain fast, clinically significant and resulted in high patient satisfaction among patients with a variety of painful conditions, both traumatic and non-traumatic.

Level of evidence 4


Sepahvand M, Gholami M, Hosseinabadi R, Beiranvand A

The use of a nurse-initiated pain protocol in the emergency department for patients with muculoskeletal injury: a pre-post intervention study

Pain Manag Nurse 2019; 20(6): 639-648

Our Observations

The authors of this prospective cohort study from Iran evaluated the use of a nurse-initiated pain management protocol. They divided the study in three phases:

1. Pre-intervention phase, during which triage performance was evaluated by independent researchers evaluating primary assessment, orthopedic assessment and pain management.

2. Intervention phase, consisted of an extensive training program for nursing staff and implementation of the pain management protocol. This protocol was NRS based:

NRS 1-3: acetaminophen 1000mg orally or IV

NRS 4-6: ibuprofen 400mg orally OR tramadol 50mg orally (and acetaminophen if not given yet)

NRS 7-10: morphine 30mg rectal suppository (and acetaminophen if not given yet)

The protocol was implemented over 2 months and posters with the protocol were used to guide implementation. Post-test data collection took place after this period.


A formal sample size calculation was performed (although not sure what for it was powered to detect)

The data collectors and their level of training, as well as methods of data collection were explicitly described (and they did not participate in care for included patients).

Besides implementation, there were very extensive training sessions for nurses.

The research team explicitly determined content validity and inter-rater reliability of the triage nurses’ performance checklist.


As an exclusion criterion 'reluctance to continue' was mentioned. However, if patients were really excluded from the study when they stopped participating AND were not recorded as included patients, this would have biased study results because of undetected and unrecorded differential loss to follow-up. 

In the current study this would have been very relevant, as the 2 questionnaires that were used contained 29 and 12 items, respectively. As there was no data presented on how many patients stopped with study participation, this could have biased results in a way that is unknown to us.

Patients were not recruited consecutively and were selected randomly, selection bias could have influenced results.

As data collection was prospective by a research assistant being present (and observing nurses' performance), a Hawthorne effect could not be ruled out.

Prehospital analgesia was not accounted for.

Clinical applicability

​Implementation of a nurse-initiated (non-IV) pain protocol decreased time to analgesia, increased patient satisfaction and resulted in clinically significant decrease in pain scores.

 Level of evidence 4


Caspi S, Meidan R, Peless E, Raizman E

Nurse-initiated oral opioid pain protocol improves the quality of musculoskeletal pain management in the emergency department

Int Emerg Nurs 2019; 43: 29-33

Our Observations

The authors of this prospective before- and after-implementation observational study from Israel reported the effects of a nurse-initiated pain protocol. This pain protocol was developed for patients presenting with moderate and severe pain (NRS 5–10): all patients got offered the combination of dipyrone 1000mg + oxycodone 0.1mg/kg (maximum of 5mg in elderly patients), both orally administered.

In case pain was still moderate or severe after 60 minutes, nurses were allowed to repeat the dose of oxycodone autonomously. 

Before using this protocol, all nurses had to attend a 1-hour educational session.


They found that although there was no difference in time to analgesia in general, opioid analgesics were administered significantly faster after implementation, leading to superior pain relief: absolute mean NRS decrease before implementation was 3.34 and after implementation this was 5.7 NRS points. A proportional decrease of 30% in NRS pain scores was achieved in 72.1% after implementation (compared to 44.8% before implementation; p=0.003)



There was a formal sample size calculation done, powered to detect a difference in NRS decrease of at least 2 NRS points between the before- and after-implementation group.

Patients were recruited prospectively in both patients groups.



Although a sample size was performed to detect differences in NRS decrease of 2 points between both groups, it must be noted that at baseline the groups were not identical, as mean NRS at baseline was significantly higher after implementation. This difference was not explained by the authors, nor measures taken to correct this, however it must be said that besides absolute NRS reduction, proportional decreases in NRS pain scores were also reported in order to correct for absolute baseline differences.

Treating nursing staff had to collect study data in case report forms. This could have influenced study results and might have changed nurses’ behavior (compared to a non-study clinical situation).


Clinical applicability

Implementation of a nurse-initiated orally administered analgesic protocol utilizing a combo of pyridine / oxycodone in all patients with moderate or severe pain resulted in fast and effective pain relief in patients presenting with acute musculoskeletal injuries.

Level of evidence 2b


Viglino D, Masson NT, Verdetti A, Champel F, Falcon C, Mouthon A, Makele PM, Muret RC, Dominici CM, Maignan M

Multimodal oral analgesia for non-severe trauma patients: evaluation of a triage-nurse directed protocol combining methoxyflurane, paracetamol and oxycodone

Intern Emerg Med 2019; 14(7): 1139-1145

Our Observations

The authors of this French prospective observational study evaluated the effect of a multimodal analgesic nurse-managed pain protocol utilizing acetaminophen, inhaled methoxyflurane and oral oxycodone.

Moderate pain: acetaminophen AND oxycodone 5mg AND inhaled methoxyflurane 3mL (only once during the Emergency Department stay).

Severe pain: the same, but with 10mg oxycodone.

They found that this resulted in fast and effective clinically relevant pain relief already at 5 minutes after administration.

Although the authors stated that it was safe to use and there were no serious adverse events, it must be emphasized that minor adverse events occurred in almost 2/3 of all patients. However, mean satisfaction among both patients and staff was rated high.



Data were collected on standard case report forms by research staff, not involved in clinical care.

Sample size calculation was performed in order to detect 80% of patients achieving an NRS score of 3 or lower.

The authors aimed to evaluate a multimodal analgesia protocol and were the first to explore the use of inhaled methoxyflurane administered by triage nursing staff.



Patients were not recruited consecutively.

Very extensive list of exclusion criteria. This might decrease external validity.

No comparison-group.

Although all patients got offered non-pharmacological injury-specific pain treatment (such as cooling), it was not explicitly described whether all patients received this.


Clinical applicability

The implementation of a triage-nurse managed pain protocol utilizing inhaled methoxyflurane together with acetaminophen and oxycodone is feasible to use and effective in fast pain relief. However, the majority of patients experience minor adverse events.

Level of evidence 4