Standardized Protocols for Optimizing Emergency Department Care

Revised June 2021

Originally approved October 2015

The American College of Emergency Physicians (ACEP) supports and endorses the use of standardized nursing protocol orders (also referred to as standardized procedures, order sets, standing orders, or triage protocols) in the emergency department (ED) for initiation of patient evaluation and care prior to evaluation by a physician, nurse practitioner (NP), or physician assistant (PA). The use of such protocols is a patient-centric practice that is safe and effective in enhancing patient care. Standardized protocols have the potential to reduce variation in care, enhance workflow, improve coordination of care, and modify practice through evidence-based care.

ACEP is committed to ensuring that patients presenting to the ED receive timely high-quality care. Due to the nature of unscheduled care and unpredictable surges in patient volume and acuity, there are times when a physician, NP, or PA is not immediately available to initiate evaluation and care. In these instances, many facilities have found it beneficial to begin the evaluation and care of patients under standardized protocols enacted by nursing staff within their scope of practice that include but are not limited to:

• Instituting evaluation or treatment for conditions that are particularly time-sensitive (eg, an electrocardiogram and aspirin for myocardial ischemia)
• Enhancing patient comfort (eg, acetaminophen for fever)
• Reducing the overall time patients spend in the ED by initiating testing and treatment earlier during the patient's stay
• Improving overall patient safety by reducing ED time to treatment
• Improving the patient experience 

Standardized protocols are a set of pre-approved orders that include a specifically defined patient population and clinical scenario(s) in which these orders may be carried out by nursing staff without any additional physician, NP, or PA input, approval, or order, either written or verbal.  

1. Standardized protocols should be developed collaboratively by physician and nursing leadership with input from other involved hospital departments as necessary, including pharmacy, risk management, laboratory, hospital administration, etc., as appropriate.
2. Standardized protocols should be based on the best available evidence. ACEP acknowledges that for some standardized protocols, sufficient evidence may not exist to either support or refute their use; in such cases consensus-based protocols are appropriate.
3. Standardized protocols should identify the pre-approving physician or medical staff body. By nature of the fact that the protocols have been pre-approved by physician and nursing leadership, ACEP does not believe that any physician, NP, or PA should be required to authenticate an order that he or she did not directly initiate.
4. ACEP believes that services rendered by nursing staff under a standardized protocol should be reimbursed as if ordered contemporaneously by a physician, NP, or PA.
5. Use of a standardized protocol does not, in and of itself, create a physician-patient relationship.
6. If standardized protocols are utilized, robust education and continuous quality improvement programs should be in place.

ACEP encourages regulatory and credentialing bodies to develop their policies and procedures regarding standardized protocols with these considerations.

* This policy does not address standardized protocols used in the indirect supervision of PAs and NPs by physicians.