American Journal of Emergency Medicine (2010) 28, 412417

www.elsevier.com/locate/ajem

Original Contribution

Triage pain scales cannot predict analgesia provision to

pediatric patients with long-bone fracture
Yi-Ming Weng MD a , Yu-Che Chang MD a,, Yu-Jr Lin MS b
a

Department of Emergency Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine,
Tao-Yuan, Taiwan 333
b
Graduate Institutes of Clinical Medical Sciences, Chang Gung University, Tao-Yuan, Taiwan 333
Received 13 December 2008; revised 25 December 2008; accepted 25 December 2008

Abstract
Purpose: This study evaluated the effects of pain assessment at triage on analgesia provision to pediatric
patients with closed long-bone fractures in the emergency department (ED).
Methods: This was a retrospective cohort study conducted at a university-affiliated teaching hospital.
Children who presented to the ED of a teaching hospital with the main diagnosis of a closed fracture of
the extremities in 2007 constituted the study cohort. We reviewed the charts and collected the following
variables regarding the subjects' ED visits: patient demographics, pain scale reassessment, category of
fracture, associated injuries, time from triage to the first administration pain medication, and the route
and type of analgesic. The data were divided on the basis of triage in accordance with pain assessment
or other triage modifiers.
Results: In our study, 211 (54.7%) patients enrolled received analgesia. Oral acetaminophen was the most
commonly prescribed medication (131 patients, 62.1%), whereas opioids were used in only 24 (11.4%)
patients. The average time taken to deliver analgesia to children arriving in our ED was 70 minutes. The
logistic regression analysis indicated that enrolled patients triaged based on the pain assessed at triage was
not associated with the subsequent provision of analgesia. Analgesia provision was not associated with
patients with moderate or severe pain assessed at triage as compared to patients with mild pain.
Conclusion: The pain management of pediatric patients with closed long-bone fractures in the ED was
inadequate and delayed. Moreover, the pain assessment at triage did not predict analgesia provision to
these patients.
2010 Elsevier Inc. All rights reserved.

1. Introduction

Corresponding author. Tel.: +886 3 3281 200x2505; fax: +886 3

3287 715.
E-mail addresses: changyuche@adm.cgmh.org.tw,
changyuche@yahoo.com.tw (Y.C. Chang).
0735-6757/$ see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2008.12.035

In recent years, considerable concerns have arisen

regarding the management of pediatric pain in the emergency
department (ED) [1,2]. Anand and Carr [3] found that pain
management in childhood may affect later pain-related
behavior and perception. The effects of pain and stress on
the immune system are important [4]. However, pain in the

Pain assessment at triage cannot predict analgesia provision to pediatric patients with fractures
ED is commonly undertreated, especially in pediatric or
trauma patients [5-8]. One of the factors contributing to
oligoanalgesia is the lack of sufficient attention to the
patient's self-report of pain by care providers [9]. To create a
pain-free ED, some have proposed that the degree of pain in
pediatric patients be screened as a fifth vital sign at triage
[1]. Measuring pain in all children who are potentially in pain
remains an important priority [2].
Triage is the process of sorting patients and classifying
them into categories for priority of care. Many countries had
adopted national uniform triage system in the ED [10-13].
Pain scales are not absolute but do allow patients to
communicate the intensity of a problem from their
perspective and act as triage modifier if patients presented
with pain complaint in the ED. However, expecting pediatric
patients to describe their pain or to quantify their emotional
response is unrealistic. Validated pain scales exist, including
the numeric rating scale, visual analog scale [14], faces pain
scale [15,16], and the nurse-assigned Face, Legs, Activity,
Cry, and Consolability score [17]. The application of pain
scales requires education and support for nursing and
medical staff. The complexity of the ideal multidimensional
pain measurement makes it impractical to complete an
adequate pain assessment at triage. Even when pain is
assessed, health care providers often underestimate it
[18,19]. Pain assessment has resulted in better documentation, but not better treatment, of pain [20-22]. Bijur et al [23]
suggested that patients' self-reported pain is not used as the
most important measure, as recommended by expert panels,
and does not influence the administration of opioids for
patients with suspected long-bone fractures.
Therefore, the aim of our study is to identify the role and
evaluated the effects of pediatric pain assessment at triage on
analgesia provision by pediatric long-bone fracture model in
the ED [24,25]. We hypothesized that the pain scale
assessment at triage could remind physicians to provide
analgesics to pediatric patients with long-bone fractures in
the ED.

2. Materials and methods

2.1. Study design and setting
This was a retrospective cohort study conducted at a
university-affiliated teaching hospital with an annual ED
volume of 227 738 2171 visits, approximately 26% whom
are pediatric patients. Our study protocol was reviewed by
our institutional review board and deemed exempt from the
requirement to obtain informed consent.

413

closed fracture of the extremities in 2007 constituted the

study cohort. Patients with closed fractures of the
extremities and International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM) codes
812, 813, 820, 821, and 823 were included. Patients with
open fractures, out-of-hospital cardiac arrest, already
intubated, and documented prehospital analgesic use
were excluded.

2.3. Study protocol

On arrival at the ED, the patients were triaged into 1 of
4 categories: emergency, more urgent, less urgent, and not
urgent. The triage decision was based on the critical look,
physiologic assessment (vital signs), and other triage
modifiers (pain, mechanism of injury, body temperature,
etc). Most patients can be assigned a triage level after the
utilizations of critical look, history, or measurement of vital
signs. Pediatric patients with severe injuries or a high
priority of care were usually triaged based on modifiers
associated with the need for an airway, breathing support,
shock or impending shock, and a decreased level of
consciousness. The triage nurse will assign an acuity level
that addresses the patient's priority of care based on the
pain assessment or other modifiers at triage when patients
enrolled on arrival at our ED with normal critical look and
physiological assessments. Pediatric patients presented at
our ED without complaints of painful limbs or those with
vital sign instability would not have pain scale assessment
at triage. Patients enrolled in this study who were
categorized based on pain assessments at triage were
assigned to group 1, and pain complaint was notified in this
cohort. Patients enrolled in this study who were categorized
based on triage modifiers other than pain scales were
assigned to group 2. Triage nurses who had at least 2 years
experience in the ED assessed the pain using a numeric
rating scale. Patients were asked verbally to rate their pain
from 0 to 10, with 0 equal to no pain and 10 equal to worst
possible pain. The nurse-assigned Face, Legs, Activity, Cry,
and Consolability score was used for patients who could
not describe and quantify their pain [17]. Each of the
5 categories is scored from 0 to 2, which results in a total
score between 0 and 10. The nurses were trained in a
departmental teaching program on pain assessment techniques. This included a reading of a manual on pain
assessment tools and participating in workshops twice a
year. All of the triage nurses had completed the program.
Pain at triage was categorized as mild (1-3 points),
moderate (4-6 points), and severe (7-10 points).

2.4. Measurements
2.2. Patient selection
Children less than 18 years of age who presented to the
ED of a teaching hospital with the main diagnosis of a

We reviewed the charts and collected the following

variables regarding the subjects' ED visits: patient demographics (age, sex, and triage category), pain scale assess-

414
ment at triage and reassessment, category of fracture
(fracture site and single or multiple fractures), associated
injuries (head, chest, or blunt abdominal injury), time
interval from ED registration to analgesic prescription, and
the route and type of analgesic.

2.5. Statistical tests

The data were analyzed using SPSS 13.0 for Windows
(SPSS, Chicago, IL). The 2 test was applied for
categorical data, and a 2-tailed t test was used for
continuous variables. The demographic characteristics of
the patients were compared between groups. The relationship between the pain scale assessment at triage or pain
intensity and analgesia provision was evaluated using
binary logistic regression analysis after adjusting for
potentially confounding variables, including sex, age, triage
category, and fracture site. A P value less than .05 was
considered statistically significant.

3. Results
We reviewed 434 cases and excluded 48 patients based on
the exclusion criteria, enrolling 386 patients in this study. Of
the patients, 218 (56.5%) were triaged into 1 of 4 categories

Y.M. Weng et al.

based on the pain scale assessed at triage, and the other
patients enrolled were categorized according to other triage
modifiers (Fig. 1).
Patients categorized as mild, moderate, and severe
intensity of pain contributed 10.1% (n = 22), 71.1% (n =
155), and 18.8% (n = 41) of the study cohort in group 1,
respectively. The chart review indicated that no pain scores
were reassessed and recorded by physicians when they
treated the patients enrolled in this study. In our study, 211
(54.7%) pediatric patients with closed long-bone fractures
received analgesia in the ED. Oral acetaminophen was the
most commonly prescribed medication (131 patients,
62.1%), whereas opioids were used in only 24 (11.4%)
patients. Nonsteroidal anti-inflammatory drugs (NSAIDs),
including intramuscular ketorolac and oral mefenamic acid
and ibuprofen, were used in 17.1%, 5.7%, and 3.8%,
respectively. However, the pain intensity did not seem to
affect physicians' choice of analgesics when pain scales were
categorized as mild to moderate (P = .097). Nevertheless, the
physicians' choice of analgesics was preferred NSAIDs and
opioids more when managing patients with severe pain as
compared to managing those categorized as mild to moderate
pain intensity (P = .001) (Fig. 2). The average time taken to
deliver analgesia to children arriving in our ED was 70 55
(mean SD) minutes. No significant difference in demographic variables was documented between groups, except
associated injury and triage category (Table 1). Pain was

Fig. 1 Study protocol. *Children less than 18 years of age with ICD-9-CM code closed fracture of extremities diagnosis of 812, 813, 820,
821, and 823 were included. Excluding ICD-9-CM code open fracture diagnoses 812.10-19, 812.30, 812.31, 812.50-59, 813.10-18, 813.3033, 813.50-54, 813.90-93, 820.10-19, 820.30-32, 820.9, 821.10, 821.11, 821.30-39, 823.10-12, 823.30-32, 823.90-92.

Pain assessment at triage cannot predict analgesia provision to pediatric patients with fractures
assessed less often at triage in patients with an associated
injury or for cases categorized as emergency or more urgent
(Pb .05). However, analgesia provision did not differ
significantly between groups.
Similar proportions of patients assigned to groups 1 and 2
received analgesia (57% vs. 52%, P = .319; Table 1). The
binary logistic regression analysis indicated that the number
of enrolled patients triaged based on the pain assessed at
triage was not associated with the subsequent provision of
analgesia after adjusting for sex, age, triage grade, and
fracture site (P = .439; odds ratio [OR], 0.840; 95%
confidence interval [CI], 0.540-1.306). The correlation
between the intensity of pain assessed at triage and analgesia
provision was also low (P = .747). Furthermore, after a
binary logistic regression adjusting for the variables mentioned above, the correlation remained low (Table 2).
Analgesia provision was not associated with patients with
moderate or severe pain assessed at triage as compared to
patients with mild pain (for the moderate pain group: OR,
0.890; 95% CI, 0.333-2.377; for the severe pain group: OR,
0.474; 95% CI, 0.067-3.362).

4. Discussion
We found that the level of pain assessed at triage was
not associated with age, sex, or fracture site. However, pain
was less assessed at triage in pediatric patients of a closed

Fig. 2 The figure clarifies the degree of pain with the choice of
analgesics. Patients categorized as mild, moderate, and severe
intensity of pain contributed 10.1% (n = 22), 71.1% (n = 155), and
18.8% (n = 41) of the study cohort in group 1, respectively. The pain
intensity did not seem to affect physicians' choice of analgesics
when pain scales were categorized as mild to moderate.
Acetaminophen was still the commonest pain medication. The
physicians' choice of analgesics was preferred NSAIDs and opioids
more when managing patients with severe pain as compared to
manage those categorized as mild to moderate pain intensity.

Table 1

415

Patient demographics and clinical characters

Sex
Male patients
Female patients
Mean age in years (SD)
Fracture site
Upper limbs
Lower limbs
Multiple
Triage category
Emergent
Urgent high
Urgent low
Nonurgent
Associated injury
Yes
No
Analgesia provision

Group 1 a
(n = 218)

Group 2 b
(n = 168)

160 (73)
58 (27)
10.0 4.3

110 (65)
58 (35)
10.3 4.6

159 (73)
49 (22)
10 (5)

110 (65)
53 (32)
5 (3)

P
.093

.507
.114

b.05
2
45
170
1

(1)
(21)
(78)
(0)

28
54
84
2

(17)
(32)
(50)
(1)
.011

15 (7)
203(93)
124 (57)

25 (15)
143(85)
87 (52)

.319

All data are given as number of patients (percentage) except for mean
age in years.
a
Patients enrolled who were triaged based upon pain scale assessed
at triage.
b
Patients enrolled who were triaged based upon triage modifies
other than pain scale.

long-bone fracture combined with associated injuries or a

high priority of care. In fact, severely injured patients were
sent to an examination room immediately after the triage
nurse quickly checked the vital signs and made a critical
assessment, as it is impractical to categorize such patients
into a triage level based on pain assessment. Martha et al
[26] reported that patients who are more seriously injured
are at particular risk for oligoanalgesia. We found no
significant difference in analgesia provision to patients with
more serious injuries in whom pain was not assessed
at triage.
In our series, the management of pain in pediatric
patients with closed long-bone fractures in the ED was
inadequate and delayed. Physicians preferred acetaminophen for analgesia for fracture pain management and used
NSAIDs and opioids sparingly. Several studies have
obtained similar results [6,27]. The median time from

Table 2 The logistic regression analysis of analgesia provision

and intensity of pain assessed at triage
Intensity of pain

OR (95%CI)

Mild (1-3), reference

Moderate (4-6)
Severe (7-10)

1
0.890 (0.333-2.377)
0.474 (0.067-3.362)

.816
.455

Adjustment variables: sex, age, fracture site, and triage category. Odds
ratio indicated whether patients received pain medications as compared
to patients enrolled with mild pain intensity.

416
triage to the first administration pain medication was
74 minutes in Jesse and Judd [28] and 95 minutes to the
first dose of opioids in Martha et al [26]. Brown et al [29]
noted that 36% of patients with closed extremity or clavicle
fractures received no analgesics, and the proportion was
even higher in children. Compared to adults, the use of
narcotic analgesics in children was also low [29].
Physicians frequently express concern about adverse
reactions to NSAIDs, and opiophobia contributes to
inadequate analgesia.
Bijur et al [23] addressed the lack of influence of
patient self-reported pain intensity on the administration of
opioids for suspected long-bone fractures [25]. We found
that pain assessment at triage and pain intensity were not
associated with analgesia delivery in pediatric patients with
closed long-bone fractures. Several explanations may be
valid. First, pain has psychological, behavioral, physiological, and emotional components [27,30]. It is a subjective
multifactorial experience. An adequate assessment of
pediatric pain should be individualized, measured comprehensively, monitored continuously, and documented. The
complexity required for the ideal multidimensional measurement makes it impractical to complete an adequate
pain assessment in the ED. Even when pain is assessed,
health care providers often underestimate it [18,19].
Second, although pain assessment has resulted in better
documentation of a patient's pain, it has not resulted in
better treatment of pain [20-22]. We found that 56.5% of
the pediatric patients with long-bone fractures were triaged
based on the pain assessed at triage. A chart review
showed that the physicians who treated these patients
never documented a reassessment of the fracture pain.
Evidence indicates a lack of the assessment and management of pain by health care providers in many settings
[27,31]. A pain scale assessed at triage might not be an
appropriate reminder for physicians and might be ineffective at raising the issue of pain management. Several
guidelines have been published for the assessment and
management of pediatric pain [20,32,33], although guidelines and continuing medical education do not necessarily
alter health care provider behavior [34,35]. Third, analgesia
provision might be individualized. No universal protocol
was applied for pediatric pain, and no definite form or
route of analgesia was indicated according to a specific
intensity of pain during our study period. Physicians
responded differently to specific intensities of pain
assessed at triage. A previous study revealed that the
introduction of a pediatric analgesia protocol increased
analgesia provision and reduced the length of time to
analgesia delivery in children arriving in the ED [36]. In
addition to injected analgesics, oral, anal, and nonpharmacologic interventions were also used. However, the
nonpharmacologic interventions were not recorded on the
chart, and we might have underestimated their use.
However, it was not reassessed whether adequate or
appropriate analgesics provision were applied. The results of

Y.M. Weng et al.

this study suggest that physicians' choice of analgesics for
treating patients with mild or moderate pain intensity was
similar. The pain scales categorized as severe intensity
seemed to affect physicians' choice of analgesics with
NSAIDs and opioids more as compared to managing those
categorized as mild to moderate pain intensity. Because
limited study patients were categorized as mild and severe
pain and acetaminophen was still the commonest pain
medication, the effect of pain scales on physicians' choice of
analgesics clearly needs further exploration.
Therefore, we propose that instead of a pediatric pain scale
assessment, documentation of the patient's or family's desire
for immediate analgesia as part of the chief complaint at triage
may be more appropriate in the ED. Further analgesia should
be given according to the patient's or family's wishes. Instead
of taking the degree of pain as a fifth vital sign, which is
considered an objective measurement, it should be viewed as
a part of the subjective chief complaint. A pain scale
assessment based on comparing the initial painful events and
post analgesia delivery during reassessment may be more
reliable and appropriate in the ED. The introduction of a
pediatric analgesia protocol, including nonpharmacologic
interventions, that concurs with patients' desires should be
considered. A further prospective randomized control study
should be conducted to verify this proposal.
This study has several limitations. The first limitation
is that our study was retrospective, and the data were
collected from a computer database and chart review.
Although we made every effort to remain objective,
possible errors may have been introduced. Although the
pain scale was assessed at triage, pain assessment by
physicians and the reason for the delay or failure to
provide analgesia were not recorded in the charts directly.
In addition, we did not collect data on nonpharmacologic
interventions and the reassessment of pain. Therefore, we
might have underestimated the pain management of
pediatric patients with closed long-bone fractures in the
ED. As a second limitation, the experience of the nurse
and the number of patients in the ED might have affected
the quality and intensity of pain measured at triage. In
addition, no notation of the nurse-assigned scoring system
was seen in the chart review that suggested how it
affected the pain intensity measured at triage. A third
limitation of our study is that it was conducted in 1
hospital only, which limits the generalizability of our
findings. The physicians' habitual practices regarding
analgesics, which could not be controlled, might have
contributed to the oligoanalgesia.

5. Conclusions
The pain management of pediatric patients with closed
long-bone fractures in the ED was inadequate and delayed.
Moreover, the pain assessment at triage did not predict
analgesia provision to these patients.

Pain assessment at triage cannot predict analgesia provision to pediatric patients with fractures

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