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To evaluate statewide emergency department assessment and management of pain in pediatric patients as a quality improvement initiative.2002 Survey of Illinois Hospital emergency department's pediatric pain assessment and management strategies, in conjunction with a retrospective chart review of children, ages 0 to 15 years, treated for an extremity fracture. Survey results were available for 123 (59.4%) hospitals; 933 charts (107 hospitals) were reviewed for pain management. Survey results were compared with practices identified by chart review.Use of a pain assessment scale estimated by the survey was 92%, compared with 59% use by chart review. Use of pain assessment scales for infants was limited. Fifty percent of patients in moderate to severe pain would be offered an analgesic. Six- to 15-year-old children would be offered opioids more often than children aged 0 to 1 and 2 to 5 years. Offering higher potency narcotic analgesics was associated with patient's age, geographic location of the facility, and emergency department volume. Providing an analgesic (odds ratio 4.53, 95% confidence interval 2.89-7.10), offering supportive care (odds ratio 2.37, 95% confidence interval 1.44-3.89), and pediatric-focused annual nurse competencies (odds ratio 1.90, 95% confidence interval 1.18-3.06) correlated with reduction of the patient's pain.Disparity exists between perceived and documented emergency department pain management practices for children. Quality improvement initiatives should focus on improving pain assessment in infants, treating moderate to severe pain in children of all age groups, and education of health care providers in pain management strategies. Resources should target health care processes effective in decreasing pediatric pain.