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Epidemiology of prehospital pain: an opportunity for improvement
  1. Paul Andrew Jennings1,2,
  2. Peter Cameron2,
  3. Stephen Bernard1,2
  1. 1Ambulance Victoria, Melbourne, Victoria, Australia
  2. 2Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Victoria, Australia
  1. Correspondence to Paul Andrew Jennings, Monash University, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria 3004, Australia; paul.jennings{at}monash.edu

Abstract

This retrospective, electronic patient care record review examined a consecutive sample of patients presenting with pain to the metropolitan region of Ambulance Victoria over a period of 12 months in 2008. The majority of patients did not achieve clinically significant pain reduction, but did achieve some pain relief while in ambulance care. Those with the most severe pain had pain reduction that was clinically significant. Further research is needed to provide optimal pain relief in the prehospital setting.

  • Pain
  • emergency medical services
  • emergency medicine
  • epidemiology
  • wounds and injuries
  • analgesia/pain control
  • major incidents
  • epidemiology
  • nursing
  • pre-hospital
  • trauma

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Introduction

Pain is a common presenting symptom for patients who are emergency cases. Between 20 and 31% of patients transported by ambulance have moderate to severe pain,1 2 and pain is the main issue in 52% to 86% of emergency department (ED) presentations nationally and internationally.3–5

An understanding of the epidemiology of prehospital pain presentations is required to inform the management of pain in the ambulance and emergency department setting.

Methods

This retrospective, electronic patient care record (ePCR) review examines a consecutive sample including all patients presenting with pain to the metropolitan region of Ambulance Victoria (AV) in 2008.

The Melbourne metropolitan region of Ambulance Victoria (population 3.8 million people,6 area 9000 km2)7 responded to 315 273 emergency cases during in the study period.

Results

During the period 1 January 2008 to 31 December 2008, 108 853/315 273 (34.5%) of patients presented experiencing pain. The median age was 56 (IQR 35 to 76) years and the proportion of men was 46.9% (95% CI 46.6 to 47.2).

The majority of patients presented to ambulance with pain of a traumatic or medical aetiology (40.1% and 39.1%, respectively). Pain of a cardiac nature only accounted for 17.0% of presentations.

Initial and final pain scores were available in 93 613/108 853 (86.0%) cases. Clinically significant pain reduction (Verbal Numerical Rating Scale (VNRS) reduction of three points or more) was achieved in 38 173/93 613 (40.7%) cases. More than half (56 598/93 613 60.4%) of the patients achieved some degree of pain relief while in ambulance care. The initial median VNRS was 5 (IQR 2 to 7) and the final median VNRS was 2 (IQR 1 to 4) with a statistically significant difference between initial and final pain scores (Wilcoxon paired singed-rank test p<0.0001). The median pain reduction was 2 (IQR 0 to 4). Most final scores fell in the mild (VNRS 0–4) pain category, with 5032/108 853 (4.6%) of patients still experiencing severe (VNRS 8–10) pain. Just over half of this small yet important group consisted of medical patients (2568/5032, 51.0%). The mean EMS contact time (which comprises scene and transport time) for all transported patients was 39.7 min (SD 18.2 min).

The majority (95 261/108 853, 87.5%) of patients attended by ambulance were transported to hospital.

During the study period, paramedics had four pharmacological agents available (table 1). Approximately half (55 541/108 853, 51.0%) of patients presenting with pain received analgesia while in the prehospital setting. Opioid analgesia was administered to 22 093/108853 (20.3%) of patients.

Table 1

Administration of prehospital analgesic agents

Discussion

Approximately one-third of ambulance requests were related to pain. The gender ratio of those with pain was representative of the population of the region6 and similar to other ED4 and prehospital8 pain surveys.

Opioid analgesia was more frequently administered to patients with pain in this prehospital setting than in the ED.8

The proportion of missing final pain scores seems initially high, however a significant proportion of those patients only received one assessment of their pain intensity (ie, at initial examination), due to not being transported due to the minor nature of their clinical condition (9810/108 853 9.0%) or patient refusal (3782/108 853 3.5%).

Conclusions

Pain is a common presentation in this prehospital setting, with approximately one-third of people reporting pain as their primary issue.

The majority of patients did not achieve clinically significant pain reduction, but did achieve some pain relief while in ambulance care. Those with the most severe pain had pain reduction that was clinically significant. The large percentage of patients arriving at hospital without significant reduction in pain makes this an area for improvement.

As effective pain management should be a minimum expectation for emergency medical systems, further research is needed to provide optimal pain relief in the prehospital setting.

Acknowledgments

The authors would like to acknowledge the support of Ambulance Victoria, and in particular Ms Janna Boulat for her assistance with data extraction and Dr Linton Harriss for his advice regarding this study.

References

View Abstract

Footnotes

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Monash University Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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