NUR 5033 Module 3 Evidence-Based Change Proposal Example

A Plan Written Before the Crisis: Individualized Emergency Pain Plans and Triage-Initiated Treatment for Adults With Sickle Cell Disease, Role by Role

Student Name

American College of Education

NUR5033: Advanced Nursing and Practice II

Module 3 Assignment

Instructor Name

July 19, 2027

The Change in Two Parts

The previous module found that national guidance sets a clear target, pain treatment within 30 minutes of triage, and that the best evidence on how to reach it points to individualized plans written in advance. The community emergency department in this course, a composite invented for the assignment, currently treats adults in a sickle cell pain crisis with a median delay of 96 minutes. The proposed change has two parts designed to remove the two largest sources of that delay: uncertainty about what and how much to give, and waiting for a physician to see the patient before any opioid is ordered.

The first part is an individualized emergency pain plan for every adult with sickle cell disease who has visited the department in the past year, 41 patients at present. Each plan is written jointly by the patient and a hematology nurse practitioner from the regional sickle cell center, through a telehealth visit, and states the patient's usual effective opioid, dose and route, the interval for repeat doses, any adjuncts that help and any medications to avoid. This follows the pediatric experience with individualized plans (Krishnamurti et al., 2014) and the hematology guidelines' emphasis on individualized care and patient preference (Brandow et al., 2020). The second part is a triage protocol, signed by the emergency department medical director, that allows the triage nurse to give the first opioid dose from the patient's plan, or from a default weight-based dose in the order set if no plan exists, within 30 minutes of triage, before the physician evaluation. The change moves the first decision from the moment a physician is free to the moment a nurse sees the patient, and it moves the dosing decision from the middle of a crisis to a calm conversation weeks earlier.

A Visit Under the New Process

A 27-year-old man with sickle cell disease arrives at 2215 with pain in his back and legs that began six hours earlier and has not responded to his home oxycodone. At registration, the electronic record displays a banner indicating that he has an individualized emergency pain plan. The triage nurse assigns him an acuity level that reflects severe pain, confirms the pain score and the time of his last home dose, checks for the warning signs listed in the plan, including fever, chest pain or new shortness of breath, and, if none is present, gives the subcutaneous hydromorphone dose written in his plan at 2231.

The plan specifies the subcutaneous route because his veins are difficult to access, which avoids a delay while a nurse attempts intravenous access. The nurse reassesses his pain and sedation 30 minutes later and gives the repeat dose the plan allows if pain remains severe. The physician sees him at 2305, reviews the plan and the response so far and decides on further treatment and disposition. Under the previous process, his first dose would typically have followed the physician evaluation. Under the new one, it precedes it by more than half an hour.

Roles and Responsibilities

The emergency department medical director owns the triage protocol, signs the standing order that authorizes nurses to give the first dose and sets the exclusion criteria that require a physician before any opioid. The hematology nurse practitioner at the regional center owns the content of each individualized plan and reviews it at least annually or after any change in the patient's regimen. The emergency department clinical nurse specialist owns implementation: training triage nurses, auditing the first months of use and serving as the point of contact for questions about the protocol.

The emergency department pharmacist reviews every plan for dose safety and interactions before it becomes active and builds the default weight-based order. The triage nurses carry out the protocol, including the safety screen, the first dose, reassessment at 30 minutes and documentation, and they may decline to give the first dose and call the physician if anything in the patient's presentation does not match the plan. The informatics analyst builds the record banner and the plan display. Two patients from the hospital's sickle cell patient advisory group review the plan template and the patient-facing explanation of the process, and one sits on the implementation team. Every step has an owner, and every owner has a limit written into the protocol, which is what makes nurse-initiated opioid treatment safe enough to approve.

Attitudes as Part of the Change

The first module found that frequent visitors wait longest, and that some staff described concern about drug-seeking. Published evidence suggests that such attitudes affect care. Glassberg et al. (2013) surveyed 722 emergency physicians and advanced practice providers and found that most reported following the cornerstones of sickle cell pain management, but that providers in the highest quartile of negative attitudes toward patients with sickle cell disease were 20 percent less likely to redose opioids within 30 minutes when pain relief was inadequate. A protocol that only changes the order set would leave that pattern untouched.

The change therefore includes a one-hour education session for all emergency nurses and providers, developed with the patient advisory group, that covers the biology of a pain crisis, why opioid requirements in tolerant patients are high, the evidence on wait times and attitudes, and the experience of patients who delay coming in because they expect to wait. The session is not presented as a correction of individuals but as part of the reason the department is changing its process. The protocol itself also reduces the room for bias, because the first dose no longer depends on a clinician's judgment about the patient in the moment but on a plan agreed in advance.

Sequence of the Rollout

The two parts of the change depend on each other, so they are sequenced. In the first month, the medical director, pharmacist and clinical nurse specialist draft the triage protocol and the default order, and the informatics analyst builds the record banner. In the second and third months, the hematology nurse practitioner holds telehealth visits with the nine patients who visit most often, since their plans will affect the largest number of visits, and then with the remaining patients as they can be scheduled. Triage nurse training and the education session take place in the third month.

The protocol goes live at the start of the fourth month for patients who have a completed plan, with the default order available for those who do not yet have one. Starting with the most frequent visitors means that about half of the expected visits in the first month will already be covered by an individualized plan, which gives the team early evidence about whether the process works before it is extended to everyone.

Conclusion

The proposed change turns the evidence into two concrete practices: individualized emergency pain plans written with each patient before the next crisis, and a triage protocol that lets nurses give the first dose within 30 minutes under a standing order with defined limits. Each step belongs to a named role, from the medical director who authorizes the protocol to the patient partners who shape it. Addressing staff attitudes directly, and designing the process so that the first dose depends less on them, is part of the change rather than an afterthought. The next module will test this proposal against the staffing, scope and cost realities of a community emergency department.

References

Brandow, A. M., Carroll, C. P., Creary, S., Edwards-Elliott, R., Glassberg, J., Hurley, R. W., Kutlar, A., Seisa, M., Stinson, J., Strouse, J. J., Yusuf, F., Zempsky, W., & Lang, E. (2020). American Society of Hematology 2020 guidelines for sickle cell disease: Management of acute and chronic pain. Blood Advances, 4(12), 2656-2701. https://doi.org/10.1182/bloodadvances.2020001851

Glassberg, J. A., Tanabe, P., Chow, A., Harper, K., Haywood, C., Jr., DeBaun, M. R., & Richardson, L. D. (2013). Emergency provider analgesic practices and attitudes toward patients with sickle cell disease. Annals of Emergency Medicine, 62(4), 293-302. https://doi.org/10.1016/j.annemergmed.2013.02.004

Krishnamurti, L., Smith-Packard, B., Gupta, A., Campbell, M., Gunawardena, S., & Saladino, R. (2014). Impact of individualized pain plan on the emergency management of children with sickle cell disease. Pediatric Blood & Cancer, 61(10), 1747-1753. https://doi.org/10.1002/pbc.25024