Page 609 - ACCCN's Critical Care Nursing

586 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

EXTENDED ROLES subsequent incremental doses in response to a reevalua-
tion of the patient’s pain score and vital signs (pulse,
Contemporary roles in many EDs have expanded to blood pressure and respiratory rate). Protocols directed
include clinical roles and functions that have emerged as towards moderate and minor pain may include either
a result of reengineering work practice processes in single or incremental IV analgesia or oral analgesia.
response to an increasing number of emergency presenta- Nurse-initiated analgesia protocols have also been found
tions, and to improve performance in patient flow, waiting to be safe and effective and to shorten the time ED
times, length of stay and patient satisfaction. 16-18 This patients wait for analgesia, 23,24 which should assist in
expanded scope of practice includes advanced clinical improving patient outcomes and satisfaction.
skills performed using agreed protocols and accreditation
supported by additional education and regular periods of CLINICAL INITIATIVE NURSE
performance review. The role has become known as an
advanced clinical nurse (ACN) or advanced practice nurse The clinical initiative nurse (CIN) is a specific advanced
17
(APN), involving, but not limited to, the following practice role introduced to primarily provide care for
advanced clinical skills: 16,18 waiting-room patients awaiting medical officer assess-
ment. The role was initially introduced into levels 5 and
l venipuncture and cannulation 6 metropolitan and several large rural EDs in New South
l arterial blood gas sampling Wales, to manage and reduce ED waiting times and asso-
l suturing ciated patient distress, improve ‘time seen’ rates, patient
l plaster application service satisfaction and patient outcomes (key perfor-
l ordering of radiology mance indicators). These and similar roles are now being
l ordering of pathology implemented nationally. The role includes initiation of
25
l administration of nurse-initiated narcotic analgesia treatment for lower-acuity waiting-room patients, follow-
and other medications. ing advanced practice protocols. The treatment provided
by the CIN includes ordering of radiology and/or patho-
NURSE-INITIATED X-RAYS logy investigations, administration of oral analgesia,
review and reassessment of waiting patients (particularly
Nurse-initiated radiology ordering enables investigations those who have waited longer than their triage bench-
of extremities, joints such as hips and shoulders, the chest mark time), and providing information and education to
and abdomen according to clinical protocols that list waiting patients and carers regarding waiting times, ED
19
inclusion and exclusion criteria based on findings from processes and patient education. The role acts as an
the ACN’s history-taking and clinical examination. The adjunct to the triage role, and maintains a close working
inclusion criteria reflect well-established clinical indica- relationship with the triage nurse. 25-27 The CIN role has
tors. While nurse-initiated radiology ordering is often contributed to timely access to interventions, investiga-
undertaken as an extended triage nurse function, it can tions and care for waiting patients, increases autonomous
be performed by any accredited nurse. The use of nurse- practice, independent decision making and enhances
initiated radiology, especially in association with extrem- patient advocacy. The role also provides opportunity for
ity injuries, is safe and accurate, reducing both waiting the clinical and professional development of emergency
time and department transit time and improving both nurses. 26
patient and staff satisfaction. 17,19-21

NURSE-INITIATED ANALGESIA NURSE PRACTITIONER
Although pain is a common complaint in the majority of The nurse practitioner (NP) level of health care is one of
the most important developments in contemporary
patients presenting to the ED, 22,23 management has previ- nursing and marks the opportunity for significant reform
ously been insufficient, especially in relation to the in Australian health care. Nurse practitioners, while
timeliness, adequacy and appropriateness of analgesia well established in North America, the UK and parts of
administered, 22,23 and resulting in poor patient satisfac- Europe, are a relatively recent development in Australia.
22
tion. To address these findings, many EDs developed Introduction of the NP level of service has been a
nurse-initiated analgesia protocols, standing orders or function of individual states rather than a national
pathways. Nurse-initiated analgesia protocols enable des- government process, and consequently implementation
ignated emergency nurses to implement analgesia regi- throughout Australia has been gradual, with title protec-
mens prior to assessment by a medical officer. These tion and practice privileges now legislated in five states
protocols are locally derived and note patient inclusion over a 15-year period.
and exclusion criteria for managing mild, moderate or
severe pain in both adult and paediatric patients, and Introduction of the NP has been complicated by existing
often include administration of an antiemetic. 22,23 A nomenclature relating to advanced practice roles in
numerical pain rating scale or a visual analogue scale is nursing, with titles such as advanced specialist, clinical
used to direct the type and route of analgesia administra- nurse consultant, clinical nurse specialist and advanced
tion. Severe pain protocols outline incremental intrave- practice nurse used interchangeably and at times prob-
nous narcotic administration, including incremental and lematically in the literature, 28,29 including internation-
30
total maximum administration dosages. After administra- ally. Consensus is gradually emerging that the NP
tion of the initial dose, the administering nurse gives role is evolving and developing globally as the most