RESEARCH
PEDIATRIC PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT: THE TRIAGE NURSES’ PERSPECTIVE Authors: Daina Thomas, MD, Janeva Kircher, MD, Amy C. Plint, MD, MSc, Eleanor Fitzpatrick, MN, RN, Amanda S. Newton, PhD, RN, Rhonda J. Rosychuk, PhD PStat, PStat(ASA), Simran Grewal, MD, and Samina Ali, MDCM, Edmonton, Alberta, Ottawa, Ontario, Halifax, Nova Scotia, and Vancouver, British Columbia, Canada Introduction: Understanding triage nurses' perspectives of
pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols. Methods: A paper-based survey was administered to all
triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012. Results: The response rate was 86% (n=126/147). The mean
rated more comfort with a protocol involving administration of acetaminophen (97mm, interquartile range [IQR] 92, 99) or ibuprofen (97mm, IQR 93, 100) than for oral morphine (67mm, IQR 35, 94) or oxycodone (57mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81mm (IQR 71, 96). Discussion: Triage nurses are willing to implement pain
protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.
respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P b .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P b .002). Most nurses
Key words: Triage; Pediatrics; Pain; Protocol; Analgesia; Emergency department
he World Health Organization has declared that pediatric pain treatment is a public health concern of major significance. 1 Studies indicate that inadequate pain management during medical care can
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have numerous detrimental effects, including an extended length of stay, slower healing, and emotional trauma and suffering. 2–5 Furthermore, negative effects may extend into adulthood and can include fear of medical events or health
Daina Thomas, is Pediatric Emergency Physician Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Samina Ali, is Pediatric Emergency Physician Departments of Pediatrics and Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. This study was funded by a Women and Children’s Health Research Institute (Edmonton, Alberta, Canada) Trainee Grant, secured by Dr Thomas. Dr Rosychuk is salary supported by Alberta Innovates–Health Solutions (Edmonton, Alberta, Canada) as a Health Scholar. Dr Newton is salary supported by the Canadian Institutes of Health Research. Dr Plint holds a University of Ottawa Faculty of Medicine Research Chair in Pediatric Emergency Medicine. For correspondence, write: Samina Ali, MDCM, Department of Pediatrics, Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Canada AB T6G 1C9; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767
Janeva Kircher, is Emergency Medicine Resident Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada. Amy C. Plint, is Pediatric Emergency Physician Department of Pediatrics and Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Eleanor Fitzpatrick, is Research Coordinator Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Amanda S. Newton, is Associate Professor (Pediatrics) Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. Rhonda J. Rosychuk, Professor (Pediatrics) and Statistician Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. Simran Grewal, is Divisional Director Division of Pediatric Emergency, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
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care consultations, avoidance or overuse of medical care, and heightened sensitivity to subsequent medical care. 2–4 Pain is the most common reason for seeking health care, accounting for up to 80% of all ED visits. 6–8 Patients may have pain from an underlying illness or injury, as well as from necessary medical procedures such as venipuncture or fracture reduction. 8,9 A large multicenter study found that only 60% of patients with moderate to severe pain receive any analgesia in the emergency department. 10 Unfortunately, oligoanalgesia (under-treatment of pain) remains a welldocumented problem in the ED setting. 11 Triage has been recognized as a site to effect large improvements in overall pain treatment in the emergency department. 12 The assessment of pain and provision of analgesia early in a patient’s stay are key to decreasing the pain experienced within the emergency department and improving patient satisfaction. 12–14 Several centers have implemented pain protocols that allow for triage nurse–initiated analgesia. Studies of these centers have found statistically significant improvements in overall analgesia provision, time to analgesia, and patient satisfaction. 15–20 Understanding and considering triage nurses’ perspectives comprise a vital step when planning the implementation of a new nursing initiative. By understanding their perspectives, we can then ensure triage nurse buy-in and participation when actualizing a new pain protocol. 16,17 The objectives of this study were to describe comfort with triage pain treatment protocols used, knowledge of pain management modalities, and perceived barriers and attitudes toward implementation of pain treatment protocols at triage. Methods STUDY DESIGN
This study was a descriptive, cross-sectional survey of all triage nurses at 3 Canadian pediatric emergency departments—2 emergency departments with pediatric-only triage and 1 emergency department with combined pediatric and adult triage. The site with combined pediatric and adult triage has a stand-alone pediatric emergency department served by a shared triage. A paper-based survey was administered on 2 occasions from December 2011 to January 2012. 21 ETHICS APPROVAL
This study was approved by the research ethics board at each participating site prior to its implementation. This process included approval for the novel survey tool and study methodology, as well as the distribution of gift cards to participants. An information letter was included at the start of
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each survey, and consent was implied by completion of the survey. SELECTION OF PARTICIPANTS
Participants were recruited from the emergency departments at the Stollery Children’s Hospital (SCH, Edmonton, Alberta, Canada), IWK Health Centre (IWK, Halifax, Nova Scotia, Canada), and Children’s Hospital of Eastern Ontario (CHEO, Ottawa, Ontario, Canada). In 2011 the annual pediatric census was 29,197 for the SCH emergency department; 28,000 for IWK; and 65,949 for CHEO. At the time of survey administration, there were 147 triage nurses (87 at SCH, 28 at IWK, and 32 at CHEO) eligible for participation in our study. METHODS OF MEASUREMENT
A novel survey tool was developed in accordance with published guidelines. 22 An expert panel—with representation from pediatrics, emergency medicine, and nursing—informed survey development by participating in the item generation and reduction phases, as well as ensuring face and content validity. The survey was piloted with a group of 6 nurses to further ensure face and content validity, as well as sensibility. 22 Completion of the survey required approximately 10 minutes. Participants were asked questions regarding their demographic characteristics (eg, age, sex, and training) and experience with pain protocols and management of pain; they also rated their comfort with, and feasibility of, providing various pharmacologic and non-pharmacologic pain treatments. Respondents were asked about their willingness to implement a triage-initiated pain protocol, as well as perceived barriers and facilitators. Respondents received a nominal ($10) coffee gift card. Responses were entered into an electronic database by a trained data entry clerk, and 20% of these were verified by the study coordinator to ensure accurate data entry. The primary site for data storage and analysis was the Department of Pediatrics at the University of Alberta, Edmonton, Alberta, Canada. PRIMARY DATA ANALYSIS
Mean, median, standard deviation, and interquartile range (IQR) were used to describe continuous data (eg, age) and frequencies and proportions to describe categorical data (eg, sex). One-way analysis of variance and the Kruskal-Wallis test were used to compare means among the 3 emergency departments for normally distributed and skewed continuous data, respectively. To compare categorical responses among the 3 emergency departments, χ 2 tests (or Fisher exact tests in
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TABLE 1
Respondent demographic data Male sex, n (%) Age, mean (SD), y Nursing experience, mean (SD), y Pediatric nursing experience, mean (SD), y Triage experience, mean (SD), y
PTED A (n = 24)
PTED B (n = 27)
GTED (n = 75)
Total (N = 126)
P value
0 43 21 19 11
4 43 18 16 10
19 38 14 11 7
23 40 14 13 9
.009 .007 .006 b .001 .047
(0) (9) (9) (9) (9)
(17) (10) (11) (10) (7)
(25) (8) (9) (8) (7)
(18) (9) (10) (9) (8)
GTED, General triage emergency department; PTED, pediatric triage emergency department.
the case of small cell counts for responses to individual questions) were used. Statistical analyses were performed with SAS software for Windows (version 9.2; SAS Institute, Cary, NC). P b .05 was considered statistically significant. Results
The response rate was 86% (126 of 147). Of the respondents, 60% (n = 75) were from the emergency department with general (combined pediatric and adult) triage (GTED) and 40% (n = 51) were from the 2 emergency departments with pediatric-only triage (PTED A and PTED B). Respondent demographic data are shown in Table 1. EXPERIENCE
Sixty-seven percent of nurses (n = 84) reported receiving training on triage pain assessment, with a median duration of
8 hours (IQR, 8-16 hours; P = .19); 74% of nurses (n = 93) reported receiving training specifically on pain measurement tools, with no evidence of a statistically significant difference among sites (P = .26). Fifty-six percent of all triage nurses (n = 70) reported receiving training specifically on pain management techniques, with a significant difference among the sites (54% at PTED A, 78% at PTED B, and 48% at the GTED; P = .0064). At the GTED, 37% of nurses (n = 28) had experience with pediatric triage pain protocols, 46% (n = 11) at PTED A, and 93% (n = 25) at PTED B (P b .001). KNOWLEDGE AND ATTITUDES
Triage nurses responded that older children were more accurate in their reporting of pain (45 mm [IQR, 25-62 mm] for a 3-year-old, P = .77; 70 mm [IQR, 55-83 mm] for an 8-year-old, P = .57; and 82 mm [IQR, 74-95 mm] for a 16-year-old, P = .63) as measured on a 100-mm visual analog scale, and this did not differ among sites.
TABLE 2
Feasibility of implementing pain management protocol tools Tool
Ice packs Acetaminophen Ibuprofen Codeine Oral morphine Oxycodone IV morphine Splinting Distraction Intranasal analgesics
P value
Median (IQR), mm PTED A (n = 24)
PTED B (n = 27)
GTED (n = 74)
All (n = 125)
94 95 92 79 85 59 40 92 66 47
89 96 97 16 47 12 8 92 72 8
96 96 96 57 49 53 13 85 81 32
94 96 96 56 53 47 13 91 75 27
(90-97) (92-98) (89-97) (61-95) (58-93) (15-82) (17-62) (87-96) (45-91) (13-82)
(72-97) (91-100) (91-99) (2-47) (11-60) (1-48) (1-13) (81-97) (57-95) (2-51)
(91-99) (92-99) (93-99) (30-85) (19-76) (15-81) (5-38) (63-97) (53-95) (11-63)
(88-98) (92-99) (91-99) (22-90) (24-88) (12-77) (4-42) (76-96) (49-94) (8-65)
.031 .498 .208 b .001 .003 b .001 b .001 .070 .430 .008
Responses were measured via a 100-mm visual analog scale, where 0 indicates “not at all” and 100 indicates “very feasible.” GTED, General triage emergency department; IQR, interquartile range; IV, intravenous; PTED, pediatric triage emergency department.
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TABLE 3
Comfort with pain management protocol tools Tool
Ice packs Acetaminophen Ibuprofen Codeine Oral morphine Oxycodone IV morphine Splinting Distraction Intranasal analgesics
P value
Median (IQR), mm PTED A (n = 24)
PTED B (n = 27)
GTED (n = 74)
All (n = 125)
93 94 95 89 89 51 67 96 86 61
98 98 98 58 67 33 11 97 90 25
96 97 97 75 62 64 20 90 94 32
96 97 97 75 67 57 17 93 93 36
(89-97) (89-98) (90-99) (70-95) (67-95) (14-77) (15-87) (89-99) (68-98) (16-93)
(93-100) (90-99) (89-100) (10-90) (23-94) (6-65) (1-17) (92-100) (69-97) (7-52)
(93-99) (94-100) (93-100) (49-96) (26-83) (31-89) (5-52) (67-97) (78-99) (13-81)
(91-99) (92-99) (93-100) (48-95) (35-94) (15-81) (6-57) (77-99) (75-98) (13-75)
.053 .189 .216 .054 .016 .009 .003 .001 .330 .051
Responses were measured via a 100-mm visual analog scale, where 0 indicates “not at all” and 100 indicates “very comfortable.” GTED, General triage emergency department; IQR, interquartile range; IV, intravenous; PTED, pediatric triage emergency department.
Triage nurses’ attitude toward feasibility and comfort with several pain management protocol tools are presented in Tables 2 and 3, respectively. More years of pediatric, triage, and overall nursing experience were associated with increased comfort with splinting (P = .001, P b .001, and P = .004, respectively). More years of pediatric and overall nursing experience were associated with increased comfort with distraction tools (P = .03 for both). Nurses were asked their opinions on the maximum acceptable delay between time of triage and administration of analgesia. The results are shown in the Figure. Male nurses accepted longer time delays for children with mild pain (P = .003), but no other sex-based associations were significant. More years of triage and overall nursing experience were associated with decreased acceptable time delays for children with mild and moderate pain (P b .001 for all) but not severe pain. More years of pediatric nursing experience were associated with decreased acceptable time delays for children with mild, moderate, and severe pain (P b .001, P b .001, and P = .02, respectively). Table 4 reports nurses’ opinions regarding adequacy of pain treatment and willingness to implement a triage-initiated pain protocol. Overall, their willingness to implement a pain protocol at triage was high (81 mm; IQR, 71-96 mm). The top 3 reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. The top 3 facilitators were other nurses, own comfort level, and physician colleagues (Table 5).
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Discussion
Our survey identified that the care of children’s pain at pediatric ED triage is not consistent and that there is room for improvement in the training of triage nurses regarding pain management, specifically in the assessment and treatment of very young children. There was wide variability in comfort with, and feasibility of, using various proposed pharmacologic tools at triage. GTED nurses accepted longer treatment delays, and respondents believed that children’s pain was treated less favorably than at PTED centers. This study suggests that Canadian pediatric emergency departments may benefit from pediatric-only triage and the development of triageinitiated pain protocols. Across the 3 study sites, the comfort with the use of triage-initiated pain protocols varied widely despite evidence that triage-initiated pain protocols decrease the time to analgesia and increase the number of children who receive analgesia in the emergency department. 15,16,20 Such triage-initiated protocols have also been shown to improve parental satisfaction and increase nurse autonomy while improving nurse-physician collegiality. 16 The results of our study suggest that triage pain treatment is variable and likely suboptimal across one western, one eastern, and one central Canadian pediatric emergency department. This crossCanadian sampling suggests that united efforts, perhaps at a national advocacy level, should be made to rectify this lack of consistency in approach to children’s pain.
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70 60
Minutes
50 40
PTED 'A' PTED 'B'
30
GTED
20 10 0 Severe Pain
Moderate Pain
Mild Pain
FIGURE Acceptable delay from time of triage to time of analgesic administration. P b .002 for all site-to-site comparisons. GTED, General triage emergency department; PTED, pediatric triage emergency department.
Our study identified a need for increased training and education of triage nurses in pediatric pain assessment and management. Boyd and Stuart 15 found that education alone was not enough to change care but that nurses being able to implement a protocol created a sense of empowerment that significantly increased the rate of analgesia, as well as decreased the time to analgesia. ED administrators must support pediatric triage systems regarding both their educational needs and implementation of protocols. Our study showed a correlation between more years of nursing experience and an increased comfort with providing non-pharmacologic analgesia, such as distraction techniques and splinting. This finding suggests that although pharmaceutical modalities are taught in nursing school, non-pharmacologic techniques might be learned “on the job.” We, and other authors, suggest that non-pharmacologic pain treatment deserves more emphasis in nursing education. 23 Very young children have long been recognized as an at-risk group for under-treatment of pain. 24–26 When one is
designing a triage-initiated pain protocol, special attention should be drawn to patients aged younger than 2 years, as well as the use of age-appropriate validated pain assessment tools. In our study the GTED nurses accepted longer delays in the initiation of pain treatment and believed that pain was treated less effectively at triage than nurses from PTED centers. These discrepancies may stem from the nature of illnesses seen in adult and pediatric patients; adults may be presenting to the emergency department with acute coronary syndromes that are extremely time-sensitive, rendering a crying child with an attentive parent to a less emergent status. Pediatric pain researchers have recently urged us to think about untreated pain as an adverse event, 27 and although children often have fewer painful life experiences than adults, their pain deserves to be treated in a timely fashion. To mitigate these differences in triage practices that may influence analgesia provision, as well as to ensure that children are not competing with adults for attention and treatment, pediatric emergency departments might benefit from their own dedicated triage process. Barriers to consider when implementing a triageinitiated pain protocol include monitoring capability, time, and access to medications. Suggested strategies to address some of these barriers from other published protocols include allowing only a limited number of oral analgesics and designing protocols that are easy to follow. 15–17 Nurses also rated protocol-specific training very highly, and this type of training should be an essential part of any protocol implementation.
Limitations
The study respondents were from only 3 emergency departments across Canada. Despite a limited number of study sites, we believe that the results are generalizable to other
TABLE 4
Nurses’ perceptions regarding pain treatment in emergency department P value
Median (IQR), mm PTED A (n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)
Adequacy of pain management in emergency department Adequacy of pain management at triage Timeliness to pain treatment in emergency department Ability to treat pain at triage Willingness to implement triage pain protocol Importance of protocol-specific training
73 62 71 72 88 91
(64-81) (50-67) (64-79) (58-79) (76-97) (77-96)
75 71 66 75 85 88
(65-87) (52-77) (60-82) (58-86) (71-92) (71-96)
75 29 65 37 88 91
(63-83) (15-50) (49-73) (25-54) (70-97) (81-96)
75 48 66 53 87 90
(65-83) .878 (26-66) b .001 (54-76) .044 (30-72) b .001 (71-96) .539 (79-96) .468
Responses were measured via a 100-mm visual analog scale, where 0 indicates “unacceptably poor” and 100 indicates “excellent,” “very willing,” or “very important.” GTED, General triage emergency department; IQR, interquartile range; PTED, pediatric triage emergency department.
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TABLE 5
Perceived barriers and facilitators to triage-initiated pain protocol implementation (n = 125 respondents, multiple responses permitted) n (%)
Barriers Monitoring capability Time Access to medications Physicians Space Administrators Other nurses Own comfort level Own knowledge Other Facilitators Other nurses Own comfort level Physicians Own knowledge Access to medications Time Administrators Space Monitoring capability Other
98 92 83 47 45 28 24 14 3 23
(78) (74) (66) (38) (36) (22) (19) (11) (2) (18)
62 59 58 57 49 22 15 14 13 15
(50) (47) (46) (46) (39) (18) (12) (11) (10) (12)
Canadian pediatric emergency departments because of the high response rate and sampling from 3 different regions of Canada (west, central, and east). Study respondent demographic characteristics were also different among sites regarding reported amount of triage experience and pediatric nursing experience. The pediatric-only triage centers had nurses with more experience in both areas; however, we do not believe that this explains all survey response differences because not all responses varied with level of experience. Surveys are inherently limited by recall bias, although this would affect only the reports of nursing experience and training background and not the willingness to implement protocols or personal comfort with various analgesic agents.
Conclusions
Triage-initiated pain protocols have been shown to decrease the time to analgesia and increase the rate of analgesia provision to children with pain. Through our survey, we have found that triage nurses are willing and able to implement triage pain protocols and have identified monitoring capability, time, and access to medications as barriers to doing so. We have also shown that children presenting to pediatric emergency departments with pediatric-only triage appear to have access to triage nurses with more comfort treating them; general triage emergency departments may benefit from more educational initiatives to support triage nurses, who are highly interested in treating children’s pain but may lack experience, training, and comfort in doing so. Acknowledgment
We thank our administrative assistant Ms Melissa Gutland, who helped with study implementation; the Clinical Research Informatics Core for data entry; and Mr Hitesh Bhatt for statistical support.
REFERENCES 1. World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. http:// whqlibdoc.who.int/publications/2012/9789241548120_Guidelines. pdf. [Published 2012. Accessed February 9, 2015]. 2. Grunau RE. Self-regulation and behavior in preterm children: effects of early pain. In: McGrath PJ, Finley GA, (eds.), Pediatric Pain: Biological and Social Context, Progress in Pain Research and Management Seattle, WA: ; 2003:23-55.
Implications for Emergency Nurses
For triage nurses, our results may contribute to improved pain treatment for pediatric patients by conveying to
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administrators, other nurses, and physicians that triageinitiated pain protocols are both feasible and desired by pediatric ED triage nurses. When designing and using triage-initiated pain protocols, emergency nurses should be especially aware of the challenges of assessing pain in children aged younger than 2 years, as well as the importance of using age-appropriate validated pain assessment tools. This study may promote the involvement of triage nurses with the development of protocols at their own institutions and further empower triage nurses to embrace active treatment of children’s pain at the most appropriate point of contact within the emergency department, namely at the time of triage.
3. Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior?. Biol Neonate. 2000;77:69-82.
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4. Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Child Health Care. 1996;25:281-298.
16. Campbell P, Dennie M, Dougherty K, et al. Implementation of an ED protocol for pain management at triage at a busy Level I trauma center. J Emerg Nurs. 2004;30(5):431-438.
5. Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998;152:147-149.
17. Fosnocht DE, Swanson ER. Use of a triage pain protocol in the ED. Am J Emerg Med. 2007;25(7):791-793.
6. Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in emergency medicine care. Am J Emerg Med. 2002;20(3)165-169. 7. Johnston CC, Bourniaki M, Gagnon AJ, Pepler CJ, Bourgault P. Self reported pain intensity and associated distress in children aged 4-18 years on admission, discharge, and one-week follow up to emergency department. Pediatr Emerg Care. 2005;21(5):342-346.
18. Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emerg Med. 2002;14:249-254. 19. Goh HK, Choo SE, Lee I, et al. Emergency department triage nurse initiated pain management. Hong Kong J Emerg Med. 2007;14(1): 16-21.
8. Verghese S, Hannallah R. Acute pain management in children. J Pain Res. 2010;3:105-123.
20. Eisen S, Amiel K. Introduction of a paediatric pain management protocol improves assessment and management of pain in children in the emergency department. Arch Dis Child. 2007;92(9):828-829.
9. Augarten A, Zaslansky R, Pharm IM, et al. The impact of educational intervention programs on pain management in a pediatric emergency department. Biomed Pharmacother. 2006;60:299-302.
21. Dillman DA, Smyth JD, Christian LM. Internet, Mail, and MixedMode Surveys: The Tailored Design Method, Hoboken, NJ: John Wiley & Sons; 2009.
10. Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8(6):460-466.
22. Burns KEA, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179(3):245-252.
11. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623.
23. Coyne ML, Reinert B, Cater K, et al. Nurses’ knowledge of pain assessment, pharmacologic and nonpharmacologic interventions. Clin Nurs Res. 1999;8(2):153-265.
12. Bible D. Pain assessment at nurse triage: a literature review. Emerg Nurse. 2006;14(3):26-29.
24. Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197-205.
13. Charney RL, Yan Y, Schootman M, et al. Oxycodone versus codeine for triage pain in children with suspected forearm fracture: a randomized controlled trial. Pediatr Emerg Care. 2008;24(9):595-600.
25. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med. 2003;41(5):617-622.
14. Teanby S. A literature review into pain assessment at triage in accident and emergency departments. Accid Emerg Nurs. 2003;11(1):12-17.
26. Dong L, Donaldson A, Metzger R, et al. Analgesic administration in the emergency department for children requiring hospitalization for longbone fracture. Pediatr Emerg Care. 2012;28(2):109-114.
15. Boyd RJ, Stuart P. The efficacy of structured assessment and analgesia provision in the paediatric emergency department. Emerg Med J. 2005;22:30-32.
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PEDIATRIC PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT: THE TRIAGE NURSES’ PERSPECTIVE Authors: Daina Thomas, MD, Janeva Kircher, MD, Amy C. Plint, MD, MSc, Eleanor Fitzpatrick, MN, RN, Amanda S. Newton, PhD, RN, Rhonda J. Rosychuk, PhD PStat, PStat(ASA), Simran Grewal, MD, and Samina Ali, MDCM, Edmonton, Alberta, Ottawa, Ontario, Halifax, Nova Scotia, and Vancouver, British Columbia, Canada Introduction: Understanding triage nurses' perspectives of
pain management is essential for timely pain care for children in the emergency department. Objectives of this study were to describe the triage pain treatment protocols used, knowledge of pain management modalities, and barriers and attitudes towards implementation of pain treatment protocols. Methods: A paper-based survey was administered to all
triage nurses at three Canadian pediatric emergency departments, between December 2011 and January 2012. Results: The response rate was 86% (n=126/147). The mean
rated more comfort with a protocol involving administration of acetaminophen (97mm, interquartile range [IQR] 92, 99) or ibuprofen (97mm, IQR 93, 100) than for oral morphine (67mm, IQR 35, 94) or oxycodone (57mm, IQR 15, 81). The top three reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. Willingness to implement a triage-initiated pain protocol was rated as 81mm (IQR 71, 96). Discussion: Triage nurses are willing to implement pain
protocols for children in the emergency department, but differences in comfort and experience exist between PTED and GTED nurses. Provision of triage initiated pain protocols and associated education may empower nurses to improve care for children in pain in the emergency department.
respondent age was 40 years (standard deviation [SD] 9.3) with 8.6 years (SD 7.7) of triage experience. General triage emergency department (GTED) nurses rated adequacy of triage pain treatment lower than pediatric-only triage emergency department (PTED) nurses (P b .001). GTED nurses reported a longer acceptable delay between triage time and administration of analgesia than PTED nurses (P b .002). Most nurses
Key words: Triage; Pediatrics; Pain; Protocol; Analgesia; Emergency department
he World Health Organization has declared that pediatric pain treatment is a public health concern of major significance. 1 Studies indicate that inadequate pain management during medical care can
T
have numerous detrimental effects, including an extended length of stay, slower healing, and emotional trauma and suffering. 2–5 Furthermore, negative effects may extend into adulthood and can include fear of medical events or health
Daina Thomas, is Pediatric Emergency Physician Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Samina Ali, is Pediatric Emergency Physician Departments of Pediatrics and Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. This study was funded by a Women and Children’s Health Research Institute (Edmonton, Alberta, Canada) Trainee Grant, secured by Dr Thomas. Dr Rosychuk is salary supported by Alberta Innovates–Health Solutions (Edmonton, Alberta, Canada) as a Health Scholar. Dr Newton is salary supported by the Canadian Institutes of Health Research. Dr Plint holds a University of Ottawa Faculty of Medicine Research Chair in Pediatric Emergency Medicine. For correspondence, write: Samina Ali, MDCM, Department of Pediatrics, Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Canada AB T6G 1C9; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767
Janeva Kircher, is Emergency Medicine Resident Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada. Amy C. Plint, is Pediatric Emergency Physician Department of Pediatrics and Emergency Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada. Eleanor Fitzpatrick, is Research Coordinator Department of Emergency Medicine, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. Amanda S. Newton, is Associate Professor (Pediatrics) Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. Rhonda J. Rosychuk, Professor (Pediatrics) and Statistician Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, and Women and Children’s Health Research Institute, Edmonton, Alberta, Canada. Simran Grewal, is Divisional Director Division of Pediatric Emergency, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
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care consultations, avoidance or overuse of medical care, and heightened sensitivity to subsequent medical care. 2–4 Pain is the most common reason for seeking health care, accounting for up to 80% of all ED visits. 6–8 Patients may have pain from an underlying illness or injury, as well as from necessary medical procedures such as venipuncture or fracture reduction. 8,9 A large multicenter study found that only 60% of patients with moderate to severe pain receive any analgesia in the emergency department. 10 Unfortunately, oligoanalgesia (under-treatment of pain) remains a welldocumented problem in the ED setting. 11 Triage has been recognized as a site to effect large improvements in overall pain treatment in the emergency department. 12 The assessment of pain and provision of analgesia early in a patient’s stay are key to decreasing the pain experienced within the emergency department and improving patient satisfaction. 12–14 Several centers have implemented pain protocols that allow for triage nurse–initiated analgesia. Studies of these centers have found statistically significant improvements in overall analgesia provision, time to analgesia, and patient satisfaction. 15–20 Understanding and considering triage nurses’ perspectives comprise a vital step when planning the implementation of a new nursing initiative. By understanding their perspectives, we can then ensure triage nurse buy-in and participation when actualizing a new pain protocol. 16,17 The objectives of this study were to describe comfort with triage pain treatment protocols used, knowledge of pain management modalities, and perceived barriers and attitudes toward implementation of pain treatment protocols at triage. Methods STUDY DESIGN
This study was a descriptive, cross-sectional survey of all triage nurses at 3 Canadian pediatric emergency departments—2 emergency departments with pediatric-only triage and 1 emergency department with combined pediatric and adult triage. The site with combined pediatric and adult triage has a stand-alone pediatric emergency department served by a shared triage. A paper-based survey was administered on 2 occasions from December 2011 to January 2012. 21 ETHICS APPROVAL
This study was approved by the research ethics board at each participating site prior to its implementation. This process included approval for the novel survey tool and study methodology, as well as the distribution of gift cards to participants. An information letter was included at the start of
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each survey, and consent was implied by completion of the survey. SELECTION OF PARTICIPANTS
Participants were recruited from the emergency departments at the Stollery Children’s Hospital (SCH, Edmonton, Alberta, Canada), IWK Health Centre (IWK, Halifax, Nova Scotia, Canada), and Children’s Hospital of Eastern Ontario (CHEO, Ottawa, Ontario, Canada). In 2011 the annual pediatric census was 29,197 for the SCH emergency department; 28,000 for IWK; and 65,949 for CHEO. At the time of survey administration, there were 147 triage nurses (87 at SCH, 28 at IWK, and 32 at CHEO) eligible for participation in our study. METHODS OF MEASUREMENT
A novel survey tool was developed in accordance with published guidelines. 22 An expert panel—with representation from pediatrics, emergency medicine, and nursing—informed survey development by participating in the item generation and reduction phases, as well as ensuring face and content validity. The survey was piloted with a group of 6 nurses to further ensure face and content validity, as well as sensibility. 22 Completion of the survey required approximately 10 minutes. Participants were asked questions regarding their demographic characteristics (eg, age, sex, and training) and experience with pain protocols and management of pain; they also rated their comfort with, and feasibility of, providing various pharmacologic and non-pharmacologic pain treatments. Respondents were asked about their willingness to implement a triage-initiated pain protocol, as well as perceived barriers and facilitators. Respondents received a nominal ($10) coffee gift card. Responses were entered into an electronic database by a trained data entry clerk, and 20% of these were verified by the study coordinator to ensure accurate data entry. The primary site for data storage and analysis was the Department of Pediatrics at the University of Alberta, Edmonton, Alberta, Canada. PRIMARY DATA ANALYSIS
Mean, median, standard deviation, and interquartile range (IQR) were used to describe continuous data (eg, age) and frequencies and proportions to describe categorical data (eg, sex). One-way analysis of variance and the Kruskal-Wallis test were used to compare means among the 3 emergency departments for normally distributed and skewed continuous data, respectively. To compare categorical responses among the 3 emergency departments, χ 2 tests (or Fisher exact tests in
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TABLE 1
Respondent demographic data Male sex, n (%) Age, mean (SD), y Nursing experience, mean (SD), y Pediatric nursing experience, mean (SD), y Triage experience, mean (SD), y
PTED A (n = 24)
PTED B (n = 27)
GTED (n = 75)
Total (N = 126)
P value
0 43 21 19 11
4 43 18 16 10
19 38 14 11 7
23 40 14 13 9
.009 .007 .006 b .001 .047
(0) (9) (9) (9) (9)
(17) (10) (11) (10) (7)
(25) (8) (9) (8) (7)
(18) (9) (10) (9) (8)
GTED, General triage emergency department; PTED, pediatric triage emergency department.
the case of small cell counts for responses to individual questions) were used. Statistical analyses were performed with SAS software for Windows (version 9.2; SAS Institute, Cary, NC). P b .05 was considered statistically significant. Results
The response rate was 86% (126 of 147). Of the respondents, 60% (n = 75) were from the emergency department with general (combined pediatric and adult) triage (GTED) and 40% (n = 51) were from the 2 emergency departments with pediatric-only triage (PTED A and PTED B). Respondent demographic data are shown in Table 1. EXPERIENCE
Sixty-seven percent of nurses (n = 84) reported receiving training on triage pain assessment, with a median duration of
8 hours (IQR, 8-16 hours; P = .19); 74% of nurses (n = 93) reported receiving training specifically on pain measurement tools, with no evidence of a statistically significant difference among sites (P = .26). Fifty-six percent of all triage nurses (n = 70) reported receiving training specifically on pain management techniques, with a significant difference among the sites (54% at PTED A, 78% at PTED B, and 48% at the GTED; P = .0064). At the GTED, 37% of nurses (n = 28) had experience with pediatric triage pain protocols, 46% (n = 11) at PTED A, and 93% (n = 25) at PTED B (P b .001). KNOWLEDGE AND ATTITUDES
Triage nurses responded that older children were more accurate in their reporting of pain (45 mm [IQR, 25-62 mm] for a 3-year-old, P = .77; 70 mm [IQR, 55-83 mm] for an 8-year-old, P = .57; and 82 mm [IQR, 74-95 mm] for a 16-year-old, P = .63) as measured on a 100-mm visual analog scale, and this did not differ among sites.
TABLE 2
Feasibility of implementing pain management protocol tools Tool
Ice packs Acetaminophen Ibuprofen Codeine Oral morphine Oxycodone IV morphine Splinting Distraction Intranasal analgesics
P value
Median (IQR), mm PTED A (n = 24)
PTED B (n = 27)
GTED (n = 74)
All (n = 125)
94 95 92 79 85 59 40 92 66 47
89 96 97 16 47 12 8 92 72 8
96 96 96 57 49 53 13 85 81 32
94 96 96 56 53 47 13 91 75 27
(90-97) (92-98) (89-97) (61-95) (58-93) (15-82) (17-62) (87-96) (45-91) (13-82)
(72-97) (91-100) (91-99) (2-47) (11-60) (1-48) (1-13) (81-97) (57-95) (2-51)
(91-99) (92-99) (93-99) (30-85) (19-76) (15-81) (5-38) (63-97) (53-95) (11-63)
(88-98) (92-99) (91-99) (22-90) (24-88) (12-77) (4-42) (76-96) (49-94) (8-65)
.031 .498 .208 b .001 .003 b .001 b .001 .070 .430 .008
Responses were measured via a 100-mm visual analog scale, where 0 indicates “not at all” and 100 indicates “very feasible.” GTED, General triage emergency department; IQR, interquartile range; IV, intravenous; PTED, pediatric triage emergency department.
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TABLE 3
Comfort with pain management protocol tools Tool
Ice packs Acetaminophen Ibuprofen Codeine Oral morphine Oxycodone IV morphine Splinting Distraction Intranasal analgesics
P value
Median (IQR), mm PTED A (n = 24)
PTED B (n = 27)
GTED (n = 74)
All (n = 125)
93 94 95 89 89 51 67 96 86 61
98 98 98 58 67 33 11 97 90 25
96 97 97 75 62 64 20 90 94 32
96 97 97 75 67 57 17 93 93 36
(89-97) (89-98) (90-99) (70-95) (67-95) (14-77) (15-87) (89-99) (68-98) (16-93)
(93-100) (90-99) (89-100) (10-90) (23-94) (6-65) (1-17) (92-100) (69-97) (7-52)
(93-99) (94-100) (93-100) (49-96) (26-83) (31-89) (5-52) (67-97) (78-99) (13-81)
(91-99) (92-99) (93-100) (48-95) (35-94) (15-81) (6-57) (77-99) (75-98) (13-75)
.053 .189 .216 .054 .016 .009 .003 .001 .330 .051
Responses were measured via a 100-mm visual analog scale, where 0 indicates “not at all” and 100 indicates “very comfortable.” GTED, General triage emergency department; IQR, interquartile range; IV, intravenous; PTED, pediatric triage emergency department.
Triage nurses’ attitude toward feasibility and comfort with several pain management protocol tools are presented in Tables 2 and 3, respectively. More years of pediatric, triage, and overall nursing experience were associated with increased comfort with splinting (P = .001, P b .001, and P = .004, respectively). More years of pediatric and overall nursing experience were associated with increased comfort with distraction tools (P = .03 for both). Nurses were asked their opinions on the maximum acceptable delay between time of triage and administration of analgesia. The results are shown in the Figure. Male nurses accepted longer time delays for children with mild pain (P = .003), but no other sex-based associations were significant. More years of triage and overall nursing experience were associated with decreased acceptable time delays for children with mild and moderate pain (P b .001 for all) but not severe pain. More years of pediatric nursing experience were associated with decreased acceptable time delays for children with mild, moderate, and severe pain (P b .001, P b .001, and P = .02, respectively). Table 4 reports nurses’ opinions regarding adequacy of pain treatment and willingness to implement a triage-initiated pain protocol. Overall, their willingness to implement a pain protocol at triage was high (81 mm; IQR, 71-96 mm). The top 3 reported barriers to triage-initiated pain protocols were monitoring capability, time, and access to medications. The top 3 facilitators were other nurses, own comfort level, and physician colleagues (Table 5).
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Discussion
Our survey identified that the care of children’s pain at pediatric ED triage is not consistent and that there is room for improvement in the training of triage nurses regarding pain management, specifically in the assessment and treatment of very young children. There was wide variability in comfort with, and feasibility of, using various proposed pharmacologic tools at triage. GTED nurses accepted longer treatment delays, and respondents believed that children’s pain was treated less favorably than at PTED centers. This study suggests that Canadian pediatric emergency departments may benefit from pediatric-only triage and the development of triageinitiated pain protocols. Across the 3 study sites, the comfort with the use of triage-initiated pain protocols varied widely despite evidence that triage-initiated pain protocols decrease the time to analgesia and increase the number of children who receive analgesia in the emergency department. 15,16,20 Such triage-initiated protocols have also been shown to improve parental satisfaction and increase nurse autonomy while improving nurse-physician collegiality. 16 The results of our study suggest that triage pain treatment is variable and likely suboptimal across one western, one eastern, and one central Canadian pediatric emergency department. This crossCanadian sampling suggests that united efforts, perhaps at a national advocacy level, should be made to rectify this lack of consistency in approach to children’s pain.
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70 60
Minutes
50 40
PTED 'A' PTED 'B'
30
GTED
20 10 0 Severe Pain
Moderate Pain
Mild Pain
FIGURE Acceptable delay from time of triage to time of analgesic administration. P b .002 for all site-to-site comparisons. GTED, General triage emergency department; PTED, pediatric triage emergency department.
Our study identified a need for increased training and education of triage nurses in pediatric pain assessment and management. Boyd and Stuart 15 found that education alone was not enough to change care but that nurses being able to implement a protocol created a sense of empowerment that significantly increased the rate of analgesia, as well as decreased the time to analgesia. ED administrators must support pediatric triage systems regarding both their educational needs and implementation of protocols. Our study showed a correlation between more years of nursing experience and an increased comfort with providing non-pharmacologic analgesia, such as distraction techniques and splinting. This finding suggests that although pharmaceutical modalities are taught in nursing school, non-pharmacologic techniques might be learned “on the job.” We, and other authors, suggest that non-pharmacologic pain treatment deserves more emphasis in nursing education. 23 Very young children have long been recognized as an at-risk group for under-treatment of pain. 24–26 When one is
designing a triage-initiated pain protocol, special attention should be drawn to patients aged younger than 2 years, as well as the use of age-appropriate validated pain assessment tools. In our study the GTED nurses accepted longer delays in the initiation of pain treatment and believed that pain was treated less effectively at triage than nurses from PTED centers. These discrepancies may stem from the nature of illnesses seen in adult and pediatric patients; adults may be presenting to the emergency department with acute coronary syndromes that are extremely time-sensitive, rendering a crying child with an attentive parent to a less emergent status. Pediatric pain researchers have recently urged us to think about untreated pain as an adverse event, 27 and although children often have fewer painful life experiences than adults, their pain deserves to be treated in a timely fashion. To mitigate these differences in triage practices that may influence analgesia provision, as well as to ensure that children are not competing with adults for attention and treatment, pediatric emergency departments might benefit from their own dedicated triage process. Barriers to consider when implementing a triageinitiated pain protocol include monitoring capability, time, and access to medications. Suggested strategies to address some of these barriers from other published protocols include allowing only a limited number of oral analgesics and designing protocols that are easy to follow. 15–17 Nurses also rated protocol-specific training very highly, and this type of training should be an essential part of any protocol implementation.
Limitations
The study respondents were from only 3 emergency departments across Canada. Despite a limited number of study sites, we believe that the results are generalizable to other
TABLE 4
Nurses’ perceptions regarding pain treatment in emergency department P value
Median (IQR), mm PTED A (n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)
Adequacy of pain management in emergency department Adequacy of pain management at triage Timeliness to pain treatment in emergency department Ability to treat pain at triage Willingness to implement triage pain protocol Importance of protocol-specific training
73 62 71 72 88 91
(64-81) (50-67) (64-79) (58-79) (76-97) (77-96)
75 71 66 75 85 88
(65-87) (52-77) (60-82) (58-86) (71-92) (71-96)
75 29 65 37 88 91
(63-83) (15-50) (49-73) (25-54) (70-97) (81-96)
75 48 66 53 87 90
(65-83) .878 (26-66) b .001 (54-76) .044 (30-72) b .001 (71-96) .539 (79-96) .468
Responses were measured via a 100-mm visual analog scale, where 0 indicates “unacceptably poor” and 100 indicates “excellent,” “very willing,” or “very important.” GTED, General triage emergency department; IQR, interquartile range; PTED, pediatric triage emergency department.
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TABLE 5
Perceived barriers and facilitators to triage-initiated pain protocol implementation (n = 125 respondents, multiple responses permitted) n (%)
Barriers Monitoring capability Time Access to medications Physicians Space Administrators Other nurses Own comfort level Own knowledge Other Facilitators Other nurses Own comfort level Physicians Own knowledge Access to medications Time Administrators Space Monitoring capability Other
98 92 83 47 45 28 24 14 3 23
(78) (74) (66) (38) (36) (22) (19) (11) (2) (18)
62 59 58 57 49 22 15 14 13 15
(50) (47) (46) (46) (39) (18) (12) (11) (10) (12)
Canadian pediatric emergency departments because of the high response rate and sampling from 3 different regions of Canada (west, central, and east). Study respondent demographic characteristics were also different among sites regarding reported amount of triage experience and pediatric nursing experience. The pediatric-only triage centers had nurses with more experience in both areas; however, we do not believe that this explains all survey response differences because not all responses varied with level of experience. Surveys are inherently limited by recall bias, although this would affect only the reports of nursing experience and training background and not the willingness to implement protocols or personal comfort with various analgesic agents.
Conclusions
Triage-initiated pain protocols have been shown to decrease the time to analgesia and increase the rate of analgesia provision to children with pain. Through our survey, we have found that triage nurses are willing and able to implement triage pain protocols and have identified monitoring capability, time, and access to medications as barriers to doing so. We have also shown that children presenting to pediatric emergency departments with pediatric-only triage appear to have access to triage nurses with more comfort treating them; general triage emergency departments may benefit from more educational initiatives to support triage nurses, who are highly interested in treating children’s pain but may lack experience, training, and comfort in doing so. Acknowledgment
We thank our administrative assistant Ms Melissa Gutland, who helped with study implementation; the Clinical Research Informatics Core for data entry; and Mr Hitesh Bhatt for statistical support.
REFERENCES 1. World Health Organization. WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. http:// whqlibdoc.who.int/publications/2012/9789241548120_Guidelines. pdf. [Published 2012. Accessed February 9, 2015]. 2. Grunau RE. Self-regulation and behavior in preterm children: effects of early pain. In: McGrath PJ, Finley GA, (eds.), Pediatric Pain: Biological and Social Context, Progress in Pain Research and Management Seattle, WA: ; 2003:23-55.
Implications for Emergency Nurses
For triage nurses, our results may contribute to improved pain treatment for pediatric patients by conveying to
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administrators, other nurses, and physicians that triageinitiated pain protocols are both feasible and desired by pediatric ED triage nurses. When designing and using triage-initiated pain protocols, emergency nurses should be especially aware of the challenges of assessing pain in children aged younger than 2 years, as well as the importance of using age-appropriate validated pain assessment tools. This study may promote the involvement of triage nurses with the development of protocols at their own institutions and further empower triage nurses to embrace active treatment of children’s pain at the most appropriate point of contact within the emergency department, namely at the time of triage.
3. Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior?. Biol Neonate. 2000;77:69-82.
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4. Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Child Health Care. 1996;25:281-298.
16. Campbell P, Dennie M, Dougherty K, et al. Implementation of an ED protocol for pain management at triage at a busy Level I trauma center. J Emerg Nurs. 2004;30(5):431-438.
5. Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998;152:147-149.
17. Fosnocht DE, Swanson ER. Use of a triage pain protocol in the ED. Am J Emerg Med. 2007;25(7):791-793.
6. Cordell WH, Keene KK, Giles BK, et al. The high prevalence of pain in emergency medicine care. Am J Emerg Med. 2002;20(3)165-169. 7. Johnston CC, Bourniaki M, Gagnon AJ, Pepler CJ, Bourgault P. Self reported pain intensity and associated distress in children aged 4-18 years on admission, discharge, and one-week follow up to emergency department. Pediatr Emerg Care. 2005;21(5):342-346.
18. Fry M, Holdgate A. Nurse-initiated intravenous morphine in the emergency department: efficacy, rate of adverse events and impact on time to analgesia. Emerg Med. 2002;14:249-254. 19. Goh HK, Choo SE, Lee I, et al. Emergency department triage nurse initiated pain management. Hong Kong J Emerg Med. 2007;14(1): 16-21.
8. Verghese S, Hannallah R. Acute pain management in children. J Pain Res. 2010;3:105-123.
20. Eisen S, Amiel K. Introduction of a paediatric pain management protocol improves assessment and management of pain in children in the emergency department. Arch Dis Child. 2007;92(9):828-829.
9. Augarten A, Zaslansky R, Pharm IM, et al. The impact of educational intervention programs on pain management in a pediatric emergency department. Biomed Pharmacother. 2006;60:299-302.
21. Dillman DA, Smyth JD, Christian LM. Internet, Mail, and MixedMode Surveys: The Tailored Design Method, Hoboken, NJ: John Wiley & Sons; 2009.
10. Todd KH, Ducharme J, Choiniere M, et al. Pain in the emergency department: results of the pain and emergency medicine initiative (PEMI) multicenter study. J Pain. 2007;8(6):460-466.
22. Burns KEA, Duffett M, Kho ME, et al. A guide for the design and conduct of self-administered surveys of clinicians. CMAJ. 2008;179(3):245-252.
11. Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am J Emerg Med. 1989;7(6):620-623.
23. Coyne ML, Reinert B, Cater K, et al. Nurses’ knowledge of pain assessment, pharmacologic and nonpharmacologic interventions. Clin Nurs Res. 1999;8(2):153-265.
12. Bible D. Pain assessment at nurse triage: a literature review. Emerg Nurse. 2006;14(3):26-29.
24. Brown JC, Klein EJ, Lewis CW, et al. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197-205.
13. Charney RL, Yan Y, Schootman M, et al. Oxycodone versus codeine for triage pain in children with suspected forearm fracture: a randomized controlled trial. Pediatr Emerg Care. 2008;24(9):595-600.
25. Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med. 2003;41(5):617-622.
14. Teanby S. A literature review into pain assessment at triage in accident and emergency departments. Accid Emerg Nurs. 2003;11(1):12-17.
26. Dong L, Donaldson A, Metzger R, et al. Analgesic administration in the emergency department for children requiring hospitalization for longbone fracture. Pediatr Emerg Care. 2012;28(2):109-114.
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27. Chorney JM, McGrath P, Finley GA. Pain as the neglected adverse event. CMAJ. 2010;182(7):732.
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