Differences in pain treatment between surgeons and anaesthesiologists in a physician staffed prehospital emergency medical service: a retrospective cohort analysis

Analgesic Therapy with the Opioids Fentanyl and Morphine by Ambulance Personnel in Rural Areas: An Observational Study Over 7 Years

Background

The treatment of severe pain is one of the basic procedures of emergency medicine. In rural regions, longer arrival times of the emergency doctor prevent the earliest possible treatment of pain. Since 2014, a project for independent analgesia by ambulance personnel has been introduced in our ambulance service area.

Methods

Over a period of 7 years the mission protocols were recorded and statistically evaluated within the framework of an observational study. Among other things, the attendance and transport times, vital signs, pain level, symptom groups (body region) and classification according to disease or accident mechanism were recorded. Treatment data by medication, including dosages, were recorded for fentanyl (monotherapy), morphine (monotherapy) and a combination (change from morphine to fentanyl, additional application of esketamine, metamizole or butylscopolamine).

Results

In 659 patients, the opioids fentanyl and morphine were used by the ambulance staff, 596 data sets could be evaluated. When an emergency physician was requested, the average time of presence at the scene was 34.8 +- 11.7 min, in cases of unavailability it was 29.0 +-9.8 min (p<0.0001). Analgesic therapy resulted in a reduction of pain from NRS 8.4 (+-1.3) to NRS 3.5 +-1.8 (p<0.0001). Pain intensity after treatment by emergency paramedics compared to emergency physicians was not significantly different with NRS 3.5 +- 1.7 versus NRS 3.6 +-1.9 (p=0.788). Fentanyl was used at a mean dose of 0.18mg +- 0.11 and morphine at a mean dose of 4.4mg +- 3.6mg. There was no clinically relevant decrease in oxygen saturation or respiratory rate in any of the treatment groups. Antagonisation of the opioid effect with naloxone was not necessary in any case.

Conclusion

Analgesia with morphine and fentanyl by specially trained ambulance personnel according to defined rules of use is a safe and necessary procedure for patients, especially in rural regions.

Application of analgesics in emergency services in Germany: a survey of the medical directors

ABSTRAC

BACKGROUND: Treatment of acute pain is an essential element of pre-hospital care for injured and critically ill patients. Clinical studies indicate the need for improvement in the prehospital analgesia.

OBJECTIVE

The aim of this study is to assess the current situation in out of hospital pain management in Germany regarding the substances, indications, dosage and the delegation of the use of analgesics to emergency medical service (EMS) staff.

MATERIAL AND METHODS

A standardized survey of the medical directors of the emergency services (MDES) in Germany was carried out using an online questionnaire. The anonymous results were evaluated using the statistical software SPSS (Chi-squared test, Mann-Whitney-U test).

RESULTS

Seventy-seven MDES responsible for 989 rescue stations and 397 EMS- physician bases in 15 federal states took part in this survey. Morphine (98.7%), Fentanyl (85.7%), Piritramide (61%), Sufentanil (18.2%) and Nalbuphine (14,3%) are provided as opioid analgesics. The non-opioid analgesics (NOA) including Ketamine/Esketamine (98,7%), Metamizole (88.3%), Paracetamol (66,2%), Ibuprofen (24,7%) and COX-2-inhibitors (7,8%) are most commonly available. The antispasmodic Butylscopolamine is available (81,8%) to most rescue stations. Fentanyl is the most commonly provided opioid analgesic for treatment of a traumatic pain (70.1%) and back pain (46.8%), Morphine for visceral colic-like (33.8%) and non-colic pain (53.2%). In cases of acute coronary syndrome is Morphine (85.7%) the leading analgesic substance. Among the non-opioid analgesics is Ketamine/Esketamine (90.9%) most frequently provided to treat traumatic pain, Metamizole for visceral colic-like (70.1%) and non-colic (68.6%) as well as back pain (41.6%). Butylscopolamine is the second most frequently provided medication after Metamizole for "visceral colic-like pain" (55.8%). EMS staff (with or without a request for presence of the EMS physician on site) are permitted to use the following: Morphine (16.9%), Piritramide (13.0%) and Nalbuphine (10.4%), and of NOAs for (Es)Ketamine (74.1%), Paracetamol (53.3%) and Metamizole (35.1%). The dosages of the most important and commonly provided analgesic substances permitted to independent treatment by the paramedics are often below the recommended range for adults (RDE). The majority of medical directors (78.4%) of the emergency services consider the independent application of analgesics by paramedics sensible. The reason for the relatively rare authorization of opioids for use by paramedics is mainly due to legal (in)certainty (53.2%).

CONCLUSION

Effective analgesics are available for EMS staff in Germany, the approach to improvement lies in the area of application. For this purpose, the adaptations of the legal framework as well as the creation of a guideline for prehospital analgesia are useful.

Factors that affect pain management in adults diagnosed with acute appendicitis in the emergency department: A retrospective study

BACKGROUND

Analgesic treatment, including with opioids, can safely be given to patients who are suspected of having appendicitis. The study examined factors which may influence the treatment of pain in appendicitis in the adult emergency department (ED). A secondary objective was to determine if analgesia affected clinical outcomes.

METHODS

This single-center retrospective study examined medical records of all adult patients with a discharge diagnosis of appendicitis. Patients were categorized based on the type of analgesia received in the ED. Variables included the day of week and staffing shift of presentation, gender, age, and triage pain scale, as well as time to ED discharge, imaging, operation, and hospital discharge. Univariable and multivariable logistic regression models were performed to determine which factors influenced treatment and affected outcomes.

RESULTS

Records of 1839 patients were categorized into three groups - 883 (48%) did not receive analgesia, 571 (31%) received only non-opioid medications, and 385 (21%) received at least one opioid. Patients with a higher triage pain level were significantly more likely to receive analgesia (4-6: OR = 1.85; 95% CI = 1.2-2.84, 7-9: OR = 3.36; 95% CI = 2.18-5.17, 10: OR = 10.78; 95% CI = 6.38-18.23) and at least one opioid (4-6: OR = 2.88; 95% CI = 1.13-7.34, 7-9: OR = 4.36; 95% CI = 1.73-11.01, 10: OR = 6.23; 95% CI = 2.42-16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61-0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41-2.48). Patients aged 25-64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25-44: OR = 1.47; 95% CI = 1.08-2.02, 45-64: OR = 1.78; 95% CI = 1.15-2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42-0.94). Regarding clinical outcomes, patients who received analgesia waited longer for imaging (+0.58 h; 95% CI = 0.31-0.85), stayed longer in the ED (+2.2 h; 95% CI = 1.60-2.79), and had a slightly longer hospitalization (+0.62d; 95% CI = 0.34-0.90).

CONCLUSIONS

Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.

Ambulance nurses’ experiences of pain management with Penthrox® in Swedish ambulance care: A mixed method study

BACKGROUND

Methoxyflurane (MTX) is an inhalation agent that has several potential benefits for limiting various types of pain in ambulance care.

AIM

To elucidate how ambulance nurses experience the characteristics of MTX in an ambulance care setting.

METHOD

This cross-sectional study applied a mixed-methods approach, using a questionnaire together with complementary interviews. The questionnaire survey was analyzed using descriptive statistics (10-point Likert scale and question index values [Q-IV], range: 0-1.0). The interviews were analyzed using directed content analysis. Study results were reported following the STROBE statement.

RESULTS

The ambulance nurses' overall general satisfaction with the MTX concept had a median of 7.0 (IQR 5-8), corresponding to a mean Q-IV of 0.84 (very good experience). The qualitative part was divided into three categories: sense of security, patient participation, and general usefulness. The results revealed varying experiences of usefulness, including pain-relieving effect and the possibility of patient participation. The perceived strong odor of MTX seemed to concern the ambulance nurses and their patients.

CONCLUSION

In general, MTX was experienced as a safe and effective analgesic. However, the experiences of the overall usefulness varied, particularly since the product had a perceived strong odor. Increasing knowledge of using MTX, could likely increase the overall usefulness.

Successful treatment of out-of-hospital cardiac arrest is still based on quick activation of the chain of survival

Background and goal of study

Cardiopulmonary resuscitation (CPR) in prehospital care is a major reason for emergency medical service (EMS) dispatches. CPR outcome depends on various factors, such as bystander CPR and initial heart rhythm. Our aim was to investigate whether short-term outcomes such as the return of spontaneous circulation (ROSC) and hospital admission with spontaneous circulation differ depending on the location of the out-of-hospital cardiac arrest (OHCA). In addition, we assessed further aspects of CPR performance.

Materials and methods

In this monocentric retrospective study, protocols of a prehospital physician-staffed EMS located in Munich, Germany, were evaluated using the Mann-Whitney U-test, chi-square test, and a multifactor logistic regression model.

Results and discussion

Of the 12,073 cases between 1 January 2014 and 31 December 2017, 723 EMS responses with OHCA were analyzed. In 393 of these cases, CPR was performed. The incidence of ROSC did not differ between public and non-public spaces (p = 0.4), but patients with OHCA in public spaces were more often admitted to the hospital with spontaneous circulation (p = 0.011). Shockable initial rhythm was not different between locations (p = 0.2), but defibrillation was performed significantly more often in public places (p < 0.001). Multivariate analyses showed that hospital admission with spontaneous circulation was more likely in patients with shockable initial heart rhythm (p < 0.001) and if CPR was started by an emergency physician (p = 0.006).

Conclusion

The location of OHCA did not seem to affect the incidence of ROSC, although patients in public spaces had a higher chance to be admitted to the hospital with spontaneous circulation. Shockable initial heart rhythm, defibrillation, and the start of resuscitative efforts by an emergency physician were associated with higher chances of hospital admission with spontaneous circulation. Bystander CPR and bystander use of automated external defibrillators were low overall, emphasizing the importance of bystander education and training in order to enhance the chain of survival.

First steps towards international competency goals for residency training: a qualitative comparison of 3 regional standards in anesthesiology

BACKGROUND

Competency-based medical education (CBME) has revolutionized approaches to training by making expectations more concrete, visible, and relevant for trainees. Designing, applying, and updating CBME requirements challenges residency programs, which must address many aspects of training simultaneously. This challenge also exists for educational regulatory bodies in creating and adjusting national competencies to standardize training expectations. We propose that an international approach for mapping residency training requirements may provide a baseline for assessing commonalities and differences. This approach allows us to take our first steps towards creating international competency goals to enhance sharing of best practices in education and clinical work.

METHODS

We chose anesthesiology residency training as our example discipline. Using two rounds of content analysis, we qualitatively compared published anesthesiology residency competencies for the European Union (The European Training Requirement), United States (ACGME Milestones), and Canada (CanMEDS Competence By Design), focusing on similarities and differences in representation (round one) and emphasis (round two) to generate hypotheses on practical solutions regarding international educational standards.

RESULTS

We mapped the similarities and discrepancies between the three repositories. Round one revealed that 93% of competencies were common between the three repositories. Major differences between European Training Requirement, US Milestones, and Competence by Design competencies involved critical emergency medicine. Round two showed that over 30% of competencies were emphasized equally, with notable exceptions that European Training Requirement emphasized Anaesthesia Non-Technical Skills, Competence by Design highlighted more granular competencies within specific anesthesiology situations, and US Milestones emphasized professionalism and behavioral practices.

CONCLUSIONS

This qualitative comparison has identified commonalities and differences in anesthesiology training which may facilitate sharing broader perspectives on diverse high-quality educational, clinical, and research practices to enhance innovative approaches. Determining these overlaps in residency training can prompt international educational societies responsible for creating competencies to collaborate to design future training programs. This approach may be considered as a feasible method to build an international core of residency competency requirements for other disciplines.

Bedside Evaluation of Early VAS/NRS Based Protocols for Intravenous Morphine in the Emergency Department: Reasons for Poor Follow-Up and Targeted Practices

Intravenous (IV) morphine protocols based on patient-reported scores, immediately at triage, are recommended for severe pain in Emergency Departments. However, a low follow-up is observed. Scarce data are available regarding bedside organization and pain etiologies to explain this phenomenon. The objective was the real-time observation of motivations and operational barriers leading to morphine avoidance. In a single French hospital, 164 adults with severe pain at triage were included in a cross-sectional study of the prevalence of IV morphine titration; caregivers were interviewed by real-time questionnaires on “real” reasons for protocol avoidance or failure. IV morphine prevalence was 6.1%, prescription avoidance was mainly linked to “Pain reassessment” (61.0%) and/or “alternative treatment prioritization” (49.3%). To further evaluate the organizational impact on prescription decisions, a parallel assessment of “simulated” prescription conditions was simultaneously performed for 98/164 patients; there were 18 titration decisions (18.3%). Treatment prioritization was a decision driver in the same proportion, while non-eligibility for morphine was more frequently cited (40.6% p = 0.001), with higher concerns about pain etiologies. Anticipation of organizational constraints cannot be excluded. In conclusion, IV morphine prescription is rarely based on first pain scores. Triage assessment is used for screening by bedside physicians, who prefer targeted practices to automatic protocols.

Pain management with methoxyflurane (Penthrox®) in Swedish ambulance care - An observational pilot study

BACKGROUND

In ambulance care, patients are often classified as high-risk, particularly when they are in immediate need of pain relief. It has been shown that, after ambulance nurses administer intravenous analgesic drugs, patients delivered to the emergency department tend to complain of moderate to severe pain.

AIMS AND OBJECTIVES

The present study aimed to evaluate the overall patient-perceived pain during treatment with methoxyflurane (MTX) in an ambulance-care setting. We also explored potential demographic variations.

METHODS

This prospective observational study included 50 patients in need of ambulance care that perceived acute pain, defined as a Numeric Rating Scale (NRS) value ≥4 (scale range: 1-10). We monitored the vital parameters of patients and MTX treatment characteristics, including the total number of inhaled MTX breaths and the average number of treatment sequences.

RESULTS

Among the 50 patients initially assessed, we excluded 8 patients (16%), due to MTX contraindications. We excluded 10 patients (24%), due to discontinued treatment. The remaining cohort (n = 32) that fulfilled the pain-relieving procedure, included equal numbers of men and women. The average time spent in ambulance care was 29 ± 15 min. The NRS scores for pain measured at the scene (median 8.0, interquartile range [IQR]: 7.25-10.0) were significantly higher than those measured at hospital admission (median 5.0, IQR: 4.0 7.0; p = .001). The median NRS scores measured at the hospital were different between sexes (men: 6.0, IQR: 5-7.25; women: 4.0, IQR: 3.76-6.0; p = .036). The average number of treatment sequences was 2. The overall average number of inhaled breaths was 17 ± 9.

CONCLUSION

This study demonstrates that MTX provided clinically significant lower pain scores among patients in ambulance care without significant effects on vital parameters. However, the pharmacological characteristics of MTX appeared to affect the potential of achieving standardized treatment objectives.

Analgesia in adult trauma patients in physician-staffed Austrian helicopter rescue: a 12-year registry analysis

Background

Sufficient analgesia is an obligation, but oligoanalgesia (NRS> 3) is frequently observed prehospitally. Potent analgesics may cause severe adverse events. Thus, analgesia in the helicopter emergency medical service (HEMS) setting is challenging. Adequacy, efficacy and administration safety of potent analgesics pertaining to injured patients in HEMS were analysed.

Methods

Observational study evaluating data from 14 year-round physician-staffed helicopter bases in Austria in a 12-year timeframe.

Results

Overall, 47,985 (34.3%) patients received analgesics, 26,059 of whom were adult patients, injured and not mechanically ventilated on site. Main drugs administered were opioids (n=20,051; 76.9%), esketamine (n=9082; 34.9%), metamizole (n=798; 3.1%) and NSAIDs (n=483; 1.9%). Monotherapy with opioids or esketamine was the most common regimen (n=21,743; 83.4%), while opioids together with esketamine (n= 3591; 13.8%) or metamizole (n=369; 1.4%) were the most common combinations. Females received opioids less frequently than did males (n=6038; 74.5% vs. n=14,013; 78.1%; p< 0.001). Pain relief was often sufficient (> 95%), but females more often had moderate to severe pain on arrival in hospital (n=34; 5.0% vs. n=59; 3.2%; p=0.043). Administration of potent analgesics was safe, as indicated by MEES, SpO₂ and respiratory rates. On 10% of all missions, clinical patient assessment was deemed sufficient by HEMS physicians and monitoring was spared.

Conclusions

Opioids and esketamine alone or in combination were the analgesics of choice in physician-staffed HEMS in Austria. Analgesia was often sufficient, but females more than males suffered from oligoanalgesia on hospital arrival. Administration safety was high, justifying liberal use of potent analgesics in physician-staffed HEMS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00839-9.

Data quality of Glasgow Coma Scale and Systolic Blood Pressure in scientific studies involving physician-staffed emergency medical services: Systematic review

BACKGROUND

Emergency physicians on-scene provide highly specialized care to severely sick or injured patients. High-quality research relies on the quality of data, but no commonly accepted definition of EMS data quality exits. Glasgow Coma Score (GCS) and Systolic Blood Pressure (SBP) are core physiological variables, but little is known about the quality of these data when reported in p-EMS research. This systematic review aims to describe the quality of pre-hospital reporting of GCS and SBP data in studies where emergency physicians are present on-scene.

METHODS

A systematic literature search was performed using CINAHL, Cochrane, Embase, Medline, Norart, Scopus, SweMed + and Web of Science, in accordance with the PRISMA guidelines. Reported data on accuracy of reporting, completeness and capture were extracted to describe the quality of documentation of GCS and SBP. External and internal validity assessment was performed by extracting a set of predefined variables.

RESULTS

We included 137 articles describing data collection for GCS, SBP or both. Most studies (81%) were conducted in Europe and 59% of studies reported trauma cases. Reporting of GCS and SBP data were not uniform and may be improved to enable comparisons. Of the predefined external and internal validity data items, 26%-45% of data were possible to extract from the included papers.

CONCLUSIONS

Reporting of GCS and SBP is variable in scientific papers. We recommend standardized reporting to enable comparisons of p-EMS.

Clinical practice of pre-hospital analgesia: An observational study of 20,978 missions in Switzerland

BACKGROUND

Pain is a frequent problem faced by emergency medical services (EMS) in pre-hospital settings. This large observational study aims to assess the prevalence of sufficiently provided analgesia and to analyze the efficacy of different analgesics. Moreover, we evaluated if quality of analgesia changed with an emergency physician on scene or depended on paramedics' gender.

METHODS

This is a retrospective analysis of all pre-hospital medical charts from adults and adolescents treated by the municipal EMS Schutz & Rettung Zürich over a period of 4 years from 2013 to 2016. Inclusion criteria were age ≥16 years, initial GCS > 13, NACA score ≥I and ≤V, an initial numeric rating scale (NRS) ≥ I and a documented NRS at hospital admission. 20,978 out of 142,484 missions fulfilled the inclusion criteria and therefore underwent further investigation. Descriptive, univariate and multivariate analyses were applied.

RESULTS

Initial NRS on scene was on average 5.2 ± 3.0. Mean NRS reduction after treatment was 2.2 ± 2.5 leading to a NRS at hospital admission of 3.0 ± 1.9. This resulted in sufficient analgesia for 77% of included patients. Among analgesics, the highest odds ratio for sufficient analgesia was observed for ketamine (OR 4.7, 95%CI 2.2-10.4, p < 0.001) followed by fentanyl (OR 1.4, 95%CI 1.1-1.7, p = 0.004). Female paramedics provided better analgesia (OR 1.2, 95%CI 1.1-1.2; p < 0.001). Patient's sex had no influence on analgesia. In patients with a NACA score > 2, the presence of an emergency physician on scene improved the quality of analgesia significantly.

CONCLUSIONS

Pre-hospital analgesia is mostly adequate, especially when done with ketamine or fentanyl. Female paramedics provided better analgesia and in selected patients, an emergency physician on scene improved quality of analgesia in critical patients.

[Analgesia in the emergency medical service: comparison between tele-emergency physician and call back procedure with respect to application safety, effectiveness and tolerance]

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.