Our hospital has allowed them but with very strict inclusion guidelines
(e.g. known asthmatic presenting with wheezing, acetaminophen for fever,
ibuprofen for pain). Thus, we are treating a condition, not a diagnosis
(because nurses aren't allowed to diagnose).

We won this argument by posing the hypothetical case, which seemed to be
what JCAHO was advocating, that a patient could arrive receiving
nebulized albuterol by protocol from the paramedic, but the nurse would
have to discontinue the medication because she/he was not allowed to
make diagnoses. We argued that this would be a step backward in terms of
patient safety, timeliness, and effectiveness.

We won the argument convincingly, as nurses are allowed to administer
albuterol, ipratoprium, and dexamethasone prior to physician evaluation.

James Chamberlain, MD
Division Chief, Emergency Medicine
Children's National Medical Center
111 Michigan Avenue, NW
Washington, DC 20010
202.476.3253 (O)
202.476.3573 (F)
202.476.5433 (Emergency Access)
-----Original Message-----
From: Pediatric Emergency Medicine Discussion List
[mailto:[log in to unmask]] On Behalf Of Givens, Timothy
Sent: Friday, April 16, 2010 1:37 PM
To: [log in to unmask]
Subject: Use of protocols & pathways in the ED

For the group:

Have any of you encountered resistance to the use/implementation of
treatment protocols in the ED?  Our hospital P&T committee recently
placed a moratorium on the approval of new or revised protocols
house-wide while they engage in a philosophical debate about the
appropriate use of protocols in general.  Their objection to some
recently submitted triage protocols (decadron for croupers, zofran for
vomiting patients, etc.) was that it required nurses in triage to
diagnose and or prescribe medications, and this violated the scope of
nursing practice.  I am interested to hear what the group's opinions in
this regard are--positive and negative.  As in everything, we are trying
to balance efficiency, throughput, and patient satisfaction with safety
concerns, and I'm certain this is the crux of the issue.  What do you

Tim Givens, MD
Medical Director, Pediatric Emergency Department
The Children's Hospital, Denver
Acting Section Chief, Section of Emergency Medicine
Department of Pediatrics
University of Colorado, Denver
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