Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.

Implementation of Nurse-Initiated Pain Protocol in Improving Time-to-Pain Treatment for Long Bone Fracture

10/7/2014 10:22:10 AM | 2 comments

By Christina Ballejos-Campos, PhD, RN; Andres Smith, MD; Pablo Velez, PhD, RN; Christine Basiliere, MSN, RN; and Sherri Navedo, MSN, RN

Sharp HealthCare of San Diego has been working toward an important goal: to provide all emergency department (ED) patients presenting with long bone fractures appropriate pain medication within 30 minutes. When they surveyed EDs across the system, they found one that was already taking an innovative approach to the problem.

Since 2007, the Sharp Chula Vista Medical Center ED has operated under a unique protocol that allows triage nurses to order pain medication in cases of suspected long bone fracture. The order is based on the patient's pain score and ranges from Tylenol for mild pain to morphine for severe pain.

In 2012, hospital administrators, medical staff and nursing staff collaborated on a research project to study the impact of the nurse-initiated protocol (along with other factors) on pain management. The following post is adapted from their poster presentation at CEP America's 2013 annual conference.


Pain is the most common reason patients seek emergency services, making oligoanalgesia a common problem in EDs across the nation. The under-treatment or non-treatment of acute pain can lead to poor patient outcomes and decreased patient satisfaction.

Additionally, the Centers for Medicare and Medicaid Services (CMS) has recognized that early pain treatment for patients experiencing long bone fracture is imperative in reducing negative outcomes and increasing satisfaction. Since 2012, measure OP-21 of CMS' Outpatient Quality Reporting (OQR) Program has required EDs to report median "time-to-pain medication" for patients with a primary diagnosis of long bone fracture.

Sharp has identified timely pain management for long bone fracture patients as a system-wide priority. Sharp's benchmark for time-to-medication is 30 minutes — currently about the top 10th percentile for hospitals nationwide.


The purpose of this project was to measure the mean time-to-pain medication order in ED patients who had a long bone fracture, as defined by CMS.

Additionally, the project analyzed whether hospital-approved nurse-initiated pain orders and other variables such as pain score influenced meeting the national benchmark.


Retrospective and observational design was employed to determine differences in the mean time to medication order from July 2012 to December 2012. Included were all patients who suffered a long bone fracture and were admitted to the ED.

Mean time-to-medication was selected as a method of measurement to allow for the inclusion of "outlier" times. By holding itself to these more rigorous standards, the team hoped to increase its likelihood of meeting the national benchmark of 30 minutes median time.

Other variables collected included:

  • Pain score
  • Provider who ordered the pain medication (e.g. triage nurse, mid-level provider or physician)
  • ESI
  • Mode of arrival
  • LOS


Data collected on patients at Sharp Chula Vista from July to October 2012 showed that there were 144 ED patients who suffered a long bone fracture. Of the 79 percent treated for pain (114/144), the mean time-to-initial pain treatment was 63 minutes (SD 62), with a median time of 33 minutes. Twelve percent of patients (17/144) had no numeric pain score recorded.

Variables such as severity of pain, ESI, mode of arrival and LOS did not affect whether the patient was treated or whether they met the 30-minute "time-to-medication" benchmark.

It was observed that nurse "time-to-treatment" had a mean time of 30 minutes when compared with orders by physicians (98 minutes) and mid-level providers (69 minutes).

Therefore, it was found to be beneficial for the nurse to order pain medication from triage in order to meet the goal of OP-21.


Introduction of pain management early in the ED visit can reduce the average time-to-pain medication administration. There is a trend toward decreased time-to-pain treatment in patients who had medications ordered by triage nurses.

More data is needed to know effect on pain reduction and patient satisfaction.

Editor's Note

Since the original study, the ED team at Sharp Chula Vista has continued to track time-to-pain medication for long bone fracture patients and refine its processes. "One of the things we wanted to get out of this study was to ensure that every fracture patient was treated promptly — including those with suspected fractures," says Christina Ballejos-Campos, clinical nurse specialist. "Now when a nurse sees a patient with a suspected fracture, they immediately order an X-ray, which automatically triggers our pain management protocol.

"We also work to keep our process consistent. The patient gets the same orders whether they're routed to a physician or a mid-level provider. Those changes in practice have really made a big difference in our metrics."


1.Campbell, P., Dennie, M., Dougherty, K., Iwaskiw, O., and Rollo, K. (2004). Implementation of an ED protocol for pain management at triage at a busy level I trauma center. Journal of Emergency Nursing, 30(5), 431-438.
2.Fosnocht, D. and Swanson, E. (2007). Use of triage pain protocol in the ED. American Journal of Emergency Medicine, 25(1), 791-793.
3.Fosnocht, D., Swanson, E., and Bossart, P. (2001). Patient expectations for pain medication delivery. American Journal of Emergency Medicine, 19(5), 399-402.
4.Goh, H., Choo, S., Lee, I, and Tham, K. (2007). Emergency department triage nurse initiated pain management. Hong Kong Journal of Emergency Medicine, 14(1), 16-21.
5.Minick, P., Clark, P., Dalton, J., Horne, E., Greene, D., and Brown, M. (2012). Long-bone fracture pain management in the emergency department. Journal of Emergency Nursing, 38(3) 211-217.
6.Retezar, R., Bessman, E., Ding, R., Zeger, S., and Mcarthy, M. (2011). The effect of triage diagnostic standing orders on emergency department treatment time. Annals of Emergency Medicine, 57(2), 89-99.
7.Seguin, D. (2004). A nurse-initiated pain management advanced triage protocol for ED patients with an extremity injury at a level I trauma center. Journal of Emergency Nursing, 30(4) 330-335.

About Sharp Chula Vista Medical Center

Sharp Chula Vista Medical Center is a 343-bed hospital with the largest array of health care services in San Diego's South Bay. A Designated Planetree Patient-Centered Care Hospital, Sharp Chula Vista is home to the region's most comprehensive heart program and also offers exceptional services for orthopedic care and women and infants. The Douglas & Nancy Barnhart Cancer Center offers patients the most advanced treatment technology, a unique healing environment and an extraordinary level of care. Learn more about Sharp Chula Vista.

[Image credit: "2012 Tib Fib Ankle Fracture 8483" by Ted Eytan is licensed under CC BY 2.0.]

Jon Brummond
Great article! Thanks for contributing..
10/9/2014 7:31:02 AM

John Fredericks
An excellent demonstration of how promoting an ED culture of caring and staff teamwork can reduce pain and suffering while improving patient throughput. Keep up the good work!
10/8/2014 12:42:47 PM