Pediatric Pain Management in the Emergency Department: The Triage Nurses' Perspective

R E S E A R C H

Daina Thomof Medicine

JanevaKircheFaculty of Me

Amy C. PlinEmergencyOntario, Ca

Eleanor FitzpFaculty of M

Amanda S. NFaculty ofMeHealth Resea

Rhonda J.Pediatrics, Faand Children

SimranGrewof Pediatrics,

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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 ofpain management is essential for timely pain care for childrenin the emergency department. Objectives of this study were todescribe the triage pain treatment protocols used, knowledge ofpain management modalities, and barriers and attitudestowards implementation of pain treatment protocols.

Methods: A paper-based survey was administered to alltriage nurses at three Canadian pediatric emergency depart-ments, between December 2011 and January 2012.

Results: The response rate was 86% (n=126/147). The meanrespondent age was 40 years (standard deviation [SD] 9.3) with8.6 years (SD 7.7) of triage experience. General triageemergency department (GTED) nurses rated adequacy of triagepain treatment lower than pediatric-only triage emergencydepartment (PTED) nurses (P b .001). GTED nurses reported alonger acceptable delay between triage time and administra-tion of analgesia than PTED nurses (P b .002). Most nurses

as, is Pediatric Emergency Physician Department of Pediatrics, Faculty& Dentistry, University of Alberta, Edmonton, Alberta, Canada.

r, is EmergencyMedicineResidentDepartment of EmergencyMedicine,dicine &Dentistry, University of Alberta, Edmonton, Alberta, Canada.

t, is Pediatric Emergency Physician Department of Pediatrics andMedicine, Faculty of Medicine, University of Ottawa, Ottawa,nada.

atrick, is Research Coordinator Department of EmergencyMedicine,edicine, Dalhousie University, Halifax, Nova Scotia, Canada.

ewton, is Associate Professor (Pediatrics) Department of Pediatrics,dicine&Dentistry, University of Alberta, andWomen andChildren’srch Institute, Edmonton, Alberta, Canada.

Rosychuk, Professor (Pediatrics) and Statistician Department ofculty of Medicine & Dentistry, University of Alberta, and Women’s Health Research Institute, Edmonton, Alberta, Canada.

al, is Divisional Director Division of Pediatric Emergency, DepartmentUniversity of BritishColumbia, Vancouver, British Columbia, Canada.

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rated more comfort with a protocol involving administration ofacetaminophen (97mm, interquartile range [IQR] 92, 99) oribuprofen (97mm, IQR 93, 100) than for oral morphine (67mm,IQR 35, 94) or oxycodone (57mm, IQR 15, 81). The top threereported barriers to triage-initiated pain protocols weremonitoring capability, time, and access to medications.Willingness to implement a triage-initiated pain protocol wasrated as 81mm (IQR 71, 96).

Discussion: Triage nurses are willing to implement painprotocols for children in the emergency department, butdifferences in comfort and experience exist between PTEDand GTED nurses. Provision of triage initiated pain protocolsand associated education may empower nurses to improvecare for children in pain in the emergency department.

Key words: Triage; Pediatrics; Pain; Protocol; Analgesia;Emergency department

The World Health Organization has declared thatpediatric pain treatment is a public health concernof major significance.1 Studies indicate that

inadequate pain management during medical care can

have numerous detrimental effects, including an extendedlength of stay, slower healing, and emotional trauma andsuffering.2–5 Furthermore, negative effects may extend intoadulthood and can include fear of medical events or health

Samina Ali, is Pediatric Emergency Physician Departments of Pediatrics andEmergency Medicine, Faculty of Medicine & Dentistry, University ofAlberta, 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. DrRosychuk is salary supported by Alberta Innovates–Health Solutions (Edmonton,Alberta, Canada) as a Health Scholar. Dr Newton is salary supported by theCanadian Institutes of Health Research. Dr Plint holds a University of OttawaFaculty 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, CanadaAB T6G 1C9; E-mail: [email protected] Emerg Nurs ■.0099-1767

Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.http://dx.doi.org/10.1016/j.jen.2015.02.012

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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 mayhave pain from an underlying illness or injury, as well asfrom necessary medical procedures such as venipuncture orfracture reduction.8,9 A large multicenter study found thatonly 60% of patients with moderate to severe pain receiveany analgesia in the emergency department.10 Unfortunately,oligoanalgesia (under-treatment of pain) remains a well-documented problem in the ED setting.11

Triage has been recognized as a site to effect largeimprovements in overall pain treatment in the emergencydepartment.12 The assessment of pain and provision ofanalgesia early in a patient’s stay are key to decreasing the painexperienced within the emergency department and improvingpatient satisfaction.12–14 Several centers have implementedpain protocols that allow for triage nurse–initiated analgesia.Studies of these centers have found statistically significantimprovements in overall analgesia provision, time to analgesia,and patient satisfaction.15–20

Understanding and considering triage nurses’ perspectivescomprise a vital step when planning the implementation of anew nursing initiative. By understanding their perspectives, wecan then ensure triage nurse buy-in and participation whenactualizing a new pain protocol.16,17 The objectives of thisstudy were to describe comfort with triage pain treatmentprotocols used, knowledge of pain management modalities,and perceived barriers and attitudes toward implementation ofpain treatment protocols at triage.

Methods

STUDY DESIGN

This study was a descriptive, cross-sectional survey of all triagenurses at 3 Canadian pediatric emergency departments—2emergency departments with pediatric-only triage and 1emergency department with combined pediatric and adulttriage. The site with combined pediatric and adult triage has astand-alone pediatric emergency department served by ashared triage. A paper-based survey was administered on 2occasions from December 2011 to January 2012.21

ETHICS APPROVAL

This study was approved by the research ethics board at eachparticipating site prior to its implementation. This processincluded approval for the novel survey tool and studymethodology, as well as the distribution of gift cards toparticipants. An information letter was included at the start of

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each survey, and consent was implied by completion ofthe survey.

SELECTION OF PARTICIPANTS

Participants were recruited from the emergency departmentsat the Stollery Children’s Hospital (SCH, Edmonton,Alberta, Canada), IWK Health Centre (IWK, Halifax,Nova Scotia, Canada), and Children’s Hospital of EasternOntario (CHEO, Ottawa, Ontario, Canada). In 2011 theannual pediatric census was 29,197 for the SCH emergencydepartment; 28,000 for IWK; and 65,949 for CHEO. At thetime of survey administration, there were 147 triage nurses(87 at SCH, 28 at IWK, and 32 at CHEO) eligible forparticipation in our study.

METHODS OF MEASUREMENT

A novel survey tool was developed in accordance withpublished guidelines.22 An expert panel—with representationfrom pediatrics, emergency medicine, and nursing—informedsurvey development by participating in the item generation andreduction phases, as well as ensuring face and content validity.The survey was piloted with a group of 6 nurses to furtherensure face and content validity, as well as sensibility.22

Completion of the survey required approximately 10minutes. Participants were asked questions regarding theirdemographic characteristics (eg, age, sex, and training) andexperience with pain protocols andmanagement of pain; theyalso rated their comfort with, and feasibility of, providingvarious pharmacologic and non-pharmacologic pain treat-ments. Respondents were asked about their willingness toimplement a triage-initiated pain protocol, as well asperceived barriers and facilitators. Respondents received anominal ($10) coffee gift card.

Responses were entered into an electronic database bya trained data entry clerk, and 20% of these were verified bythe study coordinator to ensure accurate data entry. Theprimary site for data storage and analysis was theDepartment 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) andfrequencies and proportions to describe categorical data(eg, sex). One-way analysis of variance and the Kruskal-Wallistest were used to compare means among the 3 emergencydepartments for normally distributed and skewed continuousdata, respectively. To compare categorical responses amongthe 3 emergency departments,χ2 tests (or Fisher exact tests in

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TABLE 1Respondent demographic data

PTED A (n = 24) PTED B (n = 27) GTED (n = 75) Total (N = 126) P value

Male sex, n (%) 0 (0) 4 (17) 19 (25) 23 (18) .009Age, mean (SD), y 43 (9) 43 (10) 38 (8) 40 (9) .007Nursing experience, mean (SD), y 21 (9) 18 (11) 14 (9) 14 (10) .006Pediatric nursing experience, mean (SD), y 19 (9) 16 (10) 11 (8) 13 (9) b .001Triage experience, mean (SD), y 11 (9) 10 (7) 7 (7) 9 (8) .047

GTED, General triage emergency department; PTED, pediatric triage emergency department.

Thomas et al/RESEARCH

the case of small cell counts for responses to individualquestions) were used. Statistical analyses were performed withSAS 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 withgeneral (combined pediatric and adult) triage (GTED) and40% (n = 51) were from the 2 emergency departments withpediatric-only triage (PTED A and PTED B). Respondentdemographic data are shown in Table 1.

EXPERIENCE

Sixty-seven percent of nurses (n = 84) reported receivingtraining on triage pain assessment, with a median duration of

TABLE 2Feasibility of implementing pain management protocol tool

Tool Median (IQR), mm

PTED A (n = 24) PTED B (n = 2

Ice packs 94 (90-97) 89 (72-97)Acetaminophen 95 (92-98) 96 (91-100)Ibuprofen 92 (89-97) 97 (91-99)Codeine 79 (61-95) 16 (2-47)Oral morphine 85 (58-93) 47 (11-60)Oxycodone 59 (15-82) 12 (1-48)IV morphine 40 (17-62) 8 (1-13)Splinting 92 (87-96) 92 (81-97)Distraction 66 (45-91) 72 (57-95)Intranasal analgesics 47 (13-82) 8 (2-51)

Responses were measured via a 100-mm visual analog scale, where 0 indicates “not at all” and 100 indicaGTED, General triage emergency department; IQR, interquartile range; IV, intravenous; PTED, pe

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8 hours (IQR, 8-16 hours; P = .19); 74% of nurses (n = 93)reported receiving training specifically on pain measurementtools, with no evidence of a statistically significant differenceamong sites (P = .26). Fifty-six percent of all triage nurses (n =70) reported receiving training specifically on pain manage-ment 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) hadexperience 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 moreaccurate in their reporting of pain (45 mm [IQR, 25-62mm] for a 3-year-old, P = .77; 70 mm [IQR, 55-83 mm] foran 8-year-old, P = .57; and 82 mm [IQR, 74-95 mm] for a16-year-old, P = .63) as measured on a 100-mm visualanalog scale, and this did not differ among sites.

s

P value

7) GTED (n = 74) All (n = 125)

96 (91-99) 94 (88-98) .03196 (92-99) 96 (92-99) .49896 (93-99) 96 (91-99) .20857 (30-85) 56 (22-90) b .00149 (19-76) 53 (24-88) .00353 (15-81) 47 (12-77) b .00113 (5-38) 13 (4-42) b .00185 (63-97) 91 (76-96) .07081 (53-95) 75 (49-94) .43032 (11-63) 27 (8-65) .008

tes “very feasible.”diatric triage emergency department.

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TABLE 3Comfort with pain management protocol tools

Tool Median (IQR), mm P value

PTED A (n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)

Ice packs 93 (89-97) 98 (93-100) 96 (93-99) 96 (91-99) .053Acetaminophen 94 (89-98) 98 (90-99) 97 (94-100) 97 (92-99) .189Ibuprofen 95 (90-99) 98 (89-100) 97 (93-100) 97 (93-100) .216Codeine 89 (70-95) 58 (10-90) 75 (49-96) 75 (48-95) .054Oral morphine 89 (67-95) 67 (23-94) 62 (26-83) 67 (35-94) .016Oxycodone 51 (14-77) 33 (6-65) 64 (31-89) 57 (15-81) .009IV morphine 67 (15-87) 11 (1-17) 20 (5-52) 17 (6-57) .003Splinting 96 (89-99) 97 (92-100) 90 (67-97) 93 (77-99) .001Distraction 86 (68-98) 90 (69-97) 94 (78-99) 93 (75-98) .330Intranasal analgesics 61 (16-93) 25 (7-52) 32 (13-81) 36 (13-75) .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.

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Triage nurses’ attitude toward feasibility and comfortwith several pain management protocol tools are presentedin Tables 2 and 3, respectively. More years of pediatric,triage, and overall nursing experience were associated withincreased comfort with splinting (P = .001, P b .001, andP = .004, respectively). More years of pediatric and overallnursing experience were associated with increased comfortwith distraction tools (P = .03 for both).

Nurses were asked their opinions on the maximumacceptable delay between time of triage and administra-tion of analgesia. The results are shown in the Figure.Male nurses accepted longer time delays for children withmild pain (P = .003), but no other sex-based associationswere significant. More years of triage and overall nursingexperience were associated with decreased acceptable timedelays for children with mild and moderate pain (P b .001for all) but not severe pain. More years of pediatric nursingexperience were associated with decreased acceptable timedelays for children with mild, moderate, and severe pain(P b .001, P b .001, and P = .02, respectively).

Table 4 reports nurses’ opinions regarding adequacyof pain treatment and willingness to implement atriage-initiated pain protocol. Overall, their willingnessto implement a pain protocol at triage was high (81 mm;IQR, 71-96 mm). The top 3 reported barriers totriage-initiated pain protocols were monitoring capability,time, and access to medications. The top 3 facilitatorswere other nurses, own comfort level, and physiciancolleagues (Table 5).

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Discussion

Our survey identified that the care of children’s pain atpediatric ED triage is not consistent and that there isroom for improvement in the training of triage nursesregarding pain management, specifically in the assessmentand treatment of very young children. There was widevariability in comfort with, and feasibility of, using variousproposed pharmacologic tools at triage. GTED nursesaccepted longer treatment delays, and respondentsbelieved that children’s pain was treated less favorablythan at PTED centers. This study suggests that Canadianpediatric emergency departments may benefit frompediatric-only triage and the development of triage-initiated pain protocols.

Across the 3 study sites, the comfort with the use oftriage-initiated pain protocols varied widely despite evi-dence that triage-initiated pain protocols decrease the timeto analgesia and increase the number of children whoreceive analgesia in the emergency department.15,16,20 Suchtriage-initiated protocols have also been shown to improveparental satisfaction and increase nurse autonomy whileimproving nurse-physician collegiality.16 The results of ourstudy suggest that triage pain treatment is variable and likelysuboptimal across one western, one eastern, and one centralCanadian pediatric emergency department. This cross-Canadian sampling suggests that united efforts, perhaps at anational advocacy level, should be made to rectify this lackof consistency in approach to children’s pain.

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0

10

20

30

40

50

60

70

Severe Pain Moderate Pain Mild Pain

Min

utes

PTED 'A'

PTED 'B'

GTED

FIGURE

Acceptable delay from time of triage to time of analgesic administration. P b .002for all site-to-site comparisons. GTED, General triage emergency departmentPTED, pediatric triage emergency department.

TABLE 4Nurses’ perceptions regarding pain treatment in emerg

M

PT

Adequacy of pain management in emergency department 73Adequacy of pain management at triage 62Timeliness to pain treatment in emergency department 71Ability to treat pain at triage 72Willingness to implement triage pain protocol 88Importance of protocol-specific training 91

Responses were measured via a 100-mm visual analog scale, where 0 indicates “unacceptably poGTED, General triage emergency department; IQR, interquartile range; PTED, pediatric t

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Master Proo

;

Our study identified a need for increased training andeducation of triage nurses in pediatric pain assessment andmanagement. Boyd and Stuart15 found that educationalone was not enough to change care but that nurses beingable to implement a protocol created a sense of empower-ment that significantly increased the rate of analgesia, as wellas decreased the time to analgesia. ED administrators mustsupport pediatric triage systems regarding both theireducational needs and implementation of protocols.

Our study showed a correlation between more years ofnursing experience and an increased comfort with providingnon-pharmacologic analgesia, such as distraction techniquesand splinting. This finding suggests that although pharmaceu-ticalmodalities are taught in nursing school, non-pharmacologictechniques might be learned “on the job.” We, and otherauthors, suggest that non-pharmacologic pain treatmentdeserves more emphasis in nursing education.23

Very young children have long been recognized as anat-risk group for under-treatment of pain.24–26 When one is

ency

edian

ED A

(64-8(50-6(64-7(58-7(76-9(77-9

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designing a triage-initiated pain protocol, special attentionshould be drawn to patients aged younger than 2 years, as wellas the use of age-appropriate validated pain assessment tools.

In our study the GTED nurses accepted longer delays inthe initiation of pain treatment and believed that pain wastreated less effectively at triage than nurses from PTED centers.These discrepancies may stem from the nature of illnesses seenin adult and pediatric patients; adults may be presenting to theemergency department with acute coronary syndromes that areextremely time-sensitive, rendering a crying child with anattentive parent to a less emergent status. Pediatric painresearchers have recently urged us to think about untreatedpain as an adverse event,27 and although children often havefewer painful life experiences than adults, their pain deserves tobe treated in a timely fashion. To mitigate these differences intriage practices thatmay influence analgesia provision, as well asto ensure that children are not competing with adults forattention and treatment, pediatric emergency departmentsmight benefit from their own dedicated triage process.

Barriers to consider when implementing a triage-initiated pain protocol include monitoring capability,time, and access to medications. Suggested strategies toaddress some of these barriers from other publishedprotocols include allowing only a limited number of oralanalgesics and designing protocols that are easy tofollow.15–17 Nurses also rated protocol-specific trainingvery highly, and this type of training should be an essentialpart of any protocol implementation.

Limitations

The study respondents were from only 3 emergencydepartments across Canada. Despite a limited number ofstudy sites, we believe that the results are generalizable to other

department

(IQR), mm P value

(n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)

1) 75 (65-87) 75 (63-83) 75 (65-83) .8787) 71 (52-77) 29 (15-50) 48 (26-66) b .0019) 66 (60-82) 65 (49-73) 66 (54-76) .0449) 75 (58-86) 37 (25-54) 53 (30-72) b .0017) 85 (71-92) 88 (70-97) 87 (71-96) .5396) 88 (71-96) 91 (81-96) 90 (79-96) .468

00 indicates “excellent,” “very willing,” or “very important.”rgency department.

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TABLE 5Perceived barriers and facilitators to triage-initiatedpain protocol implementation (n = 125 respondents,multiple responses permitted)

n (%)

BarriersMonitoring capability 98 (78)Time 92 (74)Access to medications 83 (66)Physicians 47 (38)Space 45 (36)Administrators 28 (22)Other nurses 24 (19)Own comfort level 14 (11)Own knowledge 3 (2)Other 23 (18)

FacilitatorsOther nurses 62 (50)Own comfort level 59 (47)Physicians 58 (46)Own knowledge 57 (46)Access to medications 49 (39)Time 22 (18)Administrators 15 (12)Space 14 (11)Monitoring capability 13 (10)Other 15 (12)

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Canadian pediatric emergency departments because of the highresponse rate and sampling from 3 different regions of Canada(west, central, and east). Study respondent demographiccharacteristics were also different among sites regardingreported amount of triage experience and pediatric nursingexperience. The pediatric-only triage centers had nurses withmore experience in both areas; however, we do not believe thatthis explains all survey response differences because not allresponses varied with level of experience. Surveys are inherentlylimited by recall bias, although this would affect only thereports of nursing experience and training background and notthe willingness to implement protocols or personal comfortwith various analgesic agents.

Implications for Emergency Nurses

For triage nurses, our results may contribute to improvedpain treatment for pediatric patients by conveying to

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administrators, other nurses, and physicians that triage-initiated pain protocols are both feasible and desired bypediatric ED triage nurses. When designing and usingtriage-initiated pain protocols, emergency nurses should beespecially aware of the challenges of assessing pain inchildren aged younger than 2 years, as well as the importance ofusing age-appropriate validated pain assessment tools. Thisstudy may promote the involvement of triage nurses with thedevelopment of protocols at their own institutions and furtherempower triage nurses to embrace active treatment of children’spain at the most appropriate point of contact within theemergency department, namely at the time of triage.

Conclusions

Triage-initiated pain protocols have been shown todecrease the time to analgesia and increase the rate ofanalgesia provision to children with pain. Through oursurvey, we have found that triage nurses are willing and ableto implement triage pain protocols and have identifiedmonitoring capability, time, and access to medications asbarriers to doing so. We have also shown that childrenpresenting to pediatric emergency departments withpediatric-only triage appear to have access to triage nurseswith more comfort treating them; general triage emergencydepartments may benefit from more educational initiativesto support triage nurses, who are highly interested intreating 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 ClinicalResearch Informatics Core for data entry; and Mr HiteshBhatt for statistical support.

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