Pain is one of the most common reasons for which children visit the emergency department (ED). Nevertheless, pain is frequently under-recognised and under-treated in this setting.1^–3 The perception of pain by children has various behavioral and emotional components that are interrelated with other external factors.4 5 Since the ED is a stressful environment, it may have a major impact on children’s perception of pain and may affect pain assessment by the staff.1

Because pain is a subjective experience, individual self-report is the favoured method to evaluate pain in children who are competent to use these tools. This is usually possible in children aged >3 years.4 5 The standard self-report pain scales, however, were not designed specifically for the assessment of pain in the ED setting. In previous ED pain assessment studies, triage nurses noted that children assessed by self-report scales seemed to pick a random value which often appeared to reflect the degree of their pain inaccurately. Furthermore, the children often appeared anxious during the initial triage evaluation and tended to defer to their parents when prompted to report a pain score.6 7

The impression of experienced emergency nurses at the Meyer Children’s Hospital was that, in triage, observational assessment by ED personnel “may well reflect” the child’s pain. Some nurses noticed differences in pain expression between the waiting room and the triage room when no analgesic intervention was provided, and speculated that these differences could be properly assessed by the staff.

Study rationale

We sought to find out if there is discordance in triage between self-reported and behavioural pain measures in children aged 3–15 years. The primary objective of the study was to compare observational scores and self-report scores in the waiting room and in the triage room. We hypothesised that pain scores measured by the two methods in the two ED locations will be similar. The secondary objective was to examine if the triage process influences children’s self-report.

Study outcome measures

The primary outcome measure was the difference in pain scores between observational assessment and self-report. The secondary outcome measure was the difference in pain scores between the waiting room and triage.

METHODS

Study design

Pain was assessed twice, first in the waiting room and then shortly after at triage before any pain management intervention. Each pain measurement was performed with two instruments: a self-assessment tool completed by the patient and an observational scoring tool completed by medical staff (fig 1).

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Figure 1 Study design. AHTPS, Alder Hey Triage Pain Score; WBS, Wong-Baker FACES Pain Rating Scale; VAS, Visual Analogue Scale.

Study instruments

Two instruments were used: a self-assessment tool completed by the patient (the Wong-Baker FACES Pain Rating Scale (WBS)5 for children aged 3–7 years or a visual analogue scale (VAS)5 for those aged 8–15 years) and an observational scoring tool (the Alder Hey Triage Pain Score (AHTPS)8) completed by medical staff.

The AHTPS is a relatively new observational instrument developed specifically for use by ED triage personnel to evaluate pain in children. In a previous study this tool was shown to have construct validity for triage purposes in children aged 1––16 years.8 The AHTPS is a behavioural tool that identifies five categories of observed pain: voice/cry, facial expression, posture, movement and colour (translated into Hebrew). Each category is scored 0, 1 or 2 by a trained observer with the total score of 0–10.8

The WBS is a self-report scoring scale mainly designed for use by children aged 3–7 years.5 The child is presented with a selection of six faces expressing different degrees of distress. After providing an explanation of the scale, the examiner used specific instructions for use. The child then picked the face that best represents his/her level of pain. The scale ranges numerically from 0 to 10 in steps of 2.

The VAS is a self-report scoring scale mainly designed for use by children aged 8–15 years.5 It consists of a horizontal line, 100 mm in length, anchored by word descriptors such as none, annoying, uncomfortable and worst imaginable pain (translated into Hebrew). After providing an explanation of the scale, the examiner asks the child to mark the line at the point that represents his or her current state of pain. The score is determined by measuring the left end of the line to the point at which the patient makes a mark.

Study preparation

Three months before the study all ED triage nurses at the Pediatric Emergency Department of Haifa Children’s Hospital were trained in the use of the AHTPS, including patient identification, discussion of AHTPS categories, clarification of specific behaviours in each category and scoring. They continued to use the VAS and WBS during the training period. When the nurses had had sufficient exposure to the new tool, we assessed its inter-rater reliability by comparing the AHTPS data gathered concurrently by one of the nurses and one of the three study investigators for 40 children. The calculated Cohen’s kappa value was 0.79 (p = 0.001).

Sample and setting

The study population consisted of a convenience sample of patients aged 3–15 years who presented at the ED of the Meyer Children’s Hospital from October 2005 to July 2006 with a chief complaint of pain. The annual volume of the ED is approximately 15 000 patients. Only children for whom this was the first visit to an ED were included. Exclusion criteria were presence of a life-threatening disease, pain that was part of a more serious condition which required immediate medical attention, an interval of more than 20 min between the waiting room and triage room and treatment for pain prior to triage.

Study protocol

Patients were enrolled into the study on the basis of a convenience sample (when MK, TH or IS were present at the ED). Data were gathered prospectively by the study’s two principal investigators, IS and MK (fig 1).

A study investigator (researcher A) was notified by the clerk at the ED desk about any child potentially eligible for the study. After registration of the patient at the ED desk, researcher A waited until the child was settled in the waiting room. The caregiver(s) of the child were then approached by researcher A who verified the inclusion criteria, explained the purpose and design of the study and obtained informed consent. Participants were told in the course of getting consent that they would be provided with two self-ratings. Researcher A then recorded the exact time of ED registration and informed the triage nurse about a new patient for the study so that the child would be seen before any pain treatment. Immediately thereafter, researcher A completed the AHTPS and then presented the patient with the WBS (for the 3–7 year age group) or the VAS (for the 8–15 year age group) for self-reporting. When the self-report instrument was completed, researcher A recorded the two pain scores on a designated study sheet. The pain scores were not recorded in the patient’s medical record and researcher A did not reveal them to anyone. Researcher A also made certain that no intervention (analgesic, sling, wheelchair, dressing) was provided to the patient while awaiting triage. Caregivers were asked to keep the child’s report of pain confidential. Researcher A was also responsible for recording the patient’s demographic characteristics for purposes of the study.

At triage the triage nurse (researcher B) completed an AHTPS first and then presented the patient with the WBS or VAS. Researcher B then recorded the two scores on a designated study sheet. She then completed patient triage including the provision of pain relieving interventions per protocol (see appendix 1).

Until the point at which the patient received treatment, the two researchers remained blind to each other’s scores and to the WBS/VAS scores of the child at each other’s location. After treatment was provided they revealed the scores to each other and researcher A recorded them on a separate study sheet.

Statistical analysis

Data were managed and analysed with the SPSS Version 13 software and SAS Version 9.2. Inter-rater agreement was measured by kappa statistics. A paired t test was used to compare pain scores in the two ED locations.

RESULTS

The caregiver(s) of 80 potential study participants were approached at ED registration during the study period. Five patients were later dropped, two because the caregiver refused to give consent prior to triage, two who received analgesia in the waiting room and one with a pre-triage wait of >20 min. The remaining 75 children met all the inclusion criteria and constituted the study group. Twenty-nine patients (22 boys, 7 girls) were aged 3–7 years (median 6 years) and 46 (22 boys, 24 girls) were aged 8–15 years (median 12 years).

Patients presented with common painful conditions: abdominal pain (45.2%), musculoskeletal pain (27.4%), headache (13.7%), chest pain (4.1%) and other causes (9.6%). The waiting time between waiting room and triage once the consenting process was completed took less than 10 min in 72 patients. Only 6 patients were diagnosed with severe pain (per protocol, appendix 1).

Analgesic treatment in triage (per protocol, appendix 1) was as follows: 37 patients were treated with paracetamol, 19 with ibuprofen, 8 with oxycodone, 4 with morphine, 5 with dypirone and 2 with tramadol.

Primary outcome measure

The scores measured by the AHTPS were significantly lower than the scores measured by the WBS/VAS (p<0.0001).

Secondary outcome measure

The level of pain of the patients measured by both methods (self-report and observational) was lower in the triage room (fig 2). The WBS and VAS scored significantly lower in the triage room than in the waiting room (p<0.042 and p<0.006, respectively). However, the differences in AHTPS scores between the waiting room and the triage room were not significant.

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Figure 2 Mean pain scores in the waiting room and in the triage room. AHTPS, Alder Hey Triage Pain Score; WBS, Wong-Baker FACES Pain Rating Scale; VAS, Visual Analogue Scale.

DISCUSSION

Evaluating the level of pain in triage is of major importance because children are at risk of inadequate pain control.1^–11 The major finding of this study is that the observational assessment tool scored significantly lower than the self-report tools. Our study shows that self-reporting performs better than the AHTPS, a tool with construct validity for triage purposes.8

The overall low scores of the observational pain assessment tool are important because they suggest that ED personnel underestimate the level of pain perceived by children. Previous studies have also shown that ED healthcare providers tend to score pain lower than the children themselves.6 7 Our study supports these results. An interesting finding of the study is that, if the triage nurses had provided analgesic treatment based on the AHTPS, three out of six patients diagnosed with severe pain (pain level 7–10 per protocol) would not have been treated with morphine or tramadol but with oxycodone, ibuprofen or dypirone.

Using the WBS, VAS and AHTPS, we found that, without any analgesic intervention, children perceived a higher level of pain in the waiting room than in triage (fig 2). These findings were not observed when the AHTPS was used. The lower perception of pain in the triage room could be explained by the fact that the more crowded and stressful environment of the waiting room contributed to the distress of the patients. Calming the patient, on the other hand, is one of the purposes of the triage process.9 These results emphasise the importance of the triage process in the assessment of pain in children in the ED.9 Like others, we have the impression that children experience distress and anxiety that may influence their perception of pain.1^–3 Adding a distress assessment tool in triage could be helpful. One obstacle, however, for the utilisation of such a tool is the fact that most commonly used behavioural pain scales have not been adequately validated.10

Limitations of the study

Our study has several limitations.

• The convenience sample was relatively small and possibly prevented equal representation of all aetiologies of paediatric pain.

• A selection bias is possible. Only a few of the patients who met the inclusion criteria had severe pain because most children who presented with severe pain at our centre were immediately triaged and were therefore ineligible for the study.

• Our search for a valid observational pain scoring tool to be used in the ED yielded only one study.8 11 We used the AHTPS as our observational tool on the basis of the study of Stewart et al8 that demonstrated its construct validity for triage purposes.

• There was no randomisation regarding when the pain is evaluated first in triage or in the waiting room. It is theoretically possible that the order of the questioning influenced the higher scores in the waiting room.

• We decided to limit the interval between the waiting room assessment and the triage room assessment to 20 min because our institutional data show that 95% of patients are triaged within this time frame.

CONCLUSIONS

Observational pain assessment underestimates children’s perception of pain and should not be recommended in children aged >3 years. Triage has a calming effect on children.