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The Effect of Standing Orders for Emergency Department Triage Nurses

Erin A. Avery

School of Nursing, James Madison University

NSG 464: Introduction to Nursing Research

Dr. Powell

April 13, 2023

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Abstract

Emergency Departments (ED) worldwide are experiencing patient volumes that are at or over

capacity. The effect of this overcrowding can be seen in several areas such as patient care and

department flow. The purpose of this paper is to find evidence that supports the implementation

of triage nurse standing orders to decrease patient length of stay. The triage process acts as a

gatekeeper to the ED and is a vital aspect of the patient encounter. This initial encounter provides

the nurse the opportunity to recognize urgent conditions that require immediate intervention. Do

examples like collecting bloodwork, urine samples, or cultures, ordering imaging and

administering medications under triage nurse standing orders improve patient outcome? The

research collected in preparation for this paper reveal the positive outcomes of triage nurse

standing orders in decreasing length of stay, lessening wait times, and improving patient

outcome and satisfaction.

Keywords: emergency department, triage, nurse, standing orders, length of stay

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The Effect of Standing Orders for Emergency Department Triage Nurses

Emergency department (ED) overcrowding is a growing concern for hospitals across the

world. In the United States alone, approximately half of all EDs are currently providing care that

is at or above their capacity (Leggio et al., 2022). Consistently functioning at an overcapacity has

the potential to lead to multiple adverse consequences. Examples of these consequences can

manifest as decreases in quality of care, delays in treatment, worsened patient outcomes, and

poor departmental flow. In an attempt to combat this growing concern, the following question is

presented: for patients visiting the ED, does completing interventions like lab work and imaging

during initial triage decrease their overall length of stay compared to waiting for these

interventions until they are in a room and have seen a provider? This paper provides research

from several studies in an effort to answer this question.

The Problem with Emergency Department Overcrowding

For many individuals, the ED serves as their main source of medical care when seeking

treatment (Sobolewski, Koo & Deutsch, 2022). Although this is not the chief purpose of an ED, a

multitude of factors contribute to this, including: ease of access to comprehensive care,

difficulty scheduling with a primary care physician, health insurance reasons, lack of available

resources, knowledge deficit, etc. As one can imagine with being the catchall, overcrowding

happens fast. Once all the treatment rooms are occupied and there is an increasing number of

patients waiting in the lobby, the systems backlogs and becomes deadlocked. This congestion

caused by overcrowding puts patient safety at risk, delays care, prolongs length of stay, increases

the chance of medication administration errors, and reduces the department’s ability to

efficiently and effectively provide emergency medical care (Sobolewski, Koo & Deutsch, 2022).

Once the ED gets to this point, it also increases the likelihood that patients will leave without
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seeing a provider, further prolongs wait times for those that have been waiting, and decreases

overall quality of care (Leggio et al., 2022).

Initiating Standing Orders for Triage Nurses

The triage process acts as a gatekeeper for the ED; it the first point of contact and

establishes the initial encounter between patients visiting the ED and a nurse. Triaging allows

ED nurses to identify priority patients and determine the level of care that is needed based on a

timely assessment that is completed using very limited information. It is imperative that this

quick, initial encounter is efficient and sharp, as correct assessments are critical for the patient’s

safety and outcome (Burgess, Kynoch & Hines, 2019). To illustrate the importance of triage,

consider conditions like cerebrovascular accidents (CVA) and ST-elevated myocardial

infarctions (STEMI), where time is of the essence. It is imperative that these conditions are

detected and treated immediately, and the patient’s outcome correlates directly with how quickly

treatment is rendered. For instance, the time between when a STEMI patient enters the ED and

the staff obtains an electrocardiogram (ECG) directly affects the time in which they are escalated

to the cardiac catheterization lab, and the shorter the door to balloon time, the better the patient

outcome (Maliszewski et al., 2020).

Incorporating triage nurse standing orders and completing treatments like lab collection,

ECGs and imaging prior to a provider evaluation can decrease the injury caused by these time-

sensitive conditions (Sobolewski, Koo & Deutsch, 2022). By developing these streamlined

standing orders with provider input, the nurse and team can eliminate the need for repeat tests

and decrease the delay involved with a diagnostic work up (Reynolds et al., 2020). Several other

positive outcomes were discovered by the implementation and execution of triage nurse standing

orders and are discussed in the next three sections.

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Decreases Length of Stay

Establishing and completing standing orders in triage allows for better departmental flow.

Reynolds et al., completed a study that showed a significant reduction in ED length of stay when

facilities employ standing orders (2020). Decreasing the length of stay for patients

correspondingly decreases overall wait time, improves time to discharge, and limits the number

of patients who leave without being seen by a provider (Leggio et al., 2022). Incorporation of

these nurse-initiated triage standing orders are beneficial to the fluidity of the department,

accelerating patient care, and maximizing patient safety (Reynolds et al., 2020).

Better Patient Outcomes

Executing standing orders during triage promotes timely recognition of urgent conditions

in which outcomes rely heavily on prompt and aggressive treatment. In a study conducted by

Ferguson et al., research determined that a sepsis bundle work up that originated in triage

reduced the hospitals sepsis-related deaths (2019). Another article found that the sooner patients

received medication, the faster they would be discharged (Sobolewski, Koo & Deutsch, 2022).

When nurses are able to collect urine samples, blood studies, and insert an IV during initial

patient encounter, it decreases the delay in a diagnostic work up once they are in a treatment

room and have seen a provider (Reynolds et al., 2020). The use of triage standing orders directly

correlates with an improvement in outcome measures (Reynolds et al., 2020).

Improves Patient Satisfaction

When a nurse is able to medicate a patient during their initial encounter, it improves both

throughput and patient satisfaction. Suppose a patient comes in with a cough and fever and has

yet to take Tylenol or Motrin. After vital signs are obtained and the nurse confirms a fever, they

can access their standing orders to administer a fever reducer and send a nasal or throat culture
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swab to the lab to run while the patient is waiting. By the time the patient is escorted to a

treatment room to see a provider, they feel better due to the medication that was administered

during triage and the culture has resulted from the lab for the provider to review and diagnose.

The ability to utilize triage nurse standing orders offers a chance to initiate patient treatment

more quickly than waiting for a room, and allows for a higher possibility of getting discharged

sooner (Sobolewski, Koo & Deutsch, 2022).

Conclusion

It is well documented that EDs across the world have been operating at or over capacity.

For patients that present to an ED seeking treatment, they are unfortunately likely to endure an

all-day event. This overcrowding causes a domino effect and its result impacts several areas

including patient safety, timeliness of care, and hinders the workflow of the department.

Research indicates that completing interventions during initial triage does decrease a patient’s

overall length of stay in an ED, as opposed to waiting for these interventions until they are in a

treatment room and seen by a provider. These interventions, that are made possible by initiating

triage nurse standing orders, decrease length of stay, lead to better patient outcomes and increase

patient satisfaction.
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References

Burgess, L., Kynoch, K., Hines, S. (2019). Implementing best practice into the emergency

department triage process. International Journal of Evidence-Based Healthcare, 17(1),

27-35. https://search.ebscohost.com/login.aspx?

direct=true&AuthType=cookie,ip,shib&db=rzh&AN=138772104&site=ehost-

live&scope=site&custid=s8863137

Ferguson, A., Coates, D., Osborn, S., Blackmore, C., Williams, B. (2019). Early, nurse-directed

sepsis care. American Journal of Nursing, 119(1), 52-58.

https://pubmed.ncbi.nlm.nih.gov/30589710/

Leggio, W., Carhart, E., Bruckner, A., Crowe, R., Costanzo, C. (2022). Reduced emergency

department length of stay and proportion of patients who left without being seen

following implementation of an interprofessional vertical flow track with pivot triage: A

retrospective pre-/postintervention evaluation. Advanced Emergency Nursing Journal, 44

(2), 136-143. https://search.ebscohost.com/login.aspx?

direct=true&AuthType=cookie,ip,shib&db=rzh&AN=156702274&site=ehost-

live&scope=site&custid=s8863137

Maliszewski, B., Whalen, M., Lindauer, C., Williams, K., Gardner, H., Baptiste, D. (2020).

Quality improvement in the emergency department: A project to reduce door-to-

electrocardiography times for patients presenting with chest pain. Journal of Emergency

Nursing, 446(4), 497-504. https://search.ebscohost.com/login.aspx?

direct=true&AuthType=cookie,ip,shib&db=rzh&AN=144420270&site=ehost-

live&scope=site&custid=s8863137
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Reynolds, M., Dunaway, A., Stevens, C., Shoemaker, D., Buckingham, D., Spencer, S. (2020).

Triage standing orders decrease time to antibiotics in neonates in pediatric emergency

department. Journal of Emergency Nursing, 46(6), 768-778.

https://pubmed.ncbi.nlm.nih.gov/32981747/

Sobolewski, K., Koo, S., Deutsch, R. (2022). Improving the flow: Optimization of available

triage standing medication orders in the pediatric emergency department. Pediatric

Emergency Care, 38(4), 157-161. https://pubmed.ncbi.nlm.nih.gov/34550917/