***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The objectives of this study were : ( i ) to measure the analgesic efficacy and frequency of adverse events following autonomous nurse-initiated intravenous morphine in patients presenting with acute pain , awaiting medical assessment ; and ( ii ) to determine whether such a process would improve the time to analgesia . METHODS A prospect i ve convenience sample of patients presenting in acute pain received titrated intravenous morphine by experienced emergency nurses . Pain scores on a 10.0 cm visual analogue scale and predetermined adverse events defined by physiological parameters were measured at regular intervals over the following 60 min . Demographic , diagnostic and waiting time data were also recorded . RESULTS Three hundred and forty nine patients were enrolled over a 12-month period . The median initial pain score was 8.5 cm , with a reduction to 4.0 cm at 1 h. Respiratory rate , oxygen saturation , heart rate and blood pressure all showed small but statistically significant reductions over 60 min . There were 15 predefined adverse events , 10 episodes of hypotension and five episodes of oxygen desaturation . No intervention other than supplemental oxygen was required . There were no episodes of bradycardia , bradypnoea or reduced level of consciousness . The median time to narcotic was 18 min and the median time to be seen by a doctor was 52 min . CONCLUSION Experienced emergency nurses can initiate effective intravenous narcotic analgesia for patients in acute pain awaiting medical assessment , with minimal change in physiological parameters . This process can improve the time to analgesia for patients in acute pain INTRODUCTION Timely and appropriate pain management is an important quality indicator of ED performance . Emergency health care workers are well positioned to become active leaders and innovatively responsive in reducing human suffering . A pain management audit was conducted to determine Australia practice patterns . METHODS A 12-month retrospective descriptive cohort audit was undertaken . Through the r and omization process a medical record audit tool was completed for each record identified . Ethical approval for the study was obtained . RESULTS Seventy-four hospitals agreed to conduct the audit , 36 ( 48 % ) provided data . The total number of patient notes review ed was 2,066 . Ninety-five percent ( 1,966 ) of patients arrived by ambulance . Of the patients ( n=547 ; 56.4 % ) with a documented triage pain score the majority arrived in severe pain ( n=300 ; 41.3 % ) . Of the total number of patients ( 1,966 ) documented arriving in pain 1,473 ( 74.9 % ) received an analgesic . Six hundred and forty-four ( 32.7 % ) patients received an opioid . From time of emergency department arrival , the median time for analgesic administration was 70 minutes ( IQR 58 minutes to 92 minutes ) . Twenty-five emergency departments ( 69.4 % ) had pain management policies that enabled nurses to initiate a pharmacological analgesia without medical consultation . DISCUSSION The Australian pain management audit highlighted current practice s and potential areas for further research . While the audit demonstrated that nurse initiated pain management interventions promoted better analgesic response , greater consistency of triage pain assessment , code allocation , and documentation of pain scores may go some way to improving the timeliness of analgesia Background : The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial . A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis . Methods : A r and omised double-blind clinical trial was conducted in Sina hospital , a general teaching hospital , from January 2004 to March 2005 . Patients scheduled for appendectomy were r and omised to receive 0.1 mg/kg morphine sulfate or saline ( 0.9 % ) to a maximum dose of 10 mg over a 5 min period . Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit . The physicians were also asked to indicate their own treatment plan . The main outcome measures were pain intensity using a visual analogue scale ( VAS ) and signs of acute appendicitis . A favourable reduction in VAS score was defined as a change of > 13 mm . Results : Of the 71 patients enrolled in the study , 35 were allocated to receive morphine and 36 to receive placebo . One patient left the hospital before receiving morphine . No significant differences were seen between the two groups with regard to age , sex and initial VAS score . A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group . Morphine administration did not cause significant changes in patients ’ signs or in the physicians ’ plans or diagnoses . No adverse events were seen in either group . Conclusion : Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy . Trial registration number : NCT00477061 OBJECTIVE To determine the effect of an ED nurse-initiated asthma management protocol on door to first salbutamol nebulization time . METHODS This was a prospect i ve before-after study . Asthmatics , aged 1 to 12 years presenting to the ED with an exacerbation during the pre and post nurse-initiated care phases ( from 1/22/08 to 2/8/08 and from 2/12/08 to 3/4/08 ) , were eligible . An asthma training program was administered to nurses prior to post phase . Respiratory therapists started the first nebulization after a physician order during the pre phase , whereas bedside nurses initiated it before physician evaluation during the post phase . Mean differences and confidence intervals ( CI ) were calculated . RESULTS Each of the study groups had 125 patients .  Door to first nebulization time was reduced by a mean of 31.3 minutes ( CI 23.0 , 39.6 ) in the post phase . Door to steroids , second nebulization , and bedside nurse evaluation time intervals were reduced by 22.8 minutes ( CI 8.8 , 36.9 ) , 21.7 minutes ( CI 9.1 , 34.4 ) and 15.6 minutes ( CI 7.5 , 23.7 ) respectively . CONCLUSION An ED nurse-initiated asthma management protocol expedited initiation of medications essential for relief of symptoms of acute asthma and bedside evaluation by nurses . St and ing nurse-initiated care protocol s may prove to be beneficial in improving acute asthma care in crowded EDs OBJECTIVE While acute musculoskeletal pain is a frequent complaint in emergency care , its management is often neglected , placing patients at risk for insufficient pain relief . Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department ( ED ) and how this affects pain relief . A secondary goal is to identify prognostic factors for clinical ly relevant pain relief . DESIGN This prospect i ve study ( PROTACT ) includes 697 patients admitted to ED with musculoskeletal extremity injury . Data regarding pain , injury , and pain management were collected using question naires and registries . RESULTS Although 39.9 % of the patients used analgesics in the prehospital phase , most patients arrived at the ED with severe pain . Despite the high pain prevalence in the ED , only 35.7 % of the patients received analgesics and 12.5 % received adequate analgesic pain management . More than two-third of the patients still had moderate to severe pain at discharge . Clinical ly relevant pain relief was achieved in only 19.7 % of the patients . Pain relief in the ED was higher in patients who received analgesics compared with those who did not . Besides analgesics , the type of injury and pain intensity on admission were associated with pain relief . CONCLUSIONS There is still room for improvement of musculoskeletal pain management in the chain of emergency care . A high percentage of patients were discharged with unacceptable pain levels . The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief . Additional research in these areas is needed OBJECTIVES The objective was to determine , among emergency department ( ED ) patients , the factors associated with a high level of satisfaction with pain management . METHODS This was a prospect i ve cohort study in a single ED . Consecutive adult patients , with triage pain scores of ≥4 ( numerical rating scale=0 to 10 ) , were enrolled . Variables examined included demographics , presenting complaint , pain scores , nurse-initiated analgesia , analgesia administered , time to first analgesia , specific pain communication , and whether " adequate analgesia " was provided ( defined as a decrease in pain score to < 4 and a decrease from the triage pain score of ≥2 ) . The level of patient satisfaction with their pain management ( six-point scale : very unsatisfied to very satisfied ) was determined by a blinded investigator 48 hours post discharge . Logistic regression analyses were undertaken . RESULTS Data were complete for 476 patients : mean ( ±st and ard deviation [ SD ] ) age was 43.6 ( ±17.2 ) years , and 237 were males ( 49.8 % , 95 % confidence interval [CI]=45.2 % to 54.4 % ) . A total of 190 ( 39.9 % , 95 % CI=35.5 % to 44.5 % ) patients were " very satisfied " with their pain management , and 207 ( 43.5 % , 95 % CI=39.0 % to 48.1 % ) patients received adequate analgesia . Three variables were associated with the patient being very satisfied : the provision of adequate analgesia ( odds ratio [OR]=7.8 , 95 % CI=4.9 to 12.4 ) , specific pain communication ( OR=2.3 , 95 % CI=1.3 to 4.1 ) , and oral opioid administration ( OR=2.0 , 95 % CI=1.1 to 3.4 ) . Notably , the provision of nurse-initiated analgesia to 211 patients ( 44.3 % , 95 % CI=39.8 % to 48.9 % ) and the short time to analgesia ( median=11.5 minutes ; interquartile range [IQR]=2.0 to 85.8 minutes ) were not associated with being very satisfied . CONCLUSIONS The receipt of adequate analgesia ( as defined ) is highly associated with patient satisfaction . This variable may serve as a clinical ly relevant and achievable target in the pursuit of best- practice pain management OBJECTIVE : To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED . METHODS : A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4 . One-to-one periods ( physician-initiated and nurse-initiated ) were analyzed from September 2009 through May 2010 . In both phases , triage nurses initiated bronchodilator therapy before physician assessment , per Pediatric Respiratory Assessment Measure score . We review ed charts of 644 consecutive children aged 2 to 17 years for the following outcomes : admission rate ; times to clinical improvement , steroid receipt , mild status , and discharge ; and rate of return ED visit and subsequent admission . RESULTS : Nurse-initiated phase children improved earlier compared to physician-initiated phase ( median difference : 24 minutes ; 95 % confidence interval [ CI ] : 1–50 ; P = .04 ) . Admission was less likely if children received steroids at triage ( odds ratio = 0.56 ; 95 % CI : 0.36–0.87 ) . Efficiency gains were made in time to steroid receipt ( median difference : 44 minutes ; 95 % CI : 39–50 ; P < .001 ) , time to mild status ( median difference : 51 minutes ; 95 % CI : 17–84 ; P = .04 ) , and time to discharge ( median difference : 44 minutes ; 95 % CI : 17–68 ; P = .02 ) . No differences were found in return visit rate or subsequent admission . CONCLUSIONS : Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge , and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations OBJECTIVES The aims of this study were to 1 ) estimate differences in pain management process and patient-reported outcomes , pre- and postimplementation of analgesic protocol s for adults with sickle cell disease ( SCD ) , and 2 ) examine the effects of site and visit frequency on changes in pain scores and time to analgesic . METHODS A multicenter , prospect i ve , longitudinal study enrolled patients from three academic medical centers between October 2007 and September 2009 . All ED patients 18 years or older with a chief complaint of a sickle cell pain episode were enrolled . Sites formed a SCD quality improvement ( QI ) team and implemented st and ard nurse-initiated emergency department ( ED ) analgesic protocol s ; outcomes were compared between study periods defined as pre- and postimplementation of protocol s. Medical record review was conducted to measure time to administration of initial analgesic , opioids used , route of opioid administration , the change in pain scores from arrival to discharge ( negative numbers reflect a decrease in pain scores ) , and the number of ED visits per individual patient during the study period at each site . On day 7 after the ED visit , a follow-up phone interview was conducted . Patients were queried about their ED pain management using a scale from  
    Output:
    
The nurse-initiated medications were salbutamol for respiratory conditions and analgesia for painful conditions , which enabled patients to receive the medications quicker by half-an-hour compared to those who did not have nurse-initiated medications .
The intervention had no effect on adverse events , doctor wait time and length of stay .
Nurse-initiated analgesia was associated with increased likelihood of receiving analgesia , achieving clinical ly-relevant pain reduction , and better patient satisfaction .
CONCLUSION Nurse-initiated medications are safe and beneficial for ED patients .