Protocols 1–12
Emergency Department Protocol Commons
Consultation Edition, Version 0.9
Phase I establishes the operational foundation of emergency-department care. It covers the patient journey from first presentation through triage, stabilization, clinical assessment, investigation, medication administration, monitoring, consultation, discharge, admission, transfer and shift handover.
These protocols are intended for professional review and responsible local adaptation. They are not approved clinical policies and must not be implemented without verification against current guidance, local resources, professional scopes of practice, medication formularies, legislation and institutional governance requirements.
Download Phase I
The complete phase may be downloaded in either of the following formats:
Download the complete Phase I package — PDF and editable Word copies
Download the Phase I editable Word package for local adaptation
Readers may also review the individual PDF consultation copies below.
How to Review This Phase
Reviewers are not expected to comment on all 12 protocols.
Please select the protocols most relevant to your experience and consider:
- Clinical safety and accuracy
- Clarity of staff roles and responsibilities
- Feasibility within local staffing and resource constraints
- Medication and equipment availability
- Laboratory and imaging capacity
- Referral and transfer arrangements
- Documentation and information-system requirements
- Legal and governance considerations
- Small-island and regional-care realities
- Important omissions or unnecessary complexity
Please submit a separate feedback form for each protocol being reviewed.
Submit feedback on a Phase I protocol
Protocol 1 — Emergency Department Patient Journey
This protocol establishes the end-to-end process for managing every patient from initial presentation through registration, triage, assessment, treatment, reassessment and final disposition. It defines responsibility, patient flow, escalation, communication and safeguards against patients being lost, delayed or left without a clear plan.
Read or download the PDF consultation copy
Protocol 2 — Emergency Department Triage and Retriage
This protocol establishes acuity-based prioritization using the Interagency Integrated Triage Tool, with provisions for immediate danger recognition, initial actions, waiting-area surveillance, repeated reassessment and escalation when a patient deteriorates or waits beyond an appropriate interval.
Read or download the PDF consultation copy
Protocol 3 — Emergency Resuscitation and Initial Stabilization
This protocol defines the common emergency response to critical illness or injury, including recognition, team activation, resuscitation-area preparation, structured ABCDE assessment, immediate life-saving interventions, repeated reassessment and safe transfer of clinical responsibility.
Read or download the PDF consultation copy
Protocol 4 — Emergency Department Clinical Assessment and Documentation
This protocol establishes minimum standards for structured clinical assessment, diagnostic reasoning, documentation of uncertainty, reassessment and maintenance of a clear and defensible record of emergency care. Life-saving treatment must never be delayed solely to complete documentation.
Read or download the PDF consultation copy
Protocol 5 — Emergency Department Investigations, Critical Results, and Results Tracking
This protocol governs diagnostic stewardship, safe ordering and specimen handling, imaging and point-of-care testing, communication of critical findings and closed-loop ownership of all results, including those remaining pending when a patient is discharged, admitted or transferred.
Read or download the PDF consultation copy
Protocol 6 — Emergency Department Medication Safety and Administration
This protocol establishes safeguards for medication history, allergy documentation, prescribing, preparation, verification, administration, monitoring, reconciliation and transition of medication responsibility. Particular attention is given to high-alert medicines, weight-based dosing, infusions and medication-related adverse events.
Read or download the PDF consultation copy
Protocol 7 — Emergency Department Monitoring and Reassessment
This protocol establishes monitoring and reassessment according to clinical risk. It addresses observation frequency, treatment-response review, recognition of deterioration, early-warning escalation, waiting-room surveillance and continued responsibility until the patient physically leaves the department or care is formally transferred.
Read or download the PDF consultation copy
Protocol 8 — Emergency Department Consultation and Escalation
This protocol governs requests for specialist advice, assessment, admission, procedures, critical-care support and transfer. It defines referral communication, expected responses, escalation of delays or disputes, chain of command and explicit clinical responsibility while the patient remains in the emergency department.
Read or download the PDF consultation copy
Protocol 9 — Emergency Department Safe Discharge
This protocol establishes the minimum requirements for safe discharge, including final reassessment, review of investigations, medication reconciliation, written and verbal information, teach-back, pending-result ownership, follow-up arrangements, return precautions and assessment of transport, function and social safety.
Read or download the PDF consultation copy
Protocol 10 — Emergency Department Admission and Ward Transfer
This protocol governs admission from the emergency department to inpatient, critical-care, theatre, maternity, mental-health or other internal services. It addresses acceptance, stabilization, boarding safety, structured handover, transfer readiness and clear transfer of medical and nursing responsibility.
Read or download the PDF consultation copy
Protocol 11 — Emergency Department Interfacility and Overseas Transfer
This protocol establishes the process for transferring patients when required care cannot be provided locally. It covers the transfer decision, receiving-facility acceptance, stabilization, transport modality, clinical escort, oxygen and equipment requirements, documentation, contingency planning and regional or overseas referral.
Read or download the PDF consultation copy
Protocol 12 — Emergency Department Shift Handover and Transfer of Responsibility
This protocol establishes a standardized process for transferring patient-specific and department-wide responsibility at shift changes, breaks, temporary cover and changes in clinical location. It includes safety huddles, structured handover, pending results, outstanding tasks, risk identification and explicit acceptance of responsibility.
Read or download the PDF consultation copy
Submit Feedback
Feedback from emergency clinicians, nurses, pharmacists, allied health professionals, administrators, patient-safety personnel and other relevant reviewers is welcomed.
Please identify:
- The protocol number
- The relevant section or page
- The concern or recommendation
- Suggested replacement wording where possible
- Supporting evidence or local experience
- Whether the issue may represent an urgent patient-safety concern
Submit feedback on the Emergency Department Protocol Commons
Complete Protocol Index
Browse all 59 protocols and download individual PDF or editable Word copies