Study: Pain management is inconsistent in EDs

A patient's race, age, and medical condition may affect whether or not they receive pain medications in the ED, according to a study of adults who presented to an emergency department with musculoskeletal pain.1

In the study of 868 adults, researchers found that fewer opioids and discharge analgesics were prescribed for black patients than for white patients. Also, younger patients, trauma patients, and patients with chronic pain received more opioids and discharge analgesics compared with older patients and those without trauma or chronic pain.

"If you were unlucky enough to get a certain ED physician, you might get analgesia for your pain only a third of the time, compared to 90% from another," says Alan Heins, MD, one of the study's authors and assistant professor in the department of emergency Medicine at University of South Alabama in Mobile.

ED nurses should use protocols for rapid assessment, standing orders for potent treatments, and perform frequent re-evaluations with orders for additional analgesics if pain is poorly controlled, recommends Heins. "ED nurses are much better at standardizing care, through use of protocols and evidence-based care guidelines, than physicians," he adds.

As advocates for patients in pain, ED nurses should work to eliminate variations in pain practice, underscores Janet Kaye Heins, RN, MSN, CRNP, the study's lead author. "We must lobby with our superiors to institute standardized nursing triage and treatment protocols to improve care and reduce disparities in pain management," she says. "Findings from several studies reveal that a nurse-initiated morphine protocol for severe pain significantly reduces time to analgesia."2

Protocol gives nurses autonomy

At Christiana Care Health System in Newark, DE, ED nurses use a pain protocol to ensure safe and effective pain management. "This protocol provides a great deal of autonomy for our triage nurses," says Karen Rollo, RN, BSN, CEN, SANE-A, an ED nurse at the hospital.

As with EDs across the country, they are busy and at times overcrowded, says Rollo. "Effective and consistent pain management is therefore definitely a priority, since the most common chief complaint in most EDs is pain," she says.

For the protocol to be used, patients must have a documented triage assessment, including vital signs and pain level, medications, allergies, and history. Nurses give ibuprofen to patients with nonurgent complaints such as headache, toothache, earache, contusions, lacerations, minor burns, and musculoskeletal pain, when pain is at a Level 4 or less on a 0-10 scale, with 10 being the worst pain.

"We start with 800 mg of ibuprofen if the patient has not taken any prior to arrival or if it has been taken prior to arrival with no relief," says Rollo. If the pain level is over 4 but less than 7, oxycodone can be given, unless patients are nauseous or have suspected sickle cell crisis, flank pain, pelvic pain, abdominal pain, or more serious traumatic injury. For patients with these complaints, or those with a pain level over 7, the ED physician is consulted and an evaluation is required within 30 minutes for intravenous pain medication. "These patients are assisted to a triage treatment area, or to a stretcher in a hallway spot equipped with call lights if a treatment room is not available," says Rollo.

Since pain is subjective, nurses are taught to accept the level a patient is reporting, but in the event that the triage nurse suspects that the patient may be seeking drugs, such as if the assessment doesn't fit with the complaint, the nurse has the option to ask the physician to first evaluate the patient to order the appropriate medication, which may not necessarily be a narcotic. "All patients medicated at triage are strongly encouraged to wait for the full evaluation and complete treatment, even if they feel better after they are medicated," says Rollo. "The percentage who leaves without completing treatment is only 2.4%."

At Jackson Memorial Hospital in Miami, FL, a pain protocol is used by triage nurses for all patients with a complaint involving pain. Standing orders allow nurses to give patients a single dose of acetaminophen after a completed nursing assessment, says Susie Tome-Manjarrez, ARNP, an ED triage nurse. (See the ED's triage standing orders for pain management.)

The nurse then documents the pain assessment findings on the nursing flow sheet, including the response to medications given and any complications. "If there is no improvement when we reassess the patient's response, we expedite the patient back to the treatment area," she says.


  1. Heins JK, Heins A, Grammas M, et al. Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. J Emerg Nurs 2006; 32:219-224.
  2. Fry M, Holdgate A. Nurse initiated intravenous morphine in the emergency department: Efficacy, rate of adverse events and impact on time to analgesia. Emerg Med 2002; 14:249-254.


For more information, contact:

  • Janet Kaye Heins, RN, MSN, CRNP, 901 Gayfer Ave., No. 328, Fairhope, AL 36532. E-mail:
  • Karen Rollo, RN, BSN, CEN, SANE-A, Forensic Nurse Examiner/Registered Nurse II, Christiana Care Health System, Christiana Emergency Department, 4755 Ogletown-Stanton Road, Newark, DE 19718. Telephone: (302) 733-4799. E-mail:
  • Susie Tome-Manjarrez, ARNP, Emergency Services, Jackson Memorial Hospital, 1611 N.W. 12th Ave, Miami, FL 33136. Telephone: (305) 585-2708. Fax: (305) 585-0000. E-mail: