RESEARCH
LONG-BONE FRACTURE PAIN MANAGEMENT
THE EMERGENCY DEPARTMENT
Authors: Ptlene Minick , PhD, RN, Patricia C. Clark , PhD, RN, FAHA, FAAN, Jo Ann Dalton , EdD, RN, FAAN,
Eva Horne , MN, APRN-C, FNP, Debbie Greene , PhD, RN, and Monica Brown , RNC, MSN, FNP-C, APRN-BC, Atlanta,
GA, Macon, GA
Earn Up to 9 CE Hours. See page 315.
Introduction: The purposes of this study were to investigate
the adequacy of pain management for patients with long-bone
fractures seen in the emergency department and to determine
whether racial disparities exist.
Methods: The design was an exploratory, correlational design
using patient data abstract ed from electronic medical records of
2 major urban medical centers located in the Southeastern United
States. Data collected included demographics, time of initial pain
assessment by the registered nurse, time of pain medication
administration, severity of pain, fracture location by radiograph,
type of pain medication, and route-dosage of pain medication
administered. The primary outcome variable, which was the pain
management index, was calculated and used as a measure of
adequate pain management.
Results: The majority of the sample (N = 218) was female (61%)
and white (63%), with 28% black and about 10% of the sample
consisting of other minorities. Seventy-nine (36%) of the 218
Ptlene Minick is Associate Professor, Byrdine F. Lewis School of Nursing,
Georgia State University, Atlanta, GA.
Patricia C. Clark is Professor, Byrdine F. Lewis School of Nursing, Georgia
State University, Atlanta, GA.
Jo Ann Dalton is Emerita Professor, Nell Hodgson Woodruff School of Nursing,
Emory University, Atlanta, GA.
Eva Horne is Clinical Assistant Professor, Byrdine F. Lewis School of Nursing,
Georgia State University, Atlanta, GA.
Debbie Greene is Associate Professor of Nursing, Macon State College,
Macon, GA.
Monica Brown is Assistant Professor of Nursing, Macon State College,
Macon, GA.
For correspondence, write: Ptlene Minick, PhD, RN, Byrdine F. Lewis
School of Nursing, Georgia State University, Atlanta, GA 30302; E-mail:
pminick@gsu.edu.
J Emerg Nurs 2012;38:211-7.
Available online 23 March 2011.
0099-1767/$36.00
Copyright © 2012 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
doi: 10.1016/j.jen.2010.11.001
May 2012 VOLUME 38 • ISSUE 3
IN
patients received no medication while in the emergency
department despite a mean pain score of 6.9 (SD = 2.5) on a 0 to
10 scale representing moderate to severe pain. Patients who
received pain medication (n = 126) waited for the medication 1.76
hours (±1.47). Among the patients who received an analgesic (n =
126), younger patients, black patients, and those with higher pain
severity were more likely to receive inadequate pain management
than were white patients.
Discussion: According to the pain management index, the
majority of the patients in this study received inadequate pain
management while in the emergency department. Future
interventions may need to focus on giving ED nurses information
about inadequate pain management and disparities in pain
management in the ED setting and exploring possible reasons for
disparities in order to ultimately improve patient care.
Key words: Pain management; Disparities; Analgesics; Opioid;
Musculoskeletal diseases; Drug therapy; Pain measurement
very year almost 2 million people are admitted to
E the emergency department in the United States
with long-bone fractures (LBFs). Most of these
patients present with moderate to severe pain. Recom-
mendations for the assessment and treatment of acute
pain are well established. 1 Barring contraindications,
patients should receive an opioid analgesic while in the
emergency department for LBF pain.1 Yet research shows
that almost half of all patients with LBF do not receive
medication for pain in the emergency department.
Furthermore, in some settings, blacks and other minority
patients are less likely than are whites to receive medica-
tion for pain.2,3 The purposes of this study were to inves-
tigate the adequacy of pain management for patients with
LBF seen in the emergency department and to determine
whether racial disparities exist in the pain management of
patients who have LBFs.
Racial disparities in pain management have been docu-
mented for cancer, 4,5 postsurgical, and LBF patients.3
Todd and colleagues2 found that acute pain management
WWW.JENONLINE.ORG 211
RESEARCH/Minick et al
of LBF was managed differently for white and black
patients while in the emergency department. Three fourths
of the white patients with LBFs received analgesics (74%)
compared with slightly more than half (57%) of the black
patients. When pain intensity and other confounders were
controlled, the disparities continued to be significant.
Although the study conducted by Todd and colleagues is
more than 10 years old, similar findings have been found
in more recent studies. Heins and colleagues6 found that
whites were 1.8 times more likely to receive opioid analge-
sics than were their black counterparts. In 2 systematic
reviews of the literature on ED pain practices and ethnicity,
disparities in pain management were found to be similar to
disparities in other aspects of health care documented by
the Institute of Medicine.7,8 Using the National Hospital
Ambulatory Medical Care Survey, 2 studies compared care
and found that the disparities in opioid prescribing rates
between blacks and whites have not changed over time.9,10
Another study that used the National Hospital Ambulatory
Medical Care Survey found no association between race
and receiving a prescription for pain; however, differences
were found with types of pain medications prescribed. Sig-
nificantly more whites than blacks and Latinos were pre-
scribed opioids for back pain and migraines.11
In another study, Bijur and colleagues12 found no
association between race and analgesic use for patients
with LBF in 2 large academic settings. In a survey of
more than 2000 ED physicians, the race or socioeco-
nomic status of patients in clinical vignettes did not influ-
ence opioid prescribing patterns.13 While studies indicate
that racial/ethnic disparities associated with LBF pain
management are mixed, the bulk of evidence suggests that
minorities are at higher risk of not receiving an opioid for
pain management.9,10 However, none of these studies
used a measure that incorporated a patient’s pain severity
level and medication prescribed to assess the adequacy of
pain management. More precise data are needed to eval-
uate the severity of pain and the appropriate treatment.
Reducing unnecessary pain and suffering is a man-
date for health professionals in acute settings as they
protect the basic human rights of the patients. The pain
that usually accompanies traumatic injury places ED
patients at risk for pain and suffering, and ED nurses
are generally the first health care provider to assess
patients admitted with LBF. In 2001, the Joint Com-
mission on Accreditation of Healthcare Organizations
designated pain as the fifth vital sign, requiring the sys-
tematic assessment of pain as well as blood pressure,
temperature, pulse, and respirations. Because triage
nurses are the first to assess pain severity, they have
an opportunity to intervene and advocate for better pain
212 JOURNAL OF EMERGENCY NURSING
management.14 ED nurses provide critical information
to the physician so that appropriate therapy can be
established in a timely fashion. Current data indicate
that slightly less than half of the patients with LBF
who are admitted to the emergency department are
not treated with an analgesic. Thus this study examined
adequacy of pain management in the emergency depart-
ment, while exploring disparities in pain management.
Methods
STUDY DESIGN AND SETTING
The design was an exploratory, correlational design using
patient data abstracted from electronic medical records
(EMRs) of 2 major urban medical centers located in
the Southeastern United States. One emergency depart-
ment had 20 beds with more than 28,000 visits annually,
and the other had 29 beds with more than 50,000 visits
annually. Data for patients admitted to the emergency
department during a 3.5-month period were used.
SELECTION OF PARTICIPANTS
After Institutional Review Board and administrative
approvals were obtained, a list of patients with LBFs
admitted to the emergency departments of the 2 medical
centers was generated. Patient records with an ICD-9
code indicating an LBF (ICD-9 codes 810-829) were
initially identified (n = 264 records). Exclusion criteria
included anyone who: (1) reported an initial pain score
of zero, indicating no pain; (2) demonstrated dementia;
(3) scored less than 8 on the Glasgow Coma Scale (on
a 3-15 scale where 3 indicates no sign of function and
15 is full function); (4) was hypotensive (systolic blood
pressure <90); and (5) patients requiring cardiopulmonary
resuscitation, endotracheal intubation, or intensive care
admission because of the possible contraindications of
narcotic analgesia for these individuals. Data were
abstracted from the EMR by 2 masters-prepared nurses
who were trained to collect data from the EMR using
the medical records abstract instrument.
Based on the ethnic/racial demographics of all encoun-
ters at both data collection sites, a power analysis indicated
that 200 patients with LBF records would be needed to
detect a moderate difference (.30) in analgesic wait time
using analysis of variance (P = .05). As a result, 264 charts
were accessed. Thirty-seven (14%) of the 264 records had
more than 20% missing data, so they were excluded from
the analysis. The relatively high rate of missing data was
attributed to the recent initiation of EMR at the 2 sites.
After exclusion criteria were applied, the final sample was
218 patients with LBF.
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 Minick et al/RESEARCH

TABLE 1
Sample characteristics
Whites Blacks Totala
Variable n = 139 n = 58 n = 218
Age M (SD) 57.13 (21.87) 49.97 (19.34) 53.78 (21.33)
Gender % (n)
Male 41.7 (58) 31.0 (18) 39.4 (86)
Female 58.3 (81) 69.0 (40) 60.6 (132)
Fracture type % (n)
No documented fractureb 6.5 (9) 15.5 (9) 8.8 (19)
Minor fractures 33.1 (46) 41.4 (24) 37.6 (82)
Major fracturesc 58.3 (81) 43.1 (25) 52.3 (114)
Type of fracture not recorded 2.2 (3) 0 (0) 1.4 (3)
Pain severity on arrival M (SD) 6.51 (2.48) 7.64 (2.33) 6.88 (2.49)
Pain severity on discharge M (SD) 2.82 (2.27) 2.52 (2.51) 2.76 (2.42)

a
Includes all minorities; N varies from 207-218 because of missing data.
b
No fracture includes patients who had an ICD-9 code of LB, but no fracture documented on radiograph.
c
Major fractures (femur, tibia, fibula, hip, scapula, patella, clavicle, humerus, radius, ulna).

MEASURES Medications Administered

Medical Records Abstract Instrument
An instrument designed to abstract data from medical
records was constructed by the research team based on
the literature and information from the EMRs. Data were
collected on demographics, mental status, acuity, time of
initial pain assessment by the registered nurse and time
of pain medication administration, severity of pain, fracture
location by radiograph, time of discharge, disposition at
discharge, and severity of pain at discharge. In addition
to time of pain medication administration, the type of pain
medication, route, and dosage of pain medication adminis-
tered were recorded.
Pain Severity
Pain severity was measured with a Verbal Rating Scale
(VRS) of 0 to 10, with 0 being no pain and 10 being
the worst pain they could imagine. This assessment is the
standard assessment used in clinical settings,1 and it has
been documented to be valid and reliable when compared
with patient self-report using the Visual Analog Scale in the
emergency department.
Time to Analgesic
Time to analgesic represented the time recorded from the
initial pain assessment to administration of the first pain
medication in the EMR. This time is reported in minutes.
Pain medications administered (if any) were categorized as
follows: 0 = no pain medication administered; 1 = nonster-
oidal antiinflammatory drug or Tylenol; 2 = mild opioid
(eg, codeine, Percocet, or Vicodin); and 3 = major opioid
(eg, morphine, fentanyl, Dilaudid, or Demerol). These
categories are consistent with World Health Organization
guidelines for cancer pain management adapted to acute
pain for this study.5,15
Adequate pain management
The Pain Management Index (PMI) incorporates the type of
medication prescribed with the pain intensity to determine
adequacy of pain management. The PMI was based on the
World Health Organization guidelines for cancer pain man-
agement adapted to acute pain for this study.5,15 Adequate
pain management is achieved when the type of analgesic
administered is appropriate for the pain severity level based
on existing guidelines. The PMI is considered a valid and
reliable measure of pain management and has been used
extensively with chronic pain.5,16,17 In a 10-year prospective
study of 2118 patients with advanced cancer, cancer pain
relief was considered effective (P = .001) using the PMI.18
When using the PMI for the evaluation of chronic
pain, report of pain intensity includes patient report of pain
over the previous week, current pain, and the level of pain
that typically impairs function.5,19 In this study only the
initial ED triage report of acute pain was used.

May 2012 VOLUME 38 • ISSUE 3 WWW.JENONLINE.ORG 213

RESEARCH/Minick et al
To calculate the PMI, the pain severity level was trans-
formed into 3 levels because we excluded patients who
reported no pain. The 3 categories for pain severity were
as follows: 1 = mild (1-3 VRS); 2 = moderate (4-7 VRS);
and 3 = severe (8-10 VRS). The analgesic was transformed
into 4 categories (0 = no analgesic, 1 = non-opioid, 2 =
mild opioid, 3 = major opioid). The PMI value was calcu-
lated by subtracting the pain severity category from the
analgesic category, and possible scores ranged from –3 to
+3. Ultimately the PMI was scored as a dichotomous vari-
able with negative numbers indicating inadequate pain
management and zeros and positive scores indicating ade-
quate pain management.5,20,21
DATA ANALYSIS
Data analysis included descriptive statistics and analysis of
variance to examine the study questions using the time-to-
analgesic as the outcome variable and race (blacks/whites)
as the predictor, controlling for age, gender, and intensity
of pain. Prior research has suggested that age, gender, and
pain intensity are related to pain management.2 The χ2
statistic was used when comparing categorical variables.
Logistic regression was used with the dichotomous PMI
as the dependent variable to examine factors associated
with adequacy of pain management.
Results
PARTICIPANT CHARACTERISTICS
The majority of the sample (N = 218) was female (61%)
and white (63%), with 28% black and about 10% of the
sample consisting of other minorities. Major fractures
(including clavicle, femur, fibula, hip, tibia, radius, and
ulnar) constituted the majority of the fractures in the sam-
ple. A total of 19 people in the sample had no fracture
documented by radiograph, and the type of fracture was
missing from 3 of the 218 records. Because all of the
patients had a diagnosis of LBF, some of the fractures
may have been occult and documented with further test-
ing.22,23 In addition, these patients presented to the emer-
gency department with pain, and guidelines suggest that
pain be treated within 15 minutes.1 Thus pain manage-
ment is expected based on the patient’s presenting symp-
toms and pain severity rather than confirmation of the
fracture. Therefore these data were retained in the data set.
PAIN MANAGEMENT CHARACTERISTICS
General pain management characteristics are displayed in
Table 1. Seventy-nine (36%) of the 218 patients received
no medication while in the emergency department despite a
mean pain score of 6.9 (SD = 2.5) on a 0 to 10 scale repre-
214 JOURNAL OF EMERGENCY NURSING
TABLE 2
Adequate pain management (based on the Pain
Management Index a ) for black and white patients
with long-bone fracturesb
Adequate Inadequate
Race/ethnicity treatment n (%) treatment n (%)
Black (n = 58) 16 (27.6) 42 (72.4)
White (n = 139) 60 (43.2) 79 (56.8)
Total 76 (39.2) 121 (60.8)
a
Pain Management Index (PMI) includes those with pain who did not receive a
medication.
χ (1, N = 197) = 4.19, P =.039.
b 2
senting moderate to severe pain. Patients who received pain
medication (n = 126) waited for the medication 1.76 hours
(SD = 1.47). Controlling for pain severity, age, and gender,
the difference in average time from initial pain assessment
to the administration of the first analgesic was not statisti-
cally significant between blacks (adjusted M = 123 minutes,
SE = 14.6 minutes) and whites (adjusted M = 106 minutes,
SE = 10.0 minutes) (F (1, 126) = .86, P = .35). However,
pain severity was significantly higher for blacks (adjusted
M = 7.63, SE = .32) than for whites (adjusted M = 6.52,
SE = .21) (F (1, 197) = 8.05, P = .005) after controlling
for age and gender. Neither age nor gender was significant
for time to analgesia or pain severity. Pain severity on dis-
charge (n = 218) from the emergency department was, on
average, mild (Table 1).
ADEQUACY OF PAIN MANAGEMENT
Although the majority of black and white patients received
inadequate pain management (Table 2), significantly fewer
blacks received adequate pain management compared with
whites (χ2 [1, N = 197] = 4.19, P =.039). Slightly more
than one third of whites (38.8%) and 29.3% of blacks did
not receive any pain medication.
Further analyses examining factors associated with the
adequacy of pain management (PMI) were conducted. One
analysis included both patients who received an analgesic
and those who did not receive an analgesic (Table 3).
The second analysis (Table 4) included only patients who
received an analgesic. Pain severity was used in the initial
regression equation (Table 3) but was not significant and
was removed for a more parsimonious model. When con-
sidering patients who did and did not receive an analgesic,
race was not a significant predictor of adequate pain man-
agement (PMI).
However, among only the patients who received an
analgesic (Table 4), race, age, and pain severity were asso-
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 Minick et al/RESEARCH

TABLE 3
Predictors of adequate versus inadequate pain management (based on the Pain Management Index), including patients who
did and did not receive an analgesic for pain (n = 197)
95% CI for Exp (β)
Variable B SE Wald Significance Exp (β) Lower Upper
Age 0.17 .007 5.278 .022 1.017 1.002 1.031
White/black –.585 .346 2.858 .091 .557 .283 1.098
Constant –1.227 .452 7.349 .007 .293

CI, Confidence interval.

TABLE 4
Predictors of adequate versus inadequate pain management for patients who received an analgesic for pain (n = 126) a
95% CI for Exp (β)
Variable B SE Wald Significance Exp (β) Lower Upper
Age .028 .011 7.064 .008 1.028 1.007 1.050
White/black .922 .452 4.165 .041 2.515 1.037 6.099
Pain severity -.459 .117 15.437 .000 .632 .503 .795
Constant 1.803 1.019 3.131 .077 6.066

CI, Confidence interval.

a
Full model = χ2 (3, N = 126) = 37.00, P < .001.

ciated with adequate pain management (PMI). The full
model was significant (χ2 [3, N = 126] = 37.00, P <
.001) and accounted for 25.4% to 34.4% of the variance.
Young patients and black patients with a higher initial pain
score were more likely to receive inadequate pain manage-
ment. The likelihood of receiving inadequate pain manage-
ment increased for blacks, who were 2.5 times more likely
to receive inadequate pain management than were their
white counterparts.
Discussion
Slightly more than one third of all patients with LBFs did
not receive any pain medication, and most patients did not
receive adequate pain management (calculated by the
PMI). Furthermore, disparities continue to exist. Although
the practice of prescribing opioids for LBF pain have
improved in recent years,9,10 these data indicate that more
progress is needed. Even though results from several studies
indicate that patients expect pain relief in the emergency
department,24,25 the majority of patients with documenta-
tion of injury in this study reported moderate to severe pain
but did not receive adequate pain management while in the
emergency department.
Patients who received an analgesic for pain waited, on
average, 1.76 hours, or more than 5 times as long as the
time recommended to receive pain medication (15 min-
utes).26 Some investigators have found that overcrowded
emergency departments contribute to timeliness and qual-
ity of patient care provided.27 However, given the retro-
spective nature of this study and the absence of specific
markers designating “overcrowding” conditions, conclu-
sions regarding delay cannot be determined. Future studies
of environmental issues should consider data regarding
acuity, staffing, and other indicators of crowding.
For the patients discharged from the emergency
department, pain on discharge was reported to be relatively
mild. Treatments other than medication such as cold
packs, splinting, or immobilizing the affected area may
have contributed to pain relief. However, data regarding
these therapies were not collected.
Using the PMI, which included patients’ pain severity
and level of analgesic administered (to determine adequacy
of pain management), fewer black patients received adequate
treatment for pain. Several explanations may account for the
differences in these findings and those of other studies.10,11,28
The PMI may be a more sensitive indicator of differences than
previous measures. Further, Bijur and colleagues29 found that

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RESEARCH/Minick et al
ED providers do not always follow expert recommendation
regarding use of the most important measure of pain, the
self-reported pain intensity rating, as a primary part of their
decisions about pain management for patients with LBF.
A number of centers have reported that the imple-
mentation of a nurse-initiated protocol for pain manage-
ment improved both the percent of patients receiving
treatment and the timeliness of treatment.30-33 Imple-
mentation of nurse-initiated protocols has resulted in an
increase in patient satisfaction with the ED services.30,32
In fact, one center reported a mean reduction of 68 min-
utes in the time from the initial assessment to the time
that analgesia was administered after the nurse-initiated
protocol was implemented. 31 However, comparisons
between minorities were not made in these studies. In
addition, the adequacy of pain management was not
addressed in any studies investigating acute pain manage-
ment. While time to analgesia is an important compo-
nent of assessing pain management, ensuring that the
correct drug and appropriate dose coincide with the type
and severity of the pain is equally important. Findings from
this study are limited by the data accessible in the medical
record. Medical records do not contain the clinical details
such as patients’ requests for pain medication or assessment
of nonverbal cues about pain during the patient encounter.
In addition, sample size limited the analysis of subgroups,
such as gender and age comparisons within race. Studies
with larger sample sizes are needed to have adequate power
to explore differences in subgroups. The findings suggest
that despite a clinical focus on pain assessment, interventions
with new approaches are needed to improve pain manage-
ment and reduce disparities. In addition to calculating time
to analgesia, measures of the adequacy of pain management
may add needed information.
Conclusions
Despite recent initiatives to improve pain management34,35
in the emergency department, it continues to be a problem
for patients with LBF. A large portion of patients in this
cohort did not receive any medication for pain while in
the emergency department. Even when patients received
an analgesic, one measure of adequate treatment, the PMI,
did not meet recommendations for care in the emergency
department. In addition, racial disparities were found, with
significantly fewer blacks receiving adequate pain manage-
ment. Because patients admitted to the emergency depart-
ment often are especially vulnerable, interventions
focusing on improving pain management for that popula-
tion need to be developed. ED clinicians have a large respon-
sibility for pain management.
216 JOURNAL OF EMERGENCY NURSING
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