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 depart-
ments, between December 2011 and January 2012.
Results: The response rate was 86% (n=126/147). The mean
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 administra-
tion of analgesia than PTED nurses (P b .002). Most nurses
he World Health Organization has declared that
T pediatric pain treatment is a public health concern
of major significance. 1 Studies indicate that
inadequate pain management during medical care can
Daina Thomas, is Pediatric Emergency Physician Department of Pediatrics, Faculty
of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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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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.
Key words: Triage; Pediatrics; Pain; Protocol; Analgesia;
Emergency department
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
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: sali@ualberta.ca.
J 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
WWW.JENONLINE.ORG 1
RESEARCH/Thomas et al
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 well-
documented 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 treat-
ments. 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
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) .009
Age, mean (SD), y 43 (9) 43 (10) 38 (8) 40 (9) .007
Nursing experience, mean (SD), y 21 (9) 18 (11) 14 (9) 14 (10) .006
Pediatric nursing experience, mean (SD), y 19 (9) 16 (10) 11 (8) 13 (9) b .001
Triage experience, mean (SD), y 11 (9) 10 (7) 7 (7) 9 (8) .047

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 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) 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 Median (IQR), mm P value
PTED A (n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)
Ice packs 94 (90-97) 89 (72-97) 96 (91-99) 94 (88-98) .031
Acetaminophen 95 (92-98) 96 (91-100) 96 (92-99) 96 (92-99) .498
Ibuprofen 92 (89-97) 97 (91-99) 96 (93-99) 96 (91-99) .208
Codeine 79 (61-95) 16 (2-47) 57 (30-85) 56 (22-90) b .001
Oral morphine 85 (58-93) 47 (11-60) 49 (19-76) 53 (24-88) .003
Oxycodone 59 (15-82) 12 (1-48) 53 (15-81) 47 (12-77) b .001
IV morphine 40 (17-62) 8 (1-13) 13 (5-38) 13 (4-42) b .001
Splinting 92 (87-96) 92 (81-97) 85 (63-97) 91 (76-96) .070
Distraction 66 (45-91) 72 (57-95) 81 (53-95) 75 (49-94) .430
Intranasal analgesics 47 (13-82) 8 (2-51) 32 (11-63) 27 (8-65) .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 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) .053
Acetaminophen 94 (89-98) 98 (90-99) 97 (94-100) 97 (92-99) .189
Ibuprofen 95 (90-99) 98 (89-100) 97 (93-100) 97 (93-100) .216
Codeine 89 (70-95) 58 (10-90) 75 (49-96) 75 (48-95) .054
Oral morphine 89 (67-95) 67 (23-94) 62 (26-83) 67 (35-94) .016
Oxycodone 51 (14-77) 33 (6-65) 64 (31-89) 57 (15-81) .009
IV morphine 67 (15-87) 11 (1-17) 20 (5-52) 17 (6-57) .003
Splinting 96 (89-99) 97 (92-100) 90 (67-97) 93 (77-99) .001
Distraction 86 (68-98) 90 (69-97) 94 (78-99) 93 (75-98) .330
Intranasal 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.

Triage nurses’ attitude toward feasibility and comfort Discussion

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 administra-
tion 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).
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 triage-
initiated pain protocols.
Across the 3 study sites, the comfort with the use of
triage-initiated pain protocols varied widely despite evi-
dence 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 cross-
Canadian 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
designing a triage-initiated pain protocol, special attention
60 should be drawn to patients aged younger than 2 years, as well
50
as the use of age-appropriate validated pain assessment tools.
In our study the GTED nurses accepted longer delays in
Minutes

40
30
20
10
0 extremely time-sensitive, rendering a crying child with an
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 empower-
ment 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 pharmaceu-
tical 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
PTED 'A' the initiation of pain treatment and believed that pain was
PTED 'B'
GTED
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
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 triage-
initiated 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
Median (IQR), mm P value
PTED A (n = 24) PTED B (n = 27) GTED (n = 74) All (n = 125)
Adequacy of pain management in emergency department 73 (64-81) 75 (65-87) 75 (63-83) 75 (65-83) .878
Adequacy of pain management at triage 62 (50-67) 71 (52-77) 29 (15-50) 48 (26-66) b .001
Timeliness to pain treatment in emergency department 71 (64-79) 66 (60-82) 65 (49-73) 66 (54-76) .044
Ability to treat pain at triage 72 (58-79) 75 (58-86) 37 (25-54) 53 (30-72) b .001
Willingness to implement triage pain protocol 88 (76-97) 85 (71-92) 88 (70-97) 87 (71-96) .539
Importance of protocol-specific training 91 (77-96) 88 (71-96) 91 (81-96) 90 (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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administrators, other nurses, and physicians that triage-

TABLE 5
initiated pain protocols are both feasible and desired by
Perceived barriers and facilitators to triage-initiated
pediatric ED triage nurses. When designing and using
pain protocol implementation (n = 125 respondents,
triage-initiated pain protocols, emergency nurses should be
multiple responses permitted)
especially aware of the challenges of assessing pain in
n (%) children aged younger than 2 years, as well as the importance of
Barriers using age-appropriate validated pain assessment tools. This
Monitoring capability 98 (78) study may promote the involvement of triage nurses with the
Time 92 (74) development of protocols at their own institutions and further
Access to medications 83 (66) empower triage nurses to embrace active treatment of children’s
Physicians 47 (38) pain at the most appropriate point of contact within the
emergency department, namely at the time of triage.
Space 45 (36)
Administrators 28 (22)
Other nurses 24 (19)
Own comfort level 14 (11) Conclusions
Own knowledge 3 (2)
Triage-initiated pain protocols have been shown to
Other 23 (18)
decrease the time to analgesia and increase the rate of
Facilitators
analgesia provision to children with pain. Through our
Other nurses 62 (50) survey, we have found that triage nurses are willing and able
Own comfort level 59 (47) to implement triage pain protocols and have identified
Physicians 58 (46) monitoring capability, time, and access to medications as
Own knowledge 57 (46) barriers to doing so. We have also shown that children
Access to medications 49 (39) presenting to pediatric emergency departments with
Time 22 (18) pediatric-only triage appear to have access to triage nurses
Administrators 15 (12) with more comfort treating them; general triage emergency
Space 14 (11) departments may benefit from more educational initiatives
Monitoring capability 13 (10) to support triage nurses, who are highly interested in
Other 15 (12) treating children’s pain but may lack experience, training,
and comfort in doing so.

Canadian pediatric emergency departments because of the high Acknowledgment

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.
Implications for Emergency Nurses
For triage nurses, our results may contribute to improved
pain treatment for pediatric patients by conveying to
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.
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