What are the recommendations for writing protocols for emergency room procedures, considering diverse patient populations, including pediatric, adult, and geriatric individuals with varied medical histories?

Protocol Writing for Emergency Room Procedures

Core Framework for Protocol Development

Emergency departments should develop comprehensive, written care protocols that are evidence-based, multidisciplinary-reviewed, and updated annually, with specific adaptations for pediatric, adult, and geriatric populations to optimize patient outcomes and standardize care delivery. 1

Essential Protocol Categories

Emergency room protocols must address the following domains to ensure comprehensive coverage across all patient populations:

Patient Safety and Risk Assessment Protocols

• Triage and Initial Evaluation: Include family/caregiver participation in the triage process, particularly for geriatric and pediatric patients 1
• Age-Specific Risk Screening: Implement the Identification of Seniors at Risk (ISAR) tool for geriatric patients, with >1 positive response indicating high-risk status requiring enhanced resources 1
• Elder Abuse and Neglect: Establish mandatory screening and reporting procedures for suspected abuse in vulnerable populations 1
• Fall Risk Assessment: Create specific clinical guidelines for evaluating geriatric adult falls, including environmental and medication factors 1

Resuscitation Protocols by Age Group

Pediatric Resuscitation (typically ≤14 years, though this varies by state from ≤8 to ≤17 years) 2:

• Start CPR immediately when heart rate is <60 bpm with signs of poor perfusion 1
• Use 30:2 compression-to-ventilation ratio for single rescuer; switch to 15:2 when second rescuer arrives 1
• Compress at least one-third of anterior-posterior chest diameter at 100-120 compressions/minute 1
• Administer epinephrine 0.01 mg/kg IV/IO as soon as vascular access is obtained, repeat every 3-5 minutes 3
• Never delay chest compressions to establish IV access or attempt defibrillation unless shockable rhythm confirmed 3

Adult Resuscitation:

• Verify scene safety, check responsiveness, and assess breathing/pulse simultaneously within 10 seconds 1, 4
• Perform high-quality compressions: push hard (at least 2 inches), push fast (100-120/minute), allow complete recoil 1, 4
• Use 30:2 compression-to-ventilation ratio for all adult patients 1
• Deploy AED as soon as available; deliver shock immediately if shockable rhythm, then resume CPR for 2 minutes 1, 4

Geriatric-Specific Protocols

Delirium and Agitation Management 1:

• Eliminate high-risk medications (particularly anticholinergics) 1
• Treat underlying causes: infections (UTI, pneumonia), dehydration, electrolyte disturbances 1
• Minimize physical restraints; when chemical restraint necessary, use haloperidol over lorazepam 1
• Provide therapeutic environment: quiet room, adequate lighting, visible calendars/clocks, consistent caregivers 1
• Foster orientation through frequent reassurance, clear communication, and family presence at bedside 1

Medication Management 1:

• Conduct medication reconciliation and pharmacy review for all geriatric patients 1
• Screen for polypharmacy (>3 medications daily increases risk) 1
• Provide adequate pain control while avoiding high-risk medications 1

End-of-Life and Palliative Care 1:

• Establish clinical protocols to identify patients who might benefit from palliative interventions 1
• Address DNR/POLST documentation and ensure access to palliative care teams 1
• Include family in "code" situations when appropriate 1

Procedural Protocols

Urinary Catheter Placement 1:

• Screen and identify appropriate patients using specific criteria 1
• Educate staff on proper technique and infection prevention 1
• Implement process improvement measures including infection rate auditing and limited duration of use 1

Wound Assessment and Care 1:

• Standardize wound evaluation and treatment approaches across all age groups 1

Protocol Development Process

Multidisciplinary Team Composition

Protocols should be developed and reviewed by teams including 1:

• Emergency physicians and medical directors 1
• Nurse managers and emergency nurses 1
• Pharmacists for medication-related protocols 1
• Case managers and social workers 1
• Specialists (geriatricians, pediatricians, rehabilitation medicine) as appropriate 1

Evidence-Based Methodology

Use the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework 5, 6:

• Define clinical questions in PICO (Patient, Intervention, Comparison, Outcome) format 5
• Prioritize outcomes to facilitate systematic literature searches 5
• Create evidence profiles for each clinical question 5
• Assign levels of evidence and graded recommendations to each decision point 5
• Format into decision tree algorithms for ease of use 5

Implementation Requirements

• Make protocols available electronically and in written format, accessible to all staff 1
• Incorporate into electronic medical record admission orders to ensure consistent use 1
• Include exclusion criteria (e.g., prohibit anticoagulants immediately after tPA) and mandatory activities (e.g., swallow evaluation before feeding) 1
• Review and update protocols at least annually using evidence-based medical guidelines 1

Quality Improvement and Performance Monitoring

Metrics to Track 1:

• Physical restraint utilization hours/days 1
• Benzodiazepine use in geriatric patients with agitated delirium 1
• Fall-risk assessment documentation rates 1
• Preventable adverse events within the department 1
• 72-hour ED return rates as balancing measure 7
• Provider-to-provider care practice variation using funnel plots 7

Ongoing Education 1:

• Provide front-end geriatric-specific and pediatric-specific educational materials 1
• Offer self-learning modules or group didactics 1
• Customize continuing medical education to individual department needs 1

Critical Implementation Considerations

Common Pitfalls to Avoid:

• Do not create protocols in isolation; involve all relevant stakeholders from the outset 1, 8
• Avoid overly complex protocols that are resource-intensive to implement; prioritize simplicity and usability 1, 5
• Do not assume one-size-fits-all; explicitly address age-specific modifications within each protocol 2
• Never implement protocols without concurrent staff education and ongoing reinforcement 1

Transition of Care 1:

• Establish discharge processes with large-font instructions for geriatric patients 1
• Provide follow-up for at-risk patients within 24 hours (preferably in-person) 1
• Coordinate with home health services and conduct home-safety assessments when indicated 1
• Communicate risk assessment results to case management for admitted patients 1

Standardization Across Systems

For multi-hospital systems 1, 2:

• Implement protocols across all facilities while reflecting individual diagnostic capabilities and treatment preferences 1
• Recognize that statewide variation exists (21 states have mandatory protocols, 17 have model protocols) 2
• Consider centralized or regionalized approach to create and maintain full set of evidence-based guidelines to optimize resources 5, 8