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Abebe Y, Hetmann F, Sumera K, Holland M, Staff T. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 2021; 29:170. [PMID: 34895311 PMCID: PMC8665507 DOI: 10.1186/s13049-021-00974-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinically meaningful pain reduction with respect to severity and the adverse events of drugs used in prehospital pain management for children are areas that have not received sufficient attention. The present systematic review therefore aims to perform a comprehensive search of databases to examine the preferable drugs for prehospital pain relief in paediatric patients with acute pain, irrespective of aetiology. METHODS The systematic review includes studies from 2000 and up to 2020 that focus on children's prehospital pain management. The study protocol is registered in PROSPERO with registration no. CRD42019126699. Pharmacological pain management using any type of analgesic drug and in all routes of administration was included. The main outcomes were (1) measurable pain reduction (effectiveness) and (2) no occurrence of any serious adverse events. Searches were conducted in PubMed, Medline, Embase, CINAHL, Epistemonikos and Cochrane library. Finally, the risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist and a textual narrative analysis was performed due to the heterogeneity of the results. RESULTS The present systematic review on the effectiveness and safety of analgesic drugs in prehospital pain relief in children identified a total of eight articles. Most of the articles reviewed identified analgesic drugs such as fentanyl (intranasal/IV), morphine (IV), methoxyflurane (inhalational) and ketamine (IV/IM). The effects of fentanyl, morphine and methoxyflurane were examined and all of the included analgesic drugs were evaluated as effective. Adverse events of fentanyl, methoxyflurane and ketamine were also reported, although none of these were considered serious. CONCLUSION The systematic review revealed that fentanyl, morphine, methoxyflurane and combination drugs are effective analgesic drugs for children in prehospital settings. No serious adverse events were reported following the administration of fentanyl, methoxyflurane and ketamine. Intranasal fentanyl and inhalational methoxyflurane seem to be the preferred drugs for children in pre-hospital settings due to their ease of administration, similar effect and safety profile when compared to other analgesic drugs. However, the level of evidence (LOE) in the included studies was only three or four, and further studies are therefore necessary.
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Affiliation(s)
- Yonas Abebe
- Department of Emergency and Critical Care Nursing, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway.
| | - Fredrik Hetmann
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | | | - Matt Holland
- Library and Knowledge Services for NHS Ambulance Services in England, Bolton, UK
| | - Trine Staff
- Bachelor Programme in Paramedics, Institute of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
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Whitley GA, Hemingway P, Law GR, Jones AW, Curtis F, Siriwardena AN. The predictors, barriers and facilitators to effective management of acute pain in children by emergency medical services: A systematic mixed studies review. J Child Health Care 2021; 25:481-503. [PMID: 32845710 PMCID: PMC8422593 DOI: 10.1177/1367493520949427] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
We aimed to identify predictors, barriers and facilitators to effective pre-hospital pain management in children. A segregated systematic mixed studies review was performed. We searched from inception to 30-June-2020: MEDLINE, CINAHL Complete, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-method studies of children under 18 years, their relatives or emergency medical service staff were eligible. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research were used to determine the confidence in cumulative evidence. From 4030 articles screened, 78 were selected for full text review, with eight quantitative and five qualitative studies included. Substantial heterogeneity precluded meta-analysis. Predictors of effective pain management included: 'child sex (male)', 'child age (younger)', 'type of pain (traumatic)' and 'analgesic administration'. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives and colleagues) influences on the clinician along with child factors (child's experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low. Efforts to facilitate analgesic administration should take priority, perhaps utilising the intranasal route. Further research is recommended to explore the experience of the child. Registration: PROSPERO CRD42017058960.
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Affiliation(s)
- Gregory A Whitley
- Community and Health Research Unit, University of Lincoln, UK,Gregory A Whitley, Community and Health Research Unit, Sarah Swift Building, University of Lincoln, Brayford Wharf East, Lincoln LN5 7AT, Lincolnshire, UK.
| | - Pippa Hemingway
- Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Graham R Law
- Community and Health Research Unit, University of Lincoln, UK
| | - Arwel W Jones
- Department of Allergy, Immunology and Respiratory Medicine, Monash University, Australia
| | - Ffion Curtis
- Lincoln Institute for Health, University of Lincoln, UK
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Handyside B, Pocock H, Deakin CD, Rodriguez-Bachiller I. An EXploration of the facilitators and barriers to paramedics' assessment and treatment of pain in PAediatric patients following Trauma (EX-PAT). Br Paramed J 2021; 6:10-18. [PMID: 34539250 PMCID: PMC8415212 DOI: 10.29045/14784726.2021.9.6.2.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Pain is a common symptom among patients presenting to ambulance services and is often associated with traumatic injury. Assessment and management of pain in children in the pre-hospital setting is suboptimal. This study aimed to understand the facilitators and barriers experienced by paramedics in their assessment and management of pain in children who have sustained traumatic injuries. Methods: Face-to-face, audio-recorded semi-structured interviews using a piloted topic guide were conducted with paramedics employed by South Central Ambulance Service NHS Foundation Trust. Interviews were professionally transcribed, coded manually and analysed using thematic analysis. Results: Eleven interviews were conducted; three themes related to assessment and three related to management were identified. Previous positive experiences of utilising pain scoring tools were identified as a facilitator to pain assessment, whereas a lack of confidence in using pain scoring tools was a barrier. Patients’ understanding of and compliance with the tools were both a facilitator and a barrier to assessment. Facilitators to management included personal sub-themes of colleagues/others, exposure, being a parent, technology, severity of the injury and subjective pain scoring. Organisational facilitators included medicines, routes, and alternative methods. Situational facilitators included patient-specific solutions and parents. Five personal barriers to management included medicines, skill, consequences to self or patient, negative interactions, and limited exposure. Three organisational barriers included medicines and routes, equipment issues and choices, and training and culture. Within the theme of situation, two sub-themes emerged: patient-specific issues and environment-specific issues. Novel facilitators to emerge were those of alternative methods and being a parent. Conclusion: A multitude of factors incorporating situational, organisational, and personal all combine to determine how paramedics treat paediatric trauma patients. A multi-stakeholder approach to providing clearer assessment tools, improved education, equipment, and pharmacy options may improve assessment and management compliance for the benefit of the patient.
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Affiliation(s)
- Barry Handyside
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0002-1842-6582
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0001-7648-5313
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0002-2565-9771
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Whitley GA, Hemingway P, Law GR, Siriwardena AN. Ambulance clinician perspectives of disparity in prehospital child pain management: A mixed methods study. Health Sci Rep 2021; 4:e261. [PMID: 33860109 PMCID: PMC8033633 DOI: 10.1002/hsr2.261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/21/2021] [Accepted: 01/24/2021] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND When children suffer acute pain, the ambulance service is often involved to provide initial assessment, treatment, and transport. Several predictors of effective pain management have been identified, including children who are younger (0-5 years), administered analgesics, and living in homes from more affluent areas. OBJECTIVE To explain previously identified predictors of effective prehospital pain management in children. DESIGN Mixed methods sequential explanatory study. SETTING AND PARTICIPANTS East Midlands Ambulance Service National Health Service Trust paramedics and emergency medical technicians (EMTs) participated in face-to-face semi-structured interviews. These were audio recorded, transcribed verbatim, and coded using thematic analysis. Meta-inferences were generated and illustrated within a joint display. RESULTS Twelve clinicians (9 paramedics and 3 EMTs) were interviewed. Median (interquartile range) age was 43.5 years (41.5, 45.75), 58% were male (n = 7) and 58% were parents (n = 7). Possible explanations were provided for all predictors. Younger children were perceived to express more emotion, were easier to distract, and lived more in the moment than their older counterparts, which explained why younger children were more likely to achieve effective pain management. Analgesics were perceived to have a psychosocial benefit in addition to the pharmacological action. Ambulance clinicians felt that children living in more affluent areas were more likely to achieve effective pain management because the kempt environment facilitated assessment and management and clinicians spent more time on scene; this allowed more time for analgesics to take effect. Participants perceived paramedics to be more confident, and it was found that paramedics were older, more experienced, had a greater scope of practice, and spent more time on scene than EMTs. CONCLUSION Prehospital pain management in children could be improved by facilitating and prioritizing analgesic administration and by ambulance services ensuring a paramedic, or highly trained clinician, is present on each vehicle, necessitating long-term commitment to staff development.
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Affiliation(s)
- Gregory Adam Whitley
- Community and Health Research Unit, School of Health and Social CareUniversity of LincolnLincolnUK
| | - Pippa Hemingway
- Faculty of Medicine and Health SciencesUniversity of NottinghamNottinghamUK
| | - Graham Richard Law
- Community and Health Research Unit, School of Health and Social CareUniversity of LincolnLincolnUK
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Whitley GA, Hemingway P, Law GR, Wilson C, Siriwardena AN. Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study. Am J Emerg Med 2019; 38:1424-1430. [PMID: 31864872 DOI: 10.1016/j.ajem.2019.11.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/25/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting. METHODS A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale). RESULTS 2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.46; CI 1.19-1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.37; CI 1.04-1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant. CONCLUSION These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.
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Affiliation(s)
- Gregory Adam Whitley
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom.
| | - Pippa Hemingway
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, England, United Kingdom
| | - Graham Richard Law
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom
| | - Caitlin Wilson
- North West Ambulance Service NHS Trust, Bolton, England, United Kingdom
| | - Aloysius Niroshan Siriwardena
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom
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Abstract
Introduction: Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. Studies have identified a number of barriers to pre-hospital pain management in children which include the route of analgesia administration. The aim of this review is to critically evaluate the pre-hospital literature, exploring the safety and efficacy of intranasal (IN) analgesics for children suffering pain. Methods: We performed a rapid evidence review, searching from inception to 17 December 2018, CINAHL, MEDLINE and Google Scholar. We included studies of children < 18 years suffering pain who were administered any IN analgesic in the pre-hospital setting. Our outcomes were effective pain management, defined as a pain score reduction of ≥ 2 out of 10, safety and rates of analgesia administration. Screening and risk of bias assessments were performed in duplicate. We performed a narrative synthesis. Results: From 310 articles screened, 23 received a full-text review resulting in 10 articles included. No interventional studies were found. Most papers reported on the use of intranasal fentanyl (INF) (n = 8) with one reporting IN ketamine and the other IN S-ketamine. Narrative synthesis showed that INF appeared safe and effective at reducing pain; however, its ability to increase analgesia administration rates was unclear. The effectiveness, safety and ability of IN ketamine and S-ketamine to increase analgesia administration rates were unclear. There was no evidence for IN diamorphine for children in this setting. Conclusion: Interventional studies are needed to determine with a higher confidence the effectiveness and safety of IN analgesics (fentanyl, ketamine, S-ketamine, diamorphine) for children in the pre-hospital setting.
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Affiliation(s)
| | - Richard Pilbery
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-5797-9788
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Gnirke A, Beckers SK, Gort S, Sommer A, Schröder H, Rossaint R, Felzen M. [Analgesia in the emergency medical service: comparison between tele-emergency physician and call back procedure with respect to application safety, effectiveness and tolerance]. Anaesthesist 2019; 68:665-675. [PMID: 31489458 DOI: 10.1007/s00101-019-00661-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute pain is a common reason for calling emergency medical services (EMS) and can require medication depending on the pain intensity. German EMS personnel feel strong pressure to reduce a patient's pain but are restricted by law. Currently, German federal law only allows the administration of opioid-containing drugs by or on the order of a physician, while in other European countries (e.g. Switzerland and The Netherlands) the administration of opioid-based analgesia by trained and certified paramedics is common practice. Consequently, a patient in Germany experiencing acute pain needs the attendance of an emergency physician in EMS missions. According to international standards pain reduction on the numeric rating scale (NRS) score by ≥2 or a NRS score ≤4 at the end of the patient transport is considered to be adequate. OBJECTIVE Comparison of two different algorithm-based concepts for analgesia with consultation of a physician analyzing the efficacy, tolerance and safety of application. MATERIAL AND METHODS In a retrospective cohort study in two different regions, two physician-supported algorithm-based analgesia concepts, a call back-supported concept (EMS Schleswig-Holstein: RKiSH) and a tele-EMS physician-based concept (EMS Aachen: RDAC), were compared over 2 years. The call back-supported concept is based on specific algorithms and certification of EMS personnel. In Aachen, the tele-EMS physician is integrated into the routine EMS system and includes immediate vital data transmission. RESULTS Over a period of 2 years call back-supported analgesia was administered in 878 cases (2016: 428, 2017: 450) and telemedically assisted analgesia was used in 728 cases (2015: 226, 2016: 502). Call back vs. telemedicine: initial NRS scores were 9 (8-10) and 8 (6-9), respectively (p < 0.0001); NRS scores were reduced by 4 (3-5) and 5 (3-6), respectively (p = 0.0002), leading to mean NRS scores of 4 (3-6) vs. 3 (2-4), respectively (p < 0.0001) at patient handover/emergency room arrival. Clinically relevant pain reduction was achieved in both groups. Complete NRS documentation was conducted in 753 (85.8%) vs. 673 (92.4%) cases, respectively, p = 0. Severe adverse events did not occur in either of the groups. CONCLUSION The administration of analgesia by EMS personnel with teleconsultation of a physician is effective and has a low rate of complications, particularly morphine. Overall, algorithm-based call back-supported as well as telemedically supported analgesia concepts based on regular training improve the management of pain in the prehospital setting. In addition, the resources of the emergency physician remain available for life-threatening emergencies. The training, certification and supervision of EMS personnel is very important in both systems to ensure the best pain management care and patient safety. Adjustments to the federal law on the administration of analgesics would facilitate the realization of algorithm-based concepts by paramedics as pain reduction could be performed with delegation by a medical director without consulting another physician.
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Affiliation(s)
- A Gnirke
- Ärztliche Leitung Rettungsdienst, Rettungsdienst-Kooperation in Schleswig-Holstein, Heide, Deutschland
| | - S K Beckers
- Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland.,Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - S Gort
- Klinik für Anästhesiologie, Marienhospital Aachen, Aachen, Deutschland
| | - A Sommer
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland.,Care and Public Health Research Institute, Universität Maastricht, Maastricht, Niederlande
| | - H Schröder
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - R Rossaint
- Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland
| | - M Felzen
- Ärztliche Leitung Rettungsdienst, Berufsfeuerwehr Aachen, Stadt Aachen, Stolberger Str. 155, 52068, Aachen, Deutschland. .,Klinik für Anästhesiologie, Medizinische Fakultät, RWTH Aachen University, Uniklinik RWTH Aachen, Aachen, Deutschland.
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Abstract
Introduction: Evidence from the past 20 years has highlighted that acute pain is not managed well in the emergency setting, in particular with children. Inadequate management of pain can result in long-term changes in both physical and mental health. This service evaluation aimed to determine how paediatric pain is assessed and managed by ambulance clinicians in a large region in England. Methods: This retrospective service evaluation analysed electronic patient record (ePR) data routinely collected between September and December 2018. All paediatric patients (< 18 years of age) with pain documented narratively, or a pain score of ≥ 1/10, were included. The primary outcome measure was the proportion of patients with severe pain (defined as a pain score of ≥ 7/10) who achieve effective pain management (reduction in pain score of ≥ 2/10). Results: A total of 2801 paediatric patients who had documented pain were included in the analysis and the median age of patients was three years (interquartile range, 1–12 years). Most had a medical cause of pain (2387/2801, 85.2%), and analgesia was administered by the ambulance crew in 403/2801 (14.4%) patients. Multiple pain scores were recorded for 667 patients. Effective pain management was achieved in 233/271 (86%) patients in moderate pain and 204/210 (97.1%) patients in severe pain. However, of the 437 children in moderate to severe pain who achieved effective pain management, 381 (87%) received no analgesia. Conclusion: Children in severe pain received effective pain management, despite the majority not receiving any analgesia. This should be investigated further since non-pharmacological methods of analgesia are unlikely to explain a reduction of this magnitude. Ambulance staff need to be encouraged to record a pain score promptly after arriving on scene and ensure it is repeated. Pain score should be documented as part of the physiological observations and not in the free text of ePRs to ensure that it is identified during audits.
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Affiliation(s)
- Richard Pilbery
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-5797-9788
| | - Jamie Miles
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-1080-768X
| | - Fiona Bell
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0003-4503-1903
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Lenssen N, Krockauer A, Beckers SK, Rossaint R, Hirsch F, Brokmann JC, Bergrath S. Quality of analgesia in physician-operated telemedical prehospital emergency care is comparable to physician-based prehospital care - a retrospective longitudinal study. Sci Rep 2017; 7:1536. [PMID: 28484212 PMCID: PMC5431537 DOI: 10.1038/s41598-017-01437-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/28/2017] [Indexed: 11/09/2022] Open
Abstract
Acute pain is a common reason for summoning emergency medical services (EMS). Yet in several countries the law restricts opioid-based analgesia administration to physicians. Telemedical support of paramedics is a novel approach to enable timely treatment under the guidance of a physician. In this retrospective observational study, conducted in the EMS of Aachen, Germany, the analgesic quality and occurrence of adverse events were compared between telemedically-supported paramedics (July-December, 2014) and a historical control group (conventional on-scene EMS physicians; January-March, 2014). Inclusion criteria: pain (initial numerical rating scale (NRS) ≥5) and/or performed analgesia. Telemedically-assisted analgesia was performed in 149 patients; conventional analgesia in 199 control cases. Teleconsultation vs. control: Initial NRS scores were 8.0 ± 1.5 and 8.1 ± 1.7. Complete NRS documentation was carried out in 140/149 vs. 130/199 cases, p < 0.0001. NRS scores were reduced by 4.94 ± 2.01 and 4.84 ± 2.28 (p = 0.5379), leading to mean NRS scores at emergency room arrival of 3.1 ± 1.7 vs. 3.3 ± 1.9 (p = 0.5229). No severe adverse events occurred in either group. Clinically relevant pain reduction was achieved in both groups. Thus, the concept of remote physician-based telemedically-delegated analgesia by paramedics is effective compared to analgesia by on-scene EMS physicians and safe.
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Affiliation(s)
- Niklas Lenssen
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany.
| | - Andreas Krockauer
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Stefan K Beckers
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany.,Emergency Medical Service, Fire Department, City of Aachen, Stolberger Str. 155, 52068 Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Frederik Hirsch
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Jörg C Brokmann
- Emergency Department, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Sebastian Bergrath
- Department of Anaesthesiology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany.,Emergency Medical Service, Fire Department, City of Aachen, Stolberger Str. 155, 52068 Aachen, Germany.,Emergency Department, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
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Brokmann JC, Rossaint R, Hirsch F, Beckers SK, Czaplik M, Chowanetz M, Tamm M, Bergrath S. Analgesia by telemedically supported paramedics compared with physician-administered analgesia: A prospective, interventional, multicentre trial. Eur J Pain 2016; 20:1176-84. [PMID: 26914284 DOI: 10.1002/ejp.843] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND In German emergency medical services (EMS), the analgesia is restricted to physicians. In this prospective, interventional, multicentre trial, complications with and quality of telemedically delegated analgesia were evaluated. METHODS If prehospital analgesia was necessary, five telemedically equipped paramedic ambulances from four different districts could consult a telemedicine centre. Analgesics were delegated based on a predefined algorithm. Telemedically assisted cases were compared with local historical regular EMS missions using matched pairs. The primary outcome was the frequency of therapeutic complications (respiratory/circulatory insufficiency, allergic reactions). Secondary outcomes were quality of analgesia (11-point numerical rating scale, NRS) and the frequency of nausea/vomiting. RESULTS Analgesia was necessary in 106 telemedically assisted missions. In 23 cases, the telemedical procedure was used until an EMS physician arrived. Of the remaining 83 cases, 80 could be matched to comparable controls. Complications did not occur in either the study group or the control group (0 vs. 0; p = N/A). Complete NRS documentation was noted in 65/80 (study group) and 32/80 (control group) cases (p < 0.0001). Adequate initial pain reduction (quality indicator: reduction of NRS ≥ 2 points or NRS < 5 at end of mission) occurred in 61/65 versus 31/32 cases (p = 1.0); NRS reduction during mission was 3.78 ± 2.0 versus 4.38 ± 2.2 points (p = 0.0159). Nausea and vomiting occurred with equal frequency in both groups. CONCLUSIONS Telemedical delegation of analgesics to paramedics was safe and led to a pain reduction superior to the published minimum standard in both groups. The documentation quality was better in the telemedicine group. WHAT DOES THIS STUDY ADD?: Little is known about the safety and quality of prehospital analgesia carried out by emergency medical services (EMS). Beside potential quality problems, in some countries meaningful pain reduction is limited by legal regulations that allow only physicians to administer analgesics. This first multicentre prospective trial for telemedically delegated analgesia demonstrates that remote analgesia is possible and safe and retains equivalent analgesic quality compared with that administered by onsite EMS physicians.
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Affiliation(s)
- J C Brokmann
- Emergency Department, University Hospital RWTH Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
| | - F Hirsch
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
| | - S K Beckers
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
| | - M Czaplik
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
| | - M Chowanetz
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
| | - M Tamm
- Department of Medical Statistics, University Hospital RWTH Aachen, Germany
| | - S Bergrath
- Department of Anaesthesiology, University Hospital RWTH Aachen, Germany
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