Effect of System-Wide Interventions on the Assessment and Treatment of Pain by Emergency Medical Services Providers

Background: An estimated 20% of patients arriving by ambulance to the emergency department are in moderate to severe pain. However, the management of pain in the prehospital setting has been shown to be inadequate. Untreated pain may have negative physiologic and psychological consequences. The prehospital community has acknowledged this inadequacy and made treatment of pain a priority. Objectives: To determine if system-wide pain management improvement efforts ( i.e. education and protocol implementation) improve the assessment of pain and treatment with opioid medications in the prehospital setting and to determine if improvements are maintained over time. Methods: This was a retrospective before and after study of a countywide prehospital patient care database. The study population included all adult patients transported by EMS between February 2004 and February 2012 with a working assessment of trauma or burn. EMS patient care records were searched for documentation of pain scores and opioid administration. Four time periods were examined: 1) before interventions, 2) after pediatric specific pain management education, 3) after pain management protocol implementation, and 4) maintenance phase. Frequencies and 95% confidence intervals were calculated for all patients meeting the inclusion criteria in each time period and Chi-square was used to compare frequencies between time periods. Results: 15,228 adult patients transported by EMS during the study period met the inclusion criteria. Subject demographics were similar between the four time periods. Pain score documentation improved between the time periods but was not maintained over time ( 13% [ 95% CI 12-15%] to 32% [ 95% CI 31-34%] to 29% [ 95 CI 27-30%] to 19% [ 95% CI 18-21%]). Opioid administration also improved between the time periods and was maintained over time ( 7% [ 95% CI 6-8%] to 18% [ 95% CI 16-19%] to 24% [ 95% CI 22-25%] to 23% [ 95% CI 22-24%]). Conclusions: In adult patients both pediatric-focused education and pain protocol implementation improved the administration of opioid pain medications. Documentation and assessment of pain scores was less affected by specific pain management improvement efforts.