Emergency Medical Services Outcomes Project (EMSOP) IV: pain measurement in out-of-hospital outcomes research

How can quality be measured within a physician-led Community Emergency Medical service? A scoping review protocol

BACKGROUND

Quality measurement as part of quality improvement in healthcare is integral for service delivery and development. This is particularly pertinent for health services that deliver care in ways that differ from traditional practice. Community Emergency Medicine (CEM) is a novel and evolving concept of care delivered by services in parts of the UK and Ireland. This scoping review aims to provide a broad overview of how quality may be measured within services delivering CEM.

METHODS AND ANALYSIS

The methodology follows both the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). It is guided by recognised work of Arksey and O'Malley and the guidelines developed by the Joanna Briggs Institute. Several databases will be searched: MEDLINE, EMbase, EMcare, CINAHL, Scopus, the Cochrane Library and grey literature. Search terms have been developed by representatives within Community Emergency Medicine services. Two reviewers will independently screen eligible studies for final study selection. Results will be collected and analysed in descriptive and tabular form to illustrate the breadth of quality indicators that may be applicable to CEM services. This scoping review protocol has been registered with the Open Science Framework platform (osf.io/e7qxg).

DISCUSSION

This is the first stage of a larger research study aimed at developing national quality indicators for CEM. The purpose of this scoping review is to provide a comprehensive review of quality indicators that could be used within CEM. The results will be mapped using a framework and identify gaps in the literature to help guide future-focused research.

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

INTRODUCTION

Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

METHODS

The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

RESULTS

A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

CONCLUSIONS

Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study

OBJECTIVES

To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting.

METHODS

We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant.

RESULTS

80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups.

CONCLUSION

Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.

Intranasal fentanyl for the prehospital management of acute pain in children

INTRODUCTION

Acute pain is the most common symptom in the emergency setting and its optimal management continues to challenge prehospital emergency care practitioners, particularly in the paediatric population. Difficulty in establishing vascular access and fear of opiate administration to small children are recognized reasons for oligoanalgesia. Intranasal fentanyl (INF) has been shown to be as safe and effective as intravenous morphine in the treatment of severe pain in children in the Emergency Department setting.

AIM

This study aimed to describe the clinical efficacy and safety of INF when administered by advanced paramedics in the prehospital treatment of acute severe pain in children.

METHODS

A 1-year prospective cross-sectional study was carried out of children (>1 year, <16 years) who received INF as part of the prehospital treatment of acute pain by the statutory national emergency medical services in Ireland.

RESULTS

Ninety-four children were included in the final analysis [median age 11 years (interquartile range 7-13)]; 53% were males and trauma was implicated in 86% of cases. A clinically effective reduction in the pain score was found in 78 children [83% (95% confidence interval: 74-89%)]. The median initial pain rating score was 10. Pain assessment at 10 min after INF administration indicated a median pain rating of 5 (interquartile range 2-7). No patient developed an adverse event as a result of INF.

DISCUSSION

INF at a dose of 1.5 µg/kg appears to be a safe and effective analgesic in the prehospital management of acute severe pain in children and may be an attractive alternative to both oral and intravenous opiates.

Acute pain in the prehospital setting: a register-based study of 41.241 patients

BACKGROUND

Acute pain is a frequent symptom, but little is known about the frequency and causes of acute pain in the prehospital population. The objectives of this study were to investigate the frequency of moderate to severe pain among prehospital patients and the underlying causes according to primary hospital diagnose codes.

METHODS

This was a register-based study on 41.241 patients transported by ambulance. Information on moderate to severe pain [Numeric Rating Scale (NRS, 0-10) > 3 or moderate pain or higher on 4-point likert scale] was extracted from a national electronic prehospital patient record. Patient information was merged with primary hospital diagnose codes based on the 10th version of the International Classification of Diseases (ICD-10) to investigate underlying causes of pain.

RESULTS

11.430 patients (27.7%) reported moderate to severe pain during ambulance transport. As a measure of opioid demanding acute pain, 3.275 of 41.241 patients (7.9%) were treated with intravenous fentanyl. Underlying causes of pain were heterogenic according to ICD-10 chapters with injuries being the largest group of patients with moderate to severe pain (XIX: 42.8% of 8.041 patients), followed by non-specific diagnoses (XVIII: 28.5% of 7.101 patients and XXI: 31.6% of 5.148 patients), diseases of the circulatory system (IX: 22.1% of 4.812 patients) and other (20.3% of 16.139 miscellaneous patients).

DISCUSSION

Due to the high frequency of moderate to severe pain affecting a wide range of patients, more attention on acute pain is necessary. Whether ambulance personnel have sufficient options for treating various pain conditions might be a subject of future evaluation. Non-specific diagnoses accounted for surprisingly many patients with moderate to severe pain, of which many were treated with intravenous fentanyl. This may be substance of further investigation.

CONCLUSIONS

Moderate to severe pain is a highly frequent and probably underestimated symptom among patients transported by ambulance. Underlying causes of pain are heterogenic as described by primary hospital diagnose codes. More focus on the treatment of acute pain is needed.

Quality Indicators for Evaluating Prehospital Emergency Care: A Scoping Review

Introduction Historically, the quality and performance of prehospital emergency care (PEC) has been assessed largely based on surrogate, non-clinical endpoints such as response time intervals or other crude measures of care (eg, stakeholder satisfaction). However, advances in Emergency Medical Services (EMS) systems and services world-wide have seen their scope and reach continue to expand. This has dictated that novel measures of performance be implemented to compliment this growth. Significant progress has been made in this area, largely in the form of the development of evidence-informed quality indicators (QIs) of PEC. Problem Quality indicators represent an increasingly popular component of health care quality and performance measurement. However, little is known about the development of QIs in the PEC environment. The purpose of this study was to assess the development and characteristics of PEC-specific QIs in the literature.

METHODS

A scoping review was conducted through a search of PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA); EMBase (Elsevier; Amsterdam, Netherlands); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science (Thomson Reuters; New York, New York USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). To increase the sensitivity of the literature, a search of the grey literature and review of select websites was additionally conducted. Articles were selected that proposed at least one PEC QI and whose aim was to discuss, analyze, or promote quality measurement in the PEC environment.

RESULTS

The majority of research (n=25 articles) was published within the last decade (68.0%) and largely originated within the USA (68.0%). Delphi and observational methodologies were the most commonly employed for QI development (28.0%). A total of 331 QIs were identified via the article review, with an additional 15 QIs identified via the website review. Of all, 42.8% were categorized as primarily Clinical, with Out-of-Hospital Cardiac Arrest contributing the highest number within this domain (30.4%). Of the QIs categorized as Non-Clinical (57.2%), Time-Based Intervals contributed the greatest number (28.8%). Population on Whom the Data Collection was Constructed made up the most commonly reported QI component (79.8%), followed by a Descriptive Statement (63.6%). Least reported were Timing of Data Collection (12.1%) and Timing of Reporting (12.1%). Pilot testing of the QIs was reported on 34.7% of QIs identified in the review.

CONCLUSION

Overall, there is considerable interest in the understanding and development of PEC quality measurement. However, closer attention to the details and reporting of QIs is required for research of this type to be more easily extrapolated and generalized. Howard I , Cameron P , Wallis L , Castren M , Lindstrom V . Quality indicators for evaluating prehospital emergency care: a scoping review. Prehosp Disaster Med. 2018;33(1):43-52.

Impact of an Offline Pain Management Protocol on Prehospital Provider Self-Efficacy: A Randomized Trial

BACKGROUND

Pain in children is inadequately treated in the prehospital setting despite the reported recognition by prehospital providers (PHPs) of pain treatment as an important part of patient care. The impact of pediatric pain management protocol (PPP) implementation on PHP self-efficacy (SE), a measure congruent with performance, is unknown.

OBJECTIVE

The aim of this study was to evaluate the impact of PPP implementation and pain management education on PHP SE.

METHODS

This was a prospective study evaluating the change in PHP SE after a PPP was implemented. Prehospital providers were randomized to 3 groups: protocol introduction alone, protocol introduction with education, and protocol introduction with education and a 3-month interim review. Prehospital provider SE was assessed for pain management given 3 age-based scenarios. Self-efficacy was measured with a tool that uses a ranked ordinal scale ranging from "certain I cannot do it" (0) to "completely certain I can do it" (100) for 10 pain management actions: pain assessment (3), medication administration (4), dosing (1), and reassessment (2). An averaged composite score (0-100) was calculated for each of the 3 age groups (adult, child, toddler). Paired-sample t tests compared post-PPP and 13-month scores to pre-PPP scores.

RESULTS

Of 264 PHPs who completed initial surveys, 142 PHPs completed 13-month surveys. Ninety-three (65%) received education with protocol review, and 49 (35%) had protocol review only. Self-efficacy scores increased over the study period, most notably for pain assessment. This increase persisted at 13 months for child (6.6 [95% confidence interval {CI}, 1.4-11.8]) and toddler pain assessment (22.3 [95% CI, 16.4-28.3]). Composite SE scores increased immediately for all age groups (adult, 3.1 [95% CI, 1.3-4.9]; child, 6.1 [95% CI, 3.8-8.5]; toddler, 12.0 [95% CI, 9.5-14.5]) and persisted at 13 months for the toddler group alone (7.0 [95% CI, 4.3-9.7]). There was no difference between groups who received protocol review alone compared with those with education or education plus a 3-month interim review.

CONCLUSIONS

After a pain management protocol was introduced, SE scores among PHPs increased immediately and remained elevated for some individual actions involved in pain management, most notably pain assessment. Prehospital provider pain assessment SE scores declined 13 months after protocol introduction for adults, but remained elevated compared with baseline for the pediatric age groups.

A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town

INTRODUCTION

Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.

METHODS

A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.

RESULTS

A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4).

DISCUSSION

Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.

[Patients with pain in outpatient care. A nationwide cross-sectional survey with path model]

BACKGROUND

There is limited knowledge on the degree of pain and pain-related impairments in home care clients. This study was carried out to provide data on the prevalence of pain and pain-related impairments in home care patients and to investigate the impact on activities of daily living and on classification into the three levels of care as defined by the statutory German long-term care insurance.

MATERIAL AND METHODS

In 2012 a representative cross-sectional multicenter study was conducted among clients of 100 German home care services. The stepwise sampling procedure included a random selection of 9 home care services in each of the 16 federal states and a randomized sampling among the clients of the participating home care services. The total sample consisted of 878 home care clients (inclusion criteria ≥ 18 years). The subjective pain intensity was measured using an 11-step Likert scale ranging from 0 (no pain) to 10 (most severe pain). Pain-related impairments were rated on a 6-step Likert scale (0 = no impairments to 5 = complete impairment) assessing the level of independence in household chores, mobility, personal hygiene, dressing and social participation. Furthermore, multimorbidity (number of diagnoses) and level of care according to the current classification in the German long-term care insurance were registered. The predictive significance of latent variables was determined by structural equation modelling.

RESULTS

Of the subjects surveyed 68.5 % (n = 672) reported suffering from pain. The average intensity of pain was 2.9 (standard deviation SD 2.8) and pain-related impairments had the greatest effect on mobility (78.2 %). Path analysis revealed that a higher degree of pain-related impairments (β = + 0.31) and a higher number of diagnoses (β = + 0.19) were associated with classification to higher levels of care as defined in the German long-term care insurance. However, stronger pain and higher age were related to a classification to a lower level of care (β = - 0.21). No relevant gender differences were identified except for the finding that old age in women had no significant effect on the classification to the level of care, whereas in men both old age and pain intensity did have an impact.

CONCLUSION

Even though the majority of home care clients in this representative study suffered from pain, the degree of pain intensity only becomes an issue in home care if it concurs with impairments in daily living and a corresponding classification to higher levels of care dependency. These findings suggest that pain and pain management should receive more attention in home care, irrespective of observable impairments in daily living. In practice, nurses in home care services should regularly assess the level of pain intensity among home care clients and the results of these regular pain assessments should be taken into account for the identification of individual care needs.

Prehospital personnel’s attitudes to pain management

Objectives

Pain is one of the most common reasons for patients to seek acute medical care. The management of pain is often inadequate both in the prehospital setting and in the emergency department. Our aim was to evaluate the attitudes towards pain management among prehospital personnel in two Scandinavian metropolitan areas.

Methods

A questionnaire with 36 items was distributed to prehospital personnel working in Helsinki, Finland (n=70) and to prehospital personnel working in Stockholm, Sweden (n=634). Each item was weighted on a five-level Likert scale. Factor loading of the questionnaire was made using maximum likelihood analysis and varimax rotation. Six scales were constructed (Hesitation, Encouragement, Side effects, Evaluation, Perceptions, Pain metre). A Student’s t-test, ANOVA, and Pearson Correlation were used for analysis of significance.

Results

: The response rate among the Finnish prehospital personnel was 66/70 (94.2%) while among the Swedish personnel it was 127/634 (20.0%). The prehospital personnel from Sweden showed significantly more Hesitation to administer pain relief compared to the Finnish personnel (mean 2.01 SD 0.539 vs. 1.67 SD 0.530, p < 0.001). Those who had received pain education at their workplace showed significantly less Hesitation than those who had not participated in education. There was a significant negative correlation (p < 0.01) between Hesitation and Side effects. There was also astatistically significant(p < 0.01) correlation between Perceptions and Hesitation, indicating that a stoic attitude towards pain was associated with indifference to possible Side effects of pain medication (p < 0.05).

Conclusions

The results show that there was a significant correlation between the extent of education and the prehospital personnel’s attitudes to pain management. Gender and age among the prehospital personnel also affected the attitudes to pain management. The main discrepancy between the Swedish and Finnish personnel was that the participants from Stockholm showed statistically significantly more hesitation about administering pain medication compared to the participants from Helsinki.

Implications

The results of the study highlight the need for continuous medical education (CME) for prehospital personnel. CME and discussions among prehospital personnel may help to make a change in the personnel’s attitudes towards pain and pain management in the prehospital context.

Emergency medical services key performance measurement in Asian cities

Background

One of the key principles in the recommended standards is that emergency medical service (EMS) providers should continuously monitor the quality and safety of their services. This requires service providers to implement performance monitoring using appropriate and relevant measures including key performance indicators. In Asia, EMS systems are at different developmental phases and maturity. This will create difficultly in benchmarking or assessing the quality of EMS performance across the region. An attempt was made to compare the EMS performance index based on the structure, process, and outcome analysis.

Findings

The data was collected from the Pan-Asian Resuscitation Outcome Study (PAROS) data among few Asian cities, namely, Tokyo, Osaka, Singapore, Bangkok, Kuala Lumpur, Taipei, and Seoul. The parameters of inclusions were broadly divided into structure, process, and outcome measurements. The data was collected by the site investigators from each city and keyed into the electronic web-based data form which is secured strictly by username and passwords. Generally, there seems to be a more uniformity for EMS performance parameters among the more developed EMS systems. The major problem with the EMS agencies in the cities of developing countries like Bangkok and Kuala Lumpur is inadequate or unavailable data pertaining to EMS performance.

Conclusions

There is non-uniformity in the EMS performance measurement across the Asian cities. This creates difficulty for EMS performance index comparison and benchmarking. Hopefully, in the future, collaborative efforts such as the PAROS networking group will further enhance the standardization in EMS performance reporting across the region.

An Evidence-based Guideline for prehospital analgesia in trauma

BACKGROUND

The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols.

OBJECTIVE

To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council.

RESULTS

Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales.

CONCLUSION

GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.

Integrating palliative care in the out-of-hospital setting: four things to jump-start an EMS-palliative care initiative

Emergency medical service (EMS) is frequently called to care for a seriously ill patient with a life-threatening or life-limiting illness. The seriously ill include both the acutely injured patients (for example in mass casualty events) and those who suffer from advanced stages of a chronic disease (for example severe malignant pain). EMS therefore plays an important role in delivering realistic, appropriate, and timely care that is consistent with the patient's wishes and in treating distressing symptoms in those who are seriously ill. The purpose of this article is to; 1) review four case scenarios that relate to palliative care and may be commonly encountered in the out-of-hospital setting and 2) provide a road map by suggesting four things to do to start an EMS-palliative care initiative in order to optimize out-of-hospital care of the seriously ill and increase preparedness of EMS providers in these difficult situations.

Paramedic attitudes regarding prehospital analgesia

INTRODUCTION

Although pain is a major reason why patients summon emergency medical services (EMS), prehospital medical providers administer analgesic agents at inappropriately low rates. One possible reason is the role of EMS provider attitudes.

OBJECTIVE

This study was conducted to elicit attitudes that may act as impediments or deterrents to administering analgesia in the prehospital environment.

METHODS

A qualitative methodology was employed. We recruited experienced paramedics, with at least one year of full-time fieldwork, from a variety of agencies in New England. We sought to include a balance of rural and urban as well as both private and hospital-based agencies. Participants at each site were selected through purposive sampling. A semistructured discussion guide was designed to elicit the paramedics' past experiences with administering analgesia, as well as reflections on their role in the care of patients in pain. Both interviews and focus groups were conducted. These sessions were recorded and transcribed verbatim. The transcripts were topic-analyzed and iteratively coded by two independent investigators utilizing the constant comparative method of Glaser and Strauss' Grounded Theory; coding ambiguities were resolved by consensus. Through a series of conceptual mapping and iterative code refinement, themes and domains were generated.

RESULTS

Fifteen paramedics from five EMS agencies in three New England states were recruited. Major themes were: 1) a reluctance to administer opioids to patients without significant objective signs (e.g., deformity, hypertension); 2) a preoccupation with potential malingering; 3) ambivalence about the degree of pain control to target or to expect (e.g., aiming to "take the edge off"); 4) a fear of masking diagnostic symptoms; and 5) an aversion to aggressive dosing of opioids (e.g., initial doses of morphine did not exceed 5 mg).

CONCLUSIONS

A number of potentially modifiable attitudinal barriers to appropriate pain management were revealed.

Recalled pain scores are not reliable after acute trauma

INTRODUCTION

Pain research in emergency settings can be problematic, as data collection is logistically difficult and pain levels are often poorly documented. Short-term recall of acute pain has been evaluated in postoperative, labour and procedural pain, with variable reported accuracy. The reliability of pain recall in trauma resuscitation patients is unknown. This study aims to determine the accuracy of short-term pain recall 1-2 days after trauma.

METHODS

Prospective, cohort study of trauma resuscitation patients transported by ambulance to a major trauma centre. Patients with haemodynamic instability (SBP<90, HR>120) or GCS<14 on arrival were excluded. Momentary pain scores were measured on an 11-point verbal numerical rating scale by paramedics during prehospital management. Patients were evaluated within 48 h of injury on the recall of their initial pain, pain during transport, and lowest pain score achieved by prehospital analgesia. Spearman's rank correlation and Bland-Altman tests were used to compare ambulance and hospital data.

RESULTS

88 trauma resuscitation patients (mean age 44 years ± 18 SD, male 74%, mean ISS: 7 ± 5 SD) were enrolled over a 5 month study period. Comparison of immediate and recalled pain scores produced Spearman's correlation coefficients of 0.71 for initial pain, 0.56 for pain during transport, and 0.45 for minimum pain scores.

DISCUSSION

In our study patients did not accurately recall their pain levels 1-2 days after acute trauma. The results suggest that retrospective pain ratings are not reliable in trauma patients.

Value generation and health reform in emergency medical services

American Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.

A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care

In 2007, the Institute of Medicine's (IOM's) Committee on the Future of Emergency Care recommended that a multidisciplinary panel establish a model for developing evidence-based protocols for the treatment of emergency medical systems (EMS) patients. In response, the National EMS Advisory Council (NEMSAC) and the Federal Interagency Committee on EMS (FICEMS) convened a panel of multidisciplinary experts to review current strategies for developing evidence-based guidelines (EBGs) and to propose a model for developing such guidelines for the prehospital milieu. This paper describes the eight-step model endorsed by FICEMS, NEMSAC, and a panel of EMS and evidence-based medicine experts. According to the model, prehospital EBG development would begin with the input of evidence from various external sources. Potential EBG topics would be suggested following a preliminary evidentiary review; those topics with sufficient extant foundational evidence would be selected for development. Next, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology would be used to determine a quality-of-evidence rating and a strength of recommendation related to the patient care guidelines. More specific, contextualized patient care protocols would then be generated and disseminated to the EMS community. After educating EMS professionals using targeted teaching materials, the protocols would be implemented in local EMS systems. Finally, effectiveness and uptake would be measured with integrated quality improvement and outcomes monitoring systems. The constituencies and experts involved in the model development process concluded that the use of such transparent, objective, and scientifically rigorous guidelines could significantly increase the quality of EMS care in the future.

A consensus-based template for documenting and reporting in physician-staffed pre-hospital services

Background

Physician-staffed pre-hospital units are employed in many Western emergency medical services (EMS) systems. Although these services usually integrate well within their EMS, little is known about the quality of care delivered, the precision of dispatch, and whether the services deliver a higher quality of care to pre-hospital patients. There is no common data set collected to document the activity of physician pre-hospital activity which makes shared research efforts difficult. The aim of this study was to develop a core data set for routine documentation and reporting in physician-staffed pre-hospital services in Europe.

Methods

Using predefined criteria, we recruited sixteen European experts in the field of pre-hospital care. These experts were guided through a four-step modified nominal group technique. The process was carried out using both e-mail-based communication and a plenary meeting in Stavanger, Norway.

Results

The core data set was divided into 5 sections: "fixed system variables", "event operational descriptors", " patient descriptors", "process mapping", and "outcome measures and quality indicators". After the initial round, a total of 361 variables were proposed by the experts. Subsequent rounds reduced the number of core variables to 45. These constituted the final core data set. Emphasis was placed on the standardisation of reporting time variables, chief complaints and diagnostic and therapeutic procedures.

Conclusions

Using a modified nominal group technique, we have established a core data set for documenting and reporting in physician-staffed pre-hospital services. We believe that this template could facilitate future studies within the field and facilitate standardised reporting and future shared research efforts in advanced pre-hospital care.

Risk adjustment measures and outcome measures for prehospital trauma research: recommendations from the emergency medical services outcomes project (EMSOP)

OBJECTIVES

The objectives were to conduct a comprehensive, systematic review of the literature for risk adjustment measures (RAMs) and outcome measures (OMs) for prehospital trauma research and to use a structured expert panel process to recommend measures for use in future emergency medical services (EMS) trauma outcomes research.

METHODS

A systematic literature search and review was performed identifying the published studies evaluating RAMs and OMs for prehospital injury research. An explicit structured review of all articles pertaining to each measure was conducted using the previously established methodology developed by the Canadian Physiotherapy Association ("Physical Rehabilitation Outcome Measures").

RESULTS

Among the 4,885 articles reviewed, 96 RAMs and/or OMs were identified from the existing literature (January 1958 to February 2010). Only one measure, the Glasgow Coma Scale (GCS), currently meets Level 1 quality of evidence status and a Category 1 (strong) recommendation for use in EMS trauma research. Twelve RAMs or OMs received Category 2 status (promising, but not sufficient current evidence to strongly recommend), including the motor component of GCS, simplified motor score (SMS), the simplified verbal score (SVS), the revised trauma score (RTS), the prehospital index (PHI), EMS provider judgment, the revised trauma index (RTI), the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the field trauma triage (FTT), the pediatric triage rule, and the out-of-hospital decision rule for pediatrics.

CONCLUSIONS

Using a previously published process, a structured literature review, and consensus expert panel opinion, only the GCS can currently be firmly recommended as a specific RAM or OM for prehospital trauma research (along with core measures that have already been established and published). This effort highlights the paucity of reliable, validated RAMs and OMs currently available for outcomes research in the prehospital setting and hopefully will encourage additional, methodologically sound evaluations of the promising, Category 2 RAMs and OMs, as well as the development of new measures.

Bispectral index monitoring in helicopter emergency medical services patients

Background. Many critically ill patients are given sedatives and paralytics to facilitate aeromedical transport. Bispectral index (BIS) monitoring is a computer-derived electroencephalography (EEG) analog currently used to monitor the level of awareness of sedated patients. It gives a score of 1-100, with 1 representing no brain function and 100 representing a completely alert patient. Objective. To evaluate whether critically ill patients are adequately sedated during aeromedical transport. Methods. This was a prospective, observational study of a convenience sample of critically ill patients transported by helicopter. All intubated patients who received sedatives and/or paralytics to facilitate transport were eligible for enrollment by the attending clinician. Prior to liftoff, a BIS sensor was applied to the patient's forehead. Minimum, maximum, and mean BIS index scores were recorded every minute during transport. Results. Forty-seven patients (57% male) were enrolled, with a median age of 60 years (interquartile range [IQR] 18-81, range 14 to 86 years). The median duration of monitoring was 15.0- minutes (IQR 6.0-26.0, range 2 to 33). The median BIS score was 54.6 (IQR 38.6-67.3, range 28 to 89.5). Only two patients (4.3%, 95% confidence interval [CI] 0.5% to 14.8%) had at least one BIS score greater than 85, the accepted threshold for recall. Conclusion. These results suggest that patients are adequately sedated during air medical transport.

Paramedic assessment of pain in the cognitively impaired adult patient

Background

Paramedics are often a first point of contact for people experiencing pain in the community. Wherever possible the patient's self report of pain should be sought to guide the assessment and management of this complaint. Communication difficulty or disability such as cognitive impairment associated with dementia may limit the patient's ability to report their pain experience, and this has the potential to affect the quality of care. The primary objective of this study was to systematically locate evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults and to identify those that have been recommended for use by paramedics.

Methods

A systematic search of health databases for evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults was undertaken using specific search criteria. An extended search included position statements and clinical practice guidelines developed by health agencies to identify evidence-based recommendations regarding pain assessment in older adults.

Results

Two systematic reviews met study inclusion criteria. Weaknesses in tools evaluated by these studies limited their application in assessing pain in the population of interest. Only one tool was designed to assess pain in acute care settings. No tools were located that are designed for paramedic use.

Conclusion

The reviews of pain assessment tools found that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. One tool - the Abbey Pain Scale - may have application in paramedic assessment of pain, but clinical evaluation is required to validate this tool in the paramedic practice setting. Further research is recommended to evaluate the Abbey Pain Scale and to evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.

The impact of patient sex on paramedic pain management in the prehospital setting

OBJECTIVE

The aim of this study was to establish the impact of patient sex on the provision of analgesia by paramedics for patients reporting pain in the prehospital setting.

METHODS

This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score higher than 12 transported to hospital by ambulance in a major metropolitan area over a 7-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics, and type of analgesia provided. The outcomes of interest were sex differences in the provision of analgesia. Data analysis was by descriptive statistics, chi2 test, and logistic regression.

RESULTS

Of the 3357 patients transported in the study period, 1766 (53%) reported pain; this forms the study sample. Fifty-two percent were female, median age was 61 years, and median initial pain score (on a 0-10 verbal numeric rating scale) was 6. Forty-five percent of patients reporting pain did not receive analgesia (791/1766) (95% confidence interval [CI], 43%-47%), with no significant difference between sexes (P = .93). There were, however, significant sex differences in the type of analgesia administered, with males more likely to receive morphine (17%; 95% CI, 15%-20%) than females (13%; 95% CI, 11%-15%) (P = .01). The difference remains significant when controlled for type of pain, age, and pain severity (odds ratio, 0.61, 95% CI, 0.44-0.84).

CONCLUSION

Sex is not associated with the rate of paramedic-initiated analgesia, but is associated with differences in the type of analgesia administered.

Effects of an Educational Intervention on Prehospital Pain Management

INTRODUCTION

Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting.

OBJECTIVES

To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers.

METHODS

All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests.

RESULTS

The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%; p < 0.001) improvement in pain reassessment following intervention.

CONCLUSION

As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.

Factors associated with unoffered trauma analgesia in critical care transport

OBJECTIVE

Pain relief is a key out-of-hospital patient care outcome measure, yet many trauma patients do not receive prompt analgesia. Although specialty critical care transport (CCT) teams provide analgesia frequently, successfully, and safely, there is still a population of CCT patients to whom analgesia is not offered. We report the factors associated with non-administration of analgesia and with analgesic effect in trauma patients cared for by CCT teams.

METHODS

This is a retrospective review of consecutive transport records for nonintubated trauma patients with self-reported pain during specialty CCT care. Patient demographics, CCT interventions, clinical traits, and pain self-reports are measured. Means comparisons are made with a univariate analysis of variance, and odds ratios (ORs) with 95% confidence intervals (CIs) are reported for between-group comparisons.

RESULTS

Of the 209 enrolled patients, 169 (80.9%; 95% CI, 75.6%-86.2%) were treated (147 received analgesia and 22 offered analgesia but refused). In patients with pain scale documentation (n=145), self-reported pain on a scale from 0 to 10 decreased from 6.8+/-2.8 to 3.3+/-2.4 (P<or=.001). Three factors were associated with absence of analgesic administration: initial pain level (OR for administration, 0.13; 95% CI, 0.04-0.40), pain scale documentation (OR, 0.31; 95% CI, 0.15-0.60), and transport program (OR, 0.36; 95% CI, 0.17-0.74). No clinical factor was associated with analgesia effectiveness in treated patients.

CONCLUSION

The identified factors may represent opportunities for CCT teams to optimize analgesic treatment.

International comparison of prehospital trauma care systems

OBJECTIVE

Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems.

METHODS

Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes.

RESULTS

After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems.

CONCLUSION

These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.

Completely Autologous Platelet Gel in Breast Reduction Surgery: A Blinded, Randomized, Controlled Trial

BACKGROUND

The objective of this study was to assess the effectiveness of topical application of completely autologous platelet gel during breast surgery to reduce postoperative wound drainage. An increasing number of surgical centers are using tissue sealants to reduce postoperative drainage and improve surgical outcomes. However, there is a paucity of randomized, double-blind, controlled trials assessing the efficacy of these agents.

METHODS

The authors conducted a within-patient, randomized, patient- and assessor-blinded, controlled trial assessing the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammaplasty. Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. The primary outcome was the difference in wound drainage over 24 hours. Secondary outcomes included subjective and objective assessments of pain and wound healing.

RESULTS

No statistically significant differences in the drainage, level of pain, size of open areas, clinical appearance, degree of scar pliability, or scar erythema were noted.

CONCLUSION

The authors' results do not support the use of completely autologous platelet gel to improve outcomes after reduction mammaplasty.

A Comprehensive Framework for Determining the Cost of an Emergency Medical Services System

To determine the cost of an emergency medical services (EMS) system, researchers, policymakers, and EMS providers need a framework with which to identify the components of the system that must be included in any cost calculations. Such a framework will allow for cost comparisons across studies, communities, and interventions. The objective of this article is to present an EMS cost framework. This framework was developed by a consensus panel after analysis of existing peer-reviewed and non-peer-reviewed resources, as well as independent expert input. The components of the framework include administrative overhead, bystander response, communications, equipment, human resources, information systems, medical oversight, physical plant, training, and vehicles. There is no hierarchical rank to these components; they are all necessary. Within each component, there are subcomponents that must be considered. This framework can be used to standardize the calculation of EMS system costs to a community. Standardizing the calculation of EMS cost will allow for comparisons of costs between studies, communities, and interventions.

Nursing attitudes and beliefs in pain assessment and management

AIMS

This paper reports a study to determine nurses' attitudes towards pain assessment tools and the relationship of these attitudes to education and experience.

BACKGROUND

The issue of pain management is of interest to caregivers nationally and internationally. For example, in the United States of America, the National Health and Medical Research Council set guidelines to assist clinicians in pain management. Research on whether healthcare teams use pain assessment tools has yielded contradictory findings.

METHODS

Using an open-ended questionnaire developed for this study, which was based on Fishbein and Ajzen expectancy-value model, a convenience sample of 52 nurses on an acute care unit were asked: (1) What do you believe about the assessment of pain? (2) What do you believe about the use of pain assessment tools? and (3) What do you believe about the use of pain assessment tools in improving the patient's outcome? The nurses then rated their attitudes about each belief and how each belief made them feel. The data were collected in 2003. Results. When Fishbein and Ajzen's formula for calculating attitude was used, attitude scores ranged from -6 to 28 with an overall mean score of +8.3. The amount of education and experience of each nurse and the attitude measure in regard to the use of pain assessment tools were compared.

CONCLUSIONS

The Fishbein and Ajzen model provides a useful way to obtain information on the attitude of nurses towards the use of pain assessment instruments. To provide further information, this study with an open-ended instrument should be followed with a fixed-response survey with a larger sample size and in various settings.

The verbal numeric pain scale: effects of patient education on self-reports of pain

BACKGROUND

Emergency department (ED) patients are frequently asked to provide a self-report of the level of pain experienced using a verbal numeric rating scale.

OBJECTIVES

To determine the effects of patient education regarding the verbal numeric rating scale on self-reports of pain among ED patients.

METHODS

In this prospective, interventional study, 310 eligible ED patients with pain, aged 18 years and older, were randomized to view either a novel educational video (n = 155) or a novel print brochure (n = 155) as an educational intervention, both developed to deliver educational information about the verbal numeric pain scale and its use. Participants initially rated their pain on a scale from 0 to 10 and then were administered the educational intervention. Following the educational intervention, participants completed a survey that included demographic information, postinterventional pain score, prior pain experience, and subjective rating of the helpfulness of the educational intervention. Fifty-five consecutive participants were enrolled as controls and received no educational intervention but gave a self-reported triage pain score and a second pain score at an equivalent time interval. Clinical significance was defined as a decrease in pain of 2 or more points following the education.

RESULTS

Following the educational interventions, there were statistically significant, although not clinically significant, decreases in mean pain scores within each intervention group (video: mean change, 1 point [95% confidence interval [CI] = 0.7 to 1.2]; printed brochure: mean change, 0.6 points [95% CI = 0.4 to 0.8]). For participants in the control group (no intervention), there was no significant change (mean change, 0.2 points [95% CI = -0.2 to 0.5]). A clinically significant decrease in pain was seen in 28% of the video group, 23% of the brochure group, and 5% of controls. Most patients had no change (71% of the video group, 73% of the brochure group, and 89% of controls). Participants rated the helpfulness of the video educational intervention as 7.1 (95% CI = 6.7 to 7.5) and the print educational intervention as 6.7 (95% CI = 6.2 to 7.1) on a scale from 0 (least effective) to 10 (most helpful).

CONCLUSIONS

Among ED participants with pain, both educational interventions (video and printed brochure) resulted in statistically and clinically significant decreased self-reported pain scores by 2 or more points in 26% of participants compared with 5% of controls. The educational interventions were rated as helpful by participants, with no appreciable difference between the two intervention groups.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Comparison of Low-Dose Intrathecal and Epidural Morphine and Bupivacaine Infiltration for Postoperative Pain Control After Surgery for Lumbar Disc Disease

This prospective, blinded, placebo-controlled study was performed to compare the postoperative analgesic efficacy of low-dose intrathecal and epidural morphine with paraspinal muscle infiltration of bupivacaine in lumbar discectomy cases. Eighty ASA I-III adult patients undergoing elective surgery for lumbar disc disease were enrolled in the study. Patients were randomized to four groups by envelopes. Study groups were as follows: group 1 (n = 20), intrathecal morphine 0.1 mg; group 2 (n = 20), epidural morphine 2 mg; group 3 (n = 20), 30 mL of bupivacaine 0.25% paraspinal muscle infiltration; group 4 (n = 20), 30 mL of saline paraspinal muscle infiltration before wound closure. Recorded parameters were time to response to painful and verbal stimuli and postoperative pain assessed at 30 minutes and 2, 4, 6, 8, 12, and 24 hours by Visual Analog Scale (VAS) and Numeric Pain Scale (NPS). Hemodynamic data, sedation scores, and side effects were also recorded. Meperidine and naproxen sodium were used for postoperative analgesia. Follow-up was performed by a blinded investigator. Mean VAS scores were lower in groups 1 and 2 at 30 minutes (P < 0.05). Mean VAS score of group 2 was lower than that of group 4 at 4 hours postoperatively (P < 0.05). Mean NPS scores were lower in groups 1 and 2 at 2, 4, and 6 hours (P < 0.05) and in group 2 at 8 hours compared with the other groups. The number of patients requiring meperidine at early postoperative phase (0-6 hours) was less in groups 1 and 2 compared with groups 3 and 4 (P < 0.05). There were no statistically significant differences in the late postoperative analgesic requirements, after correction for multiple testing. In conclusion, low-dose intrathecal and epidural morphine provide lower postoperative pain scores and a reduction in early postoperative analgesic requirement with insignificant side effects compared with paraspinal bupivacaine or saline infiltration.

Pediatric pain management in the emergency department

Over the past 25 years, pediatric emergency medicine research and literature have progressively augmented our knowledge of safe and effective pediatric pain management strategies. Yet there is still much more we need to do to understand the painful experiences of children, and to develop optimal safe ways of addressing their needs within the context of a busy pediatric emergency department (ED). In this article, the authors review the history of ED pediatric pain management and sedation, discuss special considerations in pediatric pain assessment and management, review various pharmacologic and nonpharmacologic methods of alleviating pain and anxiety, and present ideas to improve the culture of the pediatric ED, so that it can achieve the goal of becoming pain-free.

Pain Management in the Prehospital Environment

Pain measurement and relief is complex and should be a priority for prehospital providers and supervisors. The literature continues to prove that we are poor pain relievers, despite the high prevalence of pain in the out-of-hospital patient population. Lack of education and research, along with agent availability, controlled substance regulation, and many myths given credence by health care providers, hinder our ability to achieve adequate pain assessment and treatment in the prehospital setting. Protocols must be established to help guide providers through proper acknowledgment, measurement, and treatment for prehospital pain. Nonpharmacologic therapies must also be taught and reinforced as important adjuncts to pain management. Finally, formation of quality improvement pain programs that evaluate patient outcomes and provider practice patterns will help EMS systems understand the pain management process and outline areas for improvement. Only through emphasis on pain education, research, protocol and program monitoring development will the quality of pain assessment and management in the prehospital setting improve.

Measurement of pain in the prehospital setting using a visual analogue scale

INTRODUCTION

The aim of this study was to use a visual analogue scale (VAS) to measure the adequacy of prehospital pain management. Patients reported pain severity at two points in time during treatment and transport by ambulance paramedics. The change in pain score was compared with a benchmark reduction of 20 mm that has been shown to correspond with the minimum clinically significant change in pain perception reported by patients.

METHODS

This prospective, observational study used a VAS to record pain severity among patients reporting pain who were transported to a hospital by paramedics. Patients used a VAS to score pain severity during the initial patient assessment process (T0), and again at the hospital of destination (Tend). This study reports the mean changes in the scores, and the percentage of cases for whom the difference between T0 and Tend in the study population achieved or exceeded the 20 mm benchmark. A survey also was administered to paramedics who participated in this study in order to identify attitudes, values, and beliefs relating to the measurement of pain.

RESULTS

A total of 262 patients were enrolled in this study. The mean value for the reduction in VAS (T0-Tend) was 18.2+/-23.9 mm [+/-SD] (Median = 14.0mm, 95% confidence interval (CI) = 15.3-21.1 mm). One hundred and thirty-four patients (51.1%) did not receive analgesia (either morphine sulfate or methoxyflurane). The mean initial (T0) pain score for the no-analgesia group was 54.5+/-24.7 mm [+/-SD], with the mean value for the change in VAS (T0-Tend) = 10.6 mm (median = 5 mm, 95% CI = 6.4-14.8 mm). Forty-six patients (17.6%) recorded some deterioration in their pain score at Tend (T0-Tend<0 mm). Survey results identified attitudes that may affect paramedics' pain management practice.

CONCLUSION

The results suggest that inadequate analgesia is an issue in this study setting. Effective analgesia requires formal protocols or guidelines supported by effective analgesic therapies along with education that addresses attitudes that may inhibit pain assessment or management by paramedics. Regular audits form part of clinical quality assurance programs that assess analgesic practice. However, such audits must have access to data obtained from patient self-reporting of pain using a valid and reliable pain measurement tool.

Quality control programme for acute pain management in emergency medicine: a national survey

OBJECTIVE

This national survey was carried out to evaluate the quality programme for acute pain management in the emergency department (ED) and in pre-hospital emergency medical services (EMS).

METHODS

Two types of questionnaires were sent to the chief consultant and the chief nurse of all ED and EMS. Data collected were: the type of structure, quality programme organization, acute pain management, and the training needs to initiate a pain quality programme.

RESULTS

A total of 363 questionnaires were recorded (198 from chief consultants) with 98% of questionnaires being usable. A pain management committee existed in 71% of cases, a quality committee in 83%. A complete quality control procedure existed in 53% of units. An audit on pain management was carried out in only 23% of cases. Training in quality was performed for 64% of physicians and 68% of nurses. Training specifically for pain management was carried out for physicians in 56% of cases and for nurses in 68% of cases. Pain therapeutics protocols existed in 69% of cases. Pain intensity was evaluated 'systematically or often' in 64% at the beginning of patient management, and in 56% at the end of patient management. The staff was 'not very motivated' for a pain management quality programme in less than 3% of responses. A total of 61% of chief consultants and 58% of chief nurses requested advice.

CONCLUSION

Most ED and EMS units seem to master the quality control programme methodology. Units are highly motivated to initiate a quality control programme on pain. Nevertheless, its implementation could benefit from some external support.

Predictors of a child's ability to use a visual analogue scale

BACKGROUND

Visual analogue scales (VAS) are used to assess the strength of perceptions of both children and adults in many clinical and research settings. Although the VAS has been shown by some authors to be reliable for use by children aged 5 years and older, others have proposed that young children, generally < or =7 years of age, may not have the conceptual ability to use a VAS.

OBJECTIVE

To identify demographic and cognitive variables that would maximize the accuracy of predicting children's abilities to use a VAS.

METHODS

Forty kindergarten children performed a seriation task, used a VAS to perform a calibration task and completed the Block Design and Vocabulary subtests of the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R). An estimated IQ was calculated from the WPPSI-R subtest scores. Socioeconomic status was assessed using the Hollingshead Four Factor Index of Social Status. Logistic regression was used to determine the best predictive models. Sensitivity, specificity, negative predictive value, positive predictive value and accuracy were calculated for statistically significant predictive models.

MAIN OUTCOME MEASURE

Successful completion of the calibration study by the child.

RESULTS

Only 42% of the subjects could use a VAS. The subject's age (> or =5.6 years), combined with estimated IQ (> or =100), was the best predictor of a child's ability to use a VAS (88% accuracy).

CONCLUSION

The majority of kindergarten children in our study could not complete a VAS accurately. Cognitive ability, combined with chronological age, was the best predictor of a child's accurate use of a VAS, as determined by logistic regression. Paediatric researchers may need to consider alternative rating scales to measure perceptions in children under 7 years of age.