In an effort to improve the quality and flow of care provided to children presenting to the emergency department the implementation of nurse-initiated protocols is on the rise. We review the current literature on nurse-initiated protocols, validated emergency department clinical scoring systems, and the merging of the two to create Advanced Nursing Directives (ANDs). The process of developing a clinical pathway for children presenting to our pediatric emergency department (PED) with suspected appendicitis will be used to demonstrate the successful integration of validated clinical scoring systems into practice through the use of Advanced Nursing Directives. Finally, examples of 2 other Advanced Nursing Directives for common clinical PED presentations will be provided. 1. Introduction Internationally, much attention has been focused on long wait times in emergency departments (EDs) and the inaccessibility of acute inpatient hospital beds. Inpatient overcapacity and the overutilization of emergency facilities as primary care centers are thought by some to be a driving force behind ED overcrowding. As a result, health care practitioners are working to improve patient care by adopting progressive strategies such as nurse-initiated protocols and Advanced Nursing Directives (ANDs). Like many other health care centres, the Pediatric Emergency Department (PED) at the Alberta Children’s Hospital (ACH) has seen significant growth in patient visits along with the corresponding increase in ED length of stay (LOS). Focusing on departmental flow, the development and implementation of Advanced Nursing Directives and their corresponding patient care maps have been successful in our PED. Intentionally targeting 3 of the most common presentations to the PED (asthma, vomiting and diarrhea, and suspected appendicitis), we developed processes in which children meeting unit-based nursing protocol criteria receive evidence-based, timely care from nursing staff prior to being assessed by an emergency physician. Extensive academic collaboration reviewing the existing clinical scoring systems and current research pertaining to these common pediatric medical complaints were referenced to construct hospital-based care maps. The purpose of this paper is to review the theoretical constructs behind nurse-driven protocols, the evidence supporting clinical scoring systems, and how the integration of the two form Advanced Nursing Directives (ANDs), which have the potential to significantly improve patient care outcomes, administrative metrics, and overall patient and caregiver
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