Implementation of a nurse-driven pain protocol

Clinical Bottomline

A total of 6 studies evaluated the effects of implementing a nurse-driven pain protocol, in which nursing staff was allowed to administered analgesics, but only after signing off by a physician.

All studies had level of evidence 4.

In these studies several populations were evaluated:

- traumatic injuries (2 studies: 354 patients)

- renal colic (1 study: 128 patients)

- vaso-occlusive crisis in sickle cell disease (1 study: 603 patient visits)

- pain of any cause / mixed study populations (2 studies: 13513 patients)

In all studies, opioids were utilized in the pain protocol. 

It can be concluded* that...

1. a nurse-driven pain protocol decreases time to analgesia

Level of recommendation C 

Time to analgesia was measured in 2 studies. Mean time decreased statistically significant in both studies: from 53.6 to 27.9 minutes and from 238 to 168 minutes, respectively.  

2. a nurse-driven pain protocol results in efficient routes of administration

Level of recommendation C

Intramuscular opioid administration decreased significantly in renal colic patients from 76% to 3% and the IV route increased from 3% to 95%. In patients with long bone fractures, these numbers were 53% to 5% and 6% to 54%, respectively. 

3. a nurse-driven pain protocol is safe to use and leads to

- minor adverse events with IV morphine

- no adverse events with IV fentanyl

Level of recommendation C

Three studies evaluated the occurrence of adverse events. Two studies reported adverse events after protocolized IV morphine use and found a 4.7% and 10.4% incidence of adverse events, mainly hypotension and hypoxemia. No interventions were required. One study evaluated IV fentanyl use and this did not resulted in any adverse events. 

* Disclaimer:

Included studies were different in several items, such as timing and methods of measurement of several endpoints; study population; baseline situation and pain medication. Due to these large differences in study methodology, results cannot be pooled and the level of recommendation should be regarded as an estimation of the true effect. The levels of recommendation were derived according to the OCEBM levels of evidence.