Structured Analgesia Pathways, Including Nurse-Initiated Approaches, for Acute Pain in Emergency Departments: A Systematic Review and Meta-Analysis.

Acute pain is a common reason for emergency department (ED) attendance, yet delayed analgesia remains a persistent challenge in emergency care. Structured analgesia pathways, including nurse-initiated approaches, may reduce treatment delays by enabling earlier pain assessment and analgesic administration according to predefined criteria. This systematic review and meta-analysis evaluated the effects of structured analgesia pathways on acute pain management in ED settings, focusing on time to analgesia, pain reduction, analgesia administration, patient satisfaction, adverse events, and ED flow. A comprehensive database search was conducted, and eligible studies were independently screened, extracted, and appraised. Sixteen studies were included. The evidence base consisted mainly of non-randomized comparative studies, quality improvement projects, and implementation studies, and the review protocol was not prospectively registered. Meta-analysis supported a reduction in time to analgesia with structured pathways; however, results varied considerably across studies, while sensitivity analysis supported the same overall direction of effect. Overall, structured analgesia pathways were associated with earlier analgesic administration and improved pain management processes, particularly when treatment could begin at triage or before physician assessment. Findings for pain intensity, satisfaction, safety, and ED length of stay were generally favorable but less consistent because of differences in study design, outcome definitions, and reporting methods. Risk of bias was driven mainly by non-randomized implementation, residual confounding, and incomplete standardization of outcome reporting. These findings suggest that structured analgesia pathways may improve the timeliness and reliability of emergency pain management, although stronger comparative studies are needed to clarify their effects on patient-centered and system-level outcomes.