Purpose

The purpose of this policy is to support nursing assessment, interventions, and guide decision making for Nurse Initiated Care in the Emergency Department (ED).

Policy Number

CLI.5110.PL.002

Background

• Policy revision to update workflow and add supporting document tools based on staff and physician feedback.

Key Message

• Policy revisions:
  • Terminology in title and throughout policy changed from “nurse-managed” to “nurse-initiated”
  • Nurse-initiated lab & diagnostic direction added
  • Discharge instruction direction added
  • Nurse-initiated care in an open Emergency Department direction revised
  • Clinical decision tool direction added
• Supporting documents:
  • CLI.5110.PL.002.FORM.01 Emergency Department Adult Clinical Decision Tool (revised)
  • CLI.5110.PL.002.FORM.02 Emergency Department Pediatric Clinical Decision Tool (revised)
  • CLI.5110.PL.002.FORM.03 Nurse Initiated X-ray Order Tool (new)
  • CLI.5110.PL.002.FORM.04 Emergency Department Adult Clinical Decision Tool-PRN MAR (new)
  • CLI.5110.PL.002.FORM.05 Emergency Department Pediatric Clinical Decision Tool-PRN MAR (new)

Recommendation(s)/Action Required

• Southern Health-Santé Sud (SH-SS) Emergency Department Clinical staff – Managers, CRNs, Charge Nurses, Nurses, Physicians, Nurse Practitioners, Clinical Assistants, Physician Assistants participate in formal SH-SS Staff Development education.
• Shared Health Lab & Diagnostic Staff – Participate in formal SH-SS Staff Development education.
• Update/replace policy and forms and destroy all past copies.

Timeline:

• Policy and supporting documents will be published on StaffNET by September 16, 2025 for staff to access/reference for education.
• Formal Staff Development education and site agreement between Emergency Department and Lab & Diagnostic staff required prior to new forms and processes going live at each site.
• If you have any questions, please contact your Manager, Director or Educator.

Submitted by: Tamara Burnham, Collaborative Practice Lead