Pain Assessment in Pediatric Emergency Departments A National Survey Joshua Haupt, MD,* Nipam Shah, MBBS, MPH,* Matthew Fifolt, PhD,† Eric Jorge, MD,‡ Peter Glaeser, MD,* Jacob Zisette, RN,§ and Christopher Pruitt, MD* Objective: Accurate and consistent assessment of pain is essential in the pediatric emergency setting. Despite recommendations for formal assess- ment protocols, current data are lacking on pain assessment in pediatric emergency departments (EDs) and, specifically, whether appropriate tools are being used for different age groups. Our aim was to determine the status of pain assessment in US pediatric EDs. Methods: We disseminated an online cross-sectional survey (after piloting) to pediatric EDs within the Children's Hospital Association. Re- sponses were analyzed for each question owing to incomplete responders. We report descriptive statistics, with categorical variables compared with χ 2 (P < 0.05 considered statistically significant). Results: From 120 pediatric EDs, we received 57 responses (48%). Most respondents (28/49, 57%) were from freestanding pediatric centers. All 57 EDs (100%) performed formal pain assessments, with 31 (63%) of 49 using an ED-specific protocol. Freestanding children's hospitals were more likely to have ED-specific protocols (21/31, 68%) than nonfreestanding (10/31, 32%) (P = 0.04). Among 56 responders, 100% stated that nurses are tasked with assessing pain. For children 0 to 2 years, 29 (54%) of 54 used the Face, Legs, Activity, Cry, Consolability scale. Numerical scales were increasingly used with older ages: 3 to 4 years, 40 (80%) of 50; 5 to 10 years, 49 (98%) of 50; and 11 to 21 years, 50 (100%) of 50. Conclusions: In contrast to prior research, US pediatric EDs are routinely assessing pain with scales that are mostly appropriate for their respective age groups. Further research is needed to explore barriers to implementing appro- priate pain ratings for all children and, ultimately, how these assessments impact the care of children in the emergency setting. Key Words: pain, United States, protocol, scale (Pediatr Emer Care 2019;00: 00–00) P ain is one of the most common symptoms for children present- ing to the emergency department (ED). Annually, about 27 million children visit US EDs, many of them with painful con- ditions. 1 Although often challenging in the pediatric population, 2 appropriate pain assessment is an important early priority for pe- diatric emergency care. Although pain is most often assessed by nurses in triage, studies have demonstrated that these assessments are, at times, inconsistent and inappropriate, necessitating a standardized protocol. 3,4 In 2001, the Joint Commission on Accreditation of Healthcare Organizations mandated that pain be assessed for all patients. 5 Al- though it was proposed that health care organizations incorporate pain assessment protocols and ensure staff competency in their execution, it was not until 2017 that they furthered these recommen- dations by prioritizing formal policies on pediatric pain assessment for health care organizations in ways “that are consistent with the patient's age, condition, and ability to understand. ” 6,7 In light of these relatively novel requirements, little is known about the current ap- proach to pain assessment in US pediatric EDs. Moreover, there is a lack of standard recommendations for formal, age-appropriate pain assessment tools in the pediatric emergency setting. 8 In light of the importance of pain assessment for children and the evolving requirements for hospitals caring for children, we sought to describe the current state of pain assessment in US pedi- atric EDs. The primary objective of our study was to determine if assessment and documentation of pain are being performed rou- tinely for all patients and if protocols are being used to this end. Secondary objectives included the types of instruments used for pain assessment for various age ranges and which staff (in which location of the ED) are routinely assessing pain. METHODS Study Design and Population We conducted a cross-sectional study on use of pain assess- ment tools for pediatric patients using an online survey. We solicited nurse managers or nurse educators of US pediatric EDs affiliated with the Children's Hospital Association. 9 The survey was open from March to May 2018. Our protocol was reviewed by our institutional review board and approved as exempt. Survey Development and Design To develop our survey instrument, we first derived questions within 4 survey domains: demographics, existing protocols for pain assessment, pain scales used for specific age groups, and other miscellaneous information. Demographics included ED type (freestanding vs pediatric ED within a general ED), annual census, and location based on US census region (Northeast, Midwest, South, West). We then asked whether there were hospital-wide and/or ED-specific protocols for pain assessment and docu- mentation. Based on previously published literature, we inquired about use of the following pain scales for age groups 0 to 2, 3 to 4, 5 to 10, and 11 to 21 years of age: Wong-Baker FACES; visual analog scale; numerical (1–10); Face, Legs, Activity, Cry, Consolability (FLACC) scale; Children's Hospital of Eastern Ontario Pain Scale; Neonatal Infant Pain Scale; or other. 10–12 More than 1 response was allowed if multiple pain scales were used for a particular age group. Lastly, we asked about pain assess- ment tools used for cognitively impaired or nonverbal patients, as well as pain score thresholds that would trigger a higher ED triage level. In all, our instrument was comprised of 23 items, with most re- quiring either a categorical or multiple choice response. For those multiple choice questions allowing more than one response, we also included “Other” as a potential response, allowing for free text. This initial survey was reviewed by the entire research team, and an edited version was integrated into Qualtrics online software (Provo, UT). In consultation with our institutional survey expert, From the *Department of Pediatrics, Division of Pediatric Emergency Medi- cine; †School of Public Health, Department of Health Care Organization and Policy; ‡School of Medicine, University of Alabama at Birmingham; and §Children's of Alabama, Birmingham, AL. Disclosure: The authors declare no conflict of interest. Reprints: Nipam Shah, MBBS, MPH, Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Alabama at Birmingham, 1600 5th Ave S, Suite 110, Birmingham, AL 35233 (e‐mail: nshah@peds.uab.edu). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161 ORIGINAL ARTICLE Pediatric Emergency Care • Volume 00, Number 00, Month 2019 www.pec-online.com 1 Copyright © 2019 Wolters Kluwer Health, Inc. 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