Objectives: 1) To determine the time difference to analgesia administration for patients with painful limb conditions using an emergency triage nurse initiated pain management protocol versus analgesia administration by emergency doctors after consultation. 2) To determine the frequency of adverse events following such a protocol implementation. Methods: For emergency department patients with isolated limb injury or inflammation, a triage nurse initiated pain management policy was implemented in 2004. The protocol did not require the triage nurse to consult a physician. The triage nurse would record the chief complaint, past medical history, allergy, medication, vital signs, and pain severity using a combination of 0 to 10 numerical and face pain scales. Unless contraindicated, the triage nurse would offer intramuscular ketorolac to patients with pain score ≥5. Medical charts of patients fulfilling the inclusion criteria were reviewed from 1 to 30 September 2004. Results: Two hundred seventy-three patients were reviewed, of whom 73.3% were men and the overall mean age was 40.1 years (standard deviation SD 19.5). Two hundred and nine patients (76.6%) had pain score recorded at triage, and the median was 6. One hundred and five patients (38.5%) received analgesia, of which 69 were given by triage nurses and 36 by physicians. The mean time interval for analgesia given by triage nurse was 2.5 minutes (SD 8.9) and that for physician was significantly longer (p&lt;0.0001) at 68.2 minutes (SD 59.5). There was no adverse drug reaction observed in patients who received intramuscular ketorolac given by triage nurses. Conclusion: The time interval for pain relief of emergency department patients with painful limb conditions was reduced when the triage nurse initiated pain management

Choo

FRCS, FAMS Kum Ying

Hsin Goh

I Lee

Irene Lee

K Y Tham

MBBS, MRCS, MRCP Kai

R N Tham

RN Choo Swee Eng

SE H K Goh

CiteSeerX

Hong Kong Journal of Emergency Medicine
Emergency department triage nurse initiated pain management
HK Goh , SE Choo , I Lee , KY Tham 
Objectives: 1) To determine the time difference to analgesia administration for patients with painful limb
conditions using an emergency triage nurse initiated pain management protocol versus analgesia administration
by emergency doctors after consultation. 2) To determine the frequency of adverse events following such a
protocol implementation. Methods: For emergency department patients with isolated limb injury or
inflammation, a triage nurse initiated pain management policy was implemented in 2004. The protocol did
not require the triage nurse to consult a physician. The triage nurse would record the chief complaint, past
medical history, allergy, medication, vital signs, and pain severity using a combination of 0 to 10 numerical
and face pain scales. Unless contraindicated, the triage nurse would offer intramuscular ketorolac to patients
with pain score ≥5. Medical charts of patients fulfilling the inclusion criteria were reviewed from 1 to 30
September 2004. Results: Two hundred seventy-three patients were reviewed, of whom 73.3% were men
and the overall mean age was 40.1 years (standard deviation SD 19.5). Two hundred and nine patients
(76.6%) had pain score recorded at triage, and the median was 6. One hundred and five patients (38.5%)
received analgesia, of which 69 were given by triage nurses and 36 by physicians. The mean time interval for
analgesia given by triage nurse was 2.5 minutes (SD 8.9) and that for physician was significantly longer
(p<0.0001) at 68.2 minutes (SD 59.5). There was no adverse drug reaction observed in patients who received
intramuscular ketorolac given by triage nurses. Conclusion: The time interval for pain relief of emergency
department patients with painful limb conditions was reduced when the triage nurse initiated pain
management. (Hong Kong j.emerg.med. 2007;14:16-21)
1) 
2)  2004
 0-10  5 
 2004  9  1  30  273 
73.3%  40.1  19.5 209 76.6%
Correspondence to:
Goh Hsin Kai, MBBS, MRCS, MRCP
Tan Tock Seng Hospital, Department of Emergency Medicine,
11 Jalan Tan Tock Seng, Singapore 308433, Republic of Singapore
Email: hsin_kai_goh@ttsh.com.sg
Choo Swee Eng, RN
Irene Lee, RN
Tham Kum Ying, FRCS, FAMS
Goh et al./Triage nurse initiated pain management 17
 6 105 38.5% 69 36 
 2.5  8.9
68.2  59.5 p<0.0001
Keywords: Analgesia, emergency nursing, nursing assessment, pain, triage
Introduction
Pain is one of the most common reasons for seeking
help in the emergency department (ED).1-3 Worldwide,
patients with pain including those suffering from
painful musculoskeletal conditions often received
inadequate pain relief1-4 or delayed care due to frequent
ED overcrowding.2,5 Literature review has shown that
objective pain assessment and early pain relief are
becoming the standard practice in EDs in countries
such as Australia, United Kingdom (UK) and the
United States of America (USA). It is good clinical
and professional practice to relieve patients' pain as
soon as possible. It is therefore reasonable that pain
management should be initiated at the time of the
patient's first contact with a health care worker in the
ED, which is the triage. Allowing triage nurses to give
analgesia would reduce the waiting time for pain relief.
Many reports have shown that nurses can follow a
protocol and initiate effective analgesia, resulting in
more timely relief of acute pain.5-10
Our hospital has one of the busiest ED in the nation
and this  translates  to long wait ing hours for
consultation. In order to prevent prolonged delay in
administering pain relief to patients, an efficient
pain management system is needed. The study ED
implemented a triage nurse initiated pain protocol in
2004. This protocol allowed the triage nurse to assess
pain objectively and subsequently to initiate pain relief
autonomously to patients with painful limb conditions.
Objectives
The objectives of this study were:
1. To determine the time difference to analgesia
administration for patients with painful limb
conditions using an emergency triage nurse initiated
pain management protocol versus analgesia
administration by emergency doctors after
consultation.
2. To determine the frequency of adverse events
following such a protocol implementation.
Methodology
Our hospital is a 1,000 bed hospital with an ED seeing
an average of 350 patients a day. In Singapore, nurses
are not allowed to prescribe any non-OTC (over-the-
counter) medication without prior authorisation from
a physician. The physicians and nurses of the study
ED drafted a protocol to empower triage nurses to
prescribe and administer analgesia without the need
for physician's authorisation. Our medical board then
gave approval for the ED to implement administration
of analgesia by state registered triage nurse performing
the triage duty.
With approval from the medical board, ED physicians
and nurses were educated about the protocol and the
use of pain scale to assess patient's pain. For nurses,
these topics were emphasised as: -
Hong Kong j. emerg. med.  Vol. 14(1)  Jan 200718
1. Bas ic  pharmacology of  nonsteroida l  ant i -
inflammatory drugs (NSAID)
2. The "5 Rights": right patient, right drug, right dose,
right time, right route; and also a 6th right was
introduced − right to refuse
3. Indications and contraindications
The triage nurse's task was to take the history for chief
complaint, past medical history, allergy, current
medication use, and contraindications to NSAID. He/
she would then assess the severity of pain using a
combination numerical scale of 0 to 10 and faces-
graphic scale. Intramuscular ketorolac would be offered
if the patient had isolated limb injury or inflammatory
condition and a pain score ≥5. The nurse were
reminded to consult an emergency physician if he/she
had doubts when administering analgesia to the
patient.
Medical charts of consecutive cases of patients who
fulfilled the inclusion criteria and were offered analgesia
in accordance to the pain management protocol were
reviewed from 1 September 2004 to 30 September
2004. The inclusion criteria of the study were: -
1. Patients 16 years and above;
2. Pa t i e n t s  p r e s e n t i n g  w i t h  i s o l a t e d  l i m b
conditions, e.g. contusion, fractures, acute flare
of gout; and
3. Patients who were haemodynamically stable i.e.
(systolic blood pressure >100 mmHg, pulse rate
<100/min and respiratory rate <20/min).
The exclusion criteria were: -
1. Patients with multiple injuries;
2. Patients with a past history of renal impairment,
peptic ulcer and asthma; and
3. Patients with known allergy to NSAID.
Demographical data such as gender, age, race and
nationality were recorded. Other data such as the time
of registration, time of analgesic administration,
patient's pain score, principal diagnosis and disposition
status of the patient were also collected.
The collected data were managed and analysed by SPSS
version 13 for Windows. The data set was analysed
using a two-tailed t-test for all continuous variables
with the confidence interval set at 95%. A p-value of
less than 0.05 was considered significant.
Results
Two hundred and seventy-three patients met the
inclusion criteria. Among the 273 patients, 200 were
men (73.3%). The patients' age ranged from 16 years
to 93 years. The mean age was 40.1 years (standard
deviation was 19.5), and the median age was 36 years.
Two hundred and nine patients (76.6%) had their pain
score recorded at triage. The median pain score for
these patients was 6. Among them, 150 (54.9%) had
pain score ≥5. Of the 150 patients, 69 (46.0%)
accepted analgesic offered by triage nurse; while 81
(54.0%) refused pain relief at triage. The reasons for
refusal by the patients were not recorded. Subsequently,
36 of the 81 patients (44.4%) received analgesic after
consultation with emergency doctors. Totally 105
received analgesia (Figure 1).
The mean time to pain relief from registration and
from triage for the group of patients who received nurse
initiated pain relief was 18.8 and 2.5 minutes
respectively. For patients who received pain relief after
consultation with doctors, the mean time of pain relief
from registration and from triage was 84.3 and 68.2
minutes respectively (Table 1).
Seventy-one patients had minor injuries including
contusion and abrasions while 155 had fractures.
Another 47 patient had inflammatory conditions
involving their limbs. The majority of these conditions
included gouty arthritis and cellulitis (Table 2).
No adverse drug reaction was reported by patients or
observed by healthcare workers (HCW) upon patients'
discharge. There was also no medication error.
Goh et al./Triage nurse initiated pain management 19
Figure 1. The flow of subjects.
Table 1. Comparison of time to analgesia by triage nurse versus analgesia given during medical consultation
Time from Analgesia by triage nurse (n=69) Analgesia by doctor (n=36) P
Registration to analgesia (SD), min 18.8 (SD 17.8) 84.3 (SD 61.0) <0.0001
Triage to analgesia (SD), min 2.5 (SD 8.9) 68.2 (SD 59.5) <0.0001
Table 2. The different diagnoses of the patients
Diagnosis Number
Minor injury e.g. contusion 71 (26.0%)
Upper limb fracture 98 (35.9%)
Lower limb fracture 57 (20.9%)
Inflammatory condition e.g. gout, cellulitis 47 (17.2%)
Discussion
Relieving pain expediently is humane and good clinical
practice and especially important in a busy ED with
frequent overcrowding. This project and several others
show that registered nurses can initiate pain assessment
and administer analgesia safely.
In an earlier study done by our ED, 66.9% of patients
with traumatic pain expected analgesia to be given
within 15 minutes of their arrival in the ED. This
expectation was not met in 91.1% of the time.2 This
is not an isolated problem in our ED. In fact, others
had shown similar untimely management of acute pain
in the ED.11,12 This problem has led some EDs to review
their processes by establishing pain management
protocols. Different protocols use different analgesics
and different routes of administration. This study
served to address the concerns and problems that may
arise when implementing such a protocol.
The primary concern for a pain protocol is its safety
concerning the medical well being of the patients. The
first risk is in the inherent nature of the analgesic drug
used. Some studies involved opioid in their protocols.5-9
These studies highlighted the possibility of respiratory
depression and cardiovascular instability when opioid
was used. However, these studies consistently showed
that adverse effects, even with opioid, were uncommon.
Our study avoided this problem as ketorolac, an
NSAID, was used as the analgesic. However, NSAIDs
do have  the i r  own adverse  e f fect s  inc luding
bronchospasm, gastrointestinal bleeding and allergic
reaction. Safety mechanisms have to be built into the
protocol including taking a detailed history concerning
drug allergy status, previous history of asthma and
Hong Kong j. emerg. med.  Vol. 14(1)  Jan 200720
peptic ulcer disease. Any adverse effect would have to
be recorded and reported. It is encouraging to note
that no adverse effect was reported during the period
of review.
The triage nurse initiated pain management protocol
needed a paradigm shift in several groups of staff in
the hospital. The protocol required the nursing staff
to play a central role. It is logical for nursing staff to
take on this role as they are the first HCW that an ED
patient will come into contact. As in the experience of
others,6,10 there were concerns expressed by hospital
medical teams about the safety of this approach during
the developmental stage of the protocol. During
internal feedback sessions, ED nursing staff themselves
also expressed concern about this new responsibility.
Nursing staff in the study ED had previously been
involved in other protocols and had consistently shown
that they were able to follow and perform effectively.
This fact, supported by literature review of successful
implementation of pain management protocol in other
EDs, convinced the nursing and medical staff. The
nurses involved in the protocol had to go through
rigorous education sessions. Choosing only the more
experienced nurses to be involved in the initial stage
acts as a further safeguard. Another problem is related
to the multi-racial and multi-lingual population
background of our ED patients and our ED HCW.
Pain perception and severity is a culturally based
concept and is highly subjective. While some
researchers debated the objectification of the highly
subjective concept of pain, the study ED decided that
use of a face pain scale would minimise the difficulties
due to our multi-racial and multi-lingual population
background.
The project yielded favourable results because there
was proactive education and re-education of staff
members regarding the assessment and documentation
of pain severity and the administration of analgesia.
Another step done was analysing and sharing results
with the team. This served to improve performance.
Subsequent feedback among the nurses showed
satisfaction with this new autonomy. We proposed that
similar protocols could be used for other conditions
and other EDs.
Limitations
There was the problem of documentation inadequacies
in  the  s tudy.  Indeed ,  pa in  a s s e s sment  and
documentation was less than 80% and this could be
improved. This has been highlighted to the nursing
staff and subsequent audits have shown improvement.
Documentation of the reason for withholding analgesia
by the triage nurse was also incomplete. We noted that
though time from triage to analgesia was significantly
improved, effort could still be made to review this work
process and to improve time from registration to
analgesia. Finally, the patients were not followed up
after discharge to assess for late adverse drug effects.
Conclusions
A triage nurse initiated pain management protocol
supported by the ED and hospital nursing staff can
reduce the time to analgesia for patients with painful
limb conditions Careful assessment can reduce the risk
of adverse drug reaction when nurses administer
NSAID analgesia.
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Emergency department triage nurse initiated pain management

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Emergency department triage nurse initiated pain management

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