Advanced nursing directives: integrating validated clinical scoring systems into nursing care in the pediatric emergency department

Abstract

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.

Figure 1

Components of a Well-Developed Advanced Nursing Directive.

Figure 2

Analysis of processes required for the assessment and management of a patient presenting to the emergency department.

Figure 3

Factors associated with process variation in the assessment and management of patients presenting to the emergency department.

Figure 4

Alberta Children's Hospital Advanced Nursing Directive for Children with Suspected Appendicitis.

Figure 5

The Alberta Children's Hospital Appendicitis Care Map. Note the use of Alvarado Score criteria in the AND to guide initiation of IV fluids, laboratory investigations, and preparation for potential ultrasonography.

Figure 6

The Alberta Children's Hospital Pediatric Acute Asthma Pathway. Note the use of the PRAM score in the Advanced Nursing Directive to guide administration of systemic steroids, beta agonists, and anticholinergics.

Figure 7

The Alberta Children's Hospital Acute Vomiting and Diarhhea Pathway. Note the use of the Gorelick score in guiding fluid hydration and medication administration.