Long-Bone Fracture Pain Management in the Emergency Department

Published:March 24, 2011DOI:https://doi.org/10.1016/j.jen.2010.11.001


      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.


      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.


      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 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.


      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.

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        • Miaskowski C
        • Bair M
        • Chou R
        • et al.
        Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain.
        6th ed. panel. American Pain Society, Glenview, IL2008
        • Todd K
        • Deaton C
        • D'Adamo A
        • Goe L
        Ethnicity and analgesic practice.
        Ann Emerg Med. 2000; 35: 11-16
        • Epps CD
        • Ware LJ
        • Packard A
        Ethnic wait time differences in analgesic administration in the emergency department.
        Pain Manag Nurs. 2008; 9: 26-32
        • Bernabei R
        • Gambassi G
        • Lapane K
        • et al.
        Management of pain in elderly patients with cancer.
        JAMA. 1998; 279: 1877-1882
        • Cleeland CS
        • Gonin R
        • Hatfield AK
        • et al.
        Pain and its treatment in outpatients with metastatic cancer.
        N Engl J Med. 1994; 330: 592-596
        • Heins JK
        • Heins A
        • Grammas M
        • Costello M
        • Huang K
        • Mishra S
        Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department.
        J Emerg Nurs. 2006; 32: 219-224
        • Cintron A
        • Morrison RS
        Pain and ethnicity in the United States: a systematic review.
        J Palliative Med. 2006; 9: 1454-1473
        • Ezenwa MO
        • Ameringer S
        • Ward SE
        • Serlin RC
        Racial and ethnic disparities in pain management in the United States.
        J Nurs Scholarship. 2006; 38: 225-233
        • Pletcher MJ
        • Kertesz SG
        • Kohn MA
        • Gonzales R
        Trends in opioid prescribing by race/ethnicity for patients seeking care in the US emergency departments.
        JAMA. 2008; 299: 70-78
        • Quazi S
        • Eberhart M
        • Jacoby J
        • Heller M
        Are racial disparities in ED analgesia improving? Evidence from a national database.
        Am J Emerg Med. 2008; 26: 462-464
        • Tamayo-Sarver J
        • Hinze S
        • Cydulka R
        • Baker D
        Racial and ethnic disparities in emergency department analgesic prescription.
        Am J Public Health. 2003; 93: 2067-2073
        • Bijur P
        • Berard A
        • Esses D
        • Calderon Y
        • Gallagher EJ
        Race, ethnicity, and management of pain from long-bone fractures: a prospective study of two academic urban emergency departments.
        Acad Emerg Med. 2008; 15: 589-597
        • Tamayo-Sarver J
        • Dawson N
        • Hinze S
        • et al.
        The effect of race/ethnicity and desirable social characteristics on physicians decision to prescribe opioid analgesics.
        Acad Emerg Med. 2003; 10: 1239-1248
        • Emergency Nurses Association
        Mission and code of ethics.
        (Accessed October 29, 2010)
        • Stjernsward J
        WHO cancer pain relief programme.
        Cancer Surveys. 1988; 7: 195-208
        • Dalton JA
        • Youngblood R
        Clinical application of the World Health Organization analgesic ladder.
        J Intravenous Nurs. 2000; 23: 118-124
        • McCaffery M
        Pain control. Barriers to the use of available information. World Health Organization Expert Committee on Cancer Pain Relief and Active Supportive Care.
        Cancer. 1992; 70: 1438-1449
        • Zech DF
        • Grond S
        • Lynch J
        • Hertel D
        • Lehmann KA
        Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study.
        Pain. 1995; 63: 65-76
        • de Wit R
        • van Dam F
        • Loonstra S
        • et al.
        The Amsterdam Pain Management Index compared to eight frequently used outcome measures to evaluate the adequacy of pain treatment in cancer patients with chronic pain.
        Pain. 2001; 91: 339-349
        • Cleeland CS
        • Gonin R
        • Baez L
        • Loehrer P
        • Pandya KJ
        Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study.
        Ann Intern Med. 1997; 127: 813-816
        • Schug SA
        • Zech D
        • Dorr U
        Cancer pain management according to WHO analgesic guidelines.
        J Pain Symptom Manag. 1990; 5: 27-32
        • Cannon J
        • Silvestri S
        • Munro M
        Imaging choices in occult hip fracture.
        J Emerg Med. 2009; 37: 144-152
        • Ho K
        • Connell DG
        • Janzen DL
        • Grunfeld A
        • Clark TW
        Using tomography to diagnose occult ankle fractures.
        Ann Emerg Med. 1996; 27: 600-605
        • Fosnocht DE
        • Heaps ND
        • Swanson ER
        Patient expectations for pain relief in the ED.
        Am J Emerg Med. 2004; 22: 286-288
        • Yee AM
        • Puntillo K
        • Miaskowski C
        • Neighbor ML
        What patients with abdominal pain expect about pain relief in the emergency department.
        J Emerg Nurs. 2006; 32: 281-287
        • Miaskowski C
        • Nichols R
        • Brody R
        • Synold T
        Assessment of patient satisfaction utilizing the American Pain Society's Quality Assurance Standards on acute and cancer-related pain.
        J Pain Symptom Manag. 1994; 9: 5-11
        • Bernstein SL
        • Aronsky D
        • Duseja R
        • et al.
        The effect of emergency department crowding on clinically oriented outcomes.
        Acad Emerg Med. 2009; 16: 1-10
        • Fuentes EF
        • Kohn MA
        • Neighbor ML
        Lack of association between patient ethnicity or race and fracture analgesia.
        Acad Emerg. 2002; 9: 910-915
        • Bijur PE
        • Berard A
        • Esses D
        • Nestor J
        • Schechter C
        • Gallagher EJ
        Lack of influence of patient self-report of pain intensity on administration of opioids for suspected long-bone fractures.
        J Pain. 2006; 7: 438-444
        • Campbell P
        • Dennie M
        • Dougherty K
        • Iwaskiw O
        • Rollo K
        Implementation of an ED protocol for pain management at triage at a busy level I trauma center.
        J Emerg Nurs. 2004; 30: 431-438
        • Fry M
        • Ryan J
        • Alexander N
        A prospective study of nurse initiated panadeine forte: expanding pain management in the ED.
        Accid Emerg Nurs. 2004; 12: 136-140
        • Seguin D
        A nurse-initiated pain management advanced triage protocol for ED patients with an extremity injury at a level I trauma center.
        J Emerg Nurs. 2004; 30: 330-335
        • Meunier-Sham J
        • Ryan K
        Reducing pediatric pain during ED procedures with a nurse-driven protocol: an urban pediatric emergency department's experience.
        J Emergency Nurs. 2003; 29: 127-132
        • Herr K
        • Titler M
        Acute pain assessment and pharmacological management practices for the older adult with a hip fracture: review of ED trends.
        J Emerg Nurs. 2009; 35: 312-320
        • Swailes E
        • Rich E
        • Lock K
        • Cicotte C
        From triage to treatment of severe abdominal pain in the emergency department: evaluating the implementation of the emergency severity index.
        J Emerg Nurs. 2009; 35: 485-489


      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.