ABSTRACT

INTRODUCTION

The most common reason patients seek medical attention is because they are experiencing pain.^1–11Despite a chief complaint of pain, there may be significant delays in the emergency department (ED) until initiating pain therapy.^12,13 These delays include time to triage and patient assessments, followed by ordering, obtaining, and administration of the medication. As a result, the initial assessment and management of pain must begin in the prehospital setting.^12,13 Knowledge of pain principles, assessment, documentation, and management, both pharmacologic and non-pharmacologic, of pain must be included in both initial and ongoing paramedic educational programs. The institution of quality improvement (QI) programs will serve to assess the effectiveness of prehospital providers’ practices.¹⁴

In 2003, the National Association of Emergency Medical Services (EMS) Physicians produced a position paper solely for prehospital pain management, stating that every EMS system must be dedicated to the assessment and treatment of pain. To be effective, a comprehensive program must be instituted, which includes education, assessment, documentation, intervention, and QI. This program must be in place in conjunction with a prehospital standard operating procedure (SOP).¹⁵

In 2001, this EMS system instituted a QI project to assess pain management in the prehospital setting and to evaluate the perception of pain principles and knowledge of pain management. Through our regularly scheduled continuing education (CE) sessions we instituted an education intervention (EI) focused on all aspects of pain. As a result of the EI, paramedics had an increased understanding of pain (17.5% P < 0.001), improved perceptions of pain principles (4.2% P < 0.003) and improved field management of pain (21% P < 0.001). More specifically, paramedics were more likely to provide prehospital non-pharmacologic pain therapy (32.2% improvement P < 0.001), and were more likely to document the results of their interventions (repeat vs 14.7% P < 0.001, repeat pain score 11.3% P< 0.001, pain reassessment 13% P < 0.001, pain reassessment on ED arrival 15.4% P < 0.001). From this study we approved the addition of a pain management SOP, giving paramedics the authority to manage pain without requiring permission from medical control via telemetry.¹⁶

As a follow-up to this study, we reassessed the paramedics in our EMS system to measure the long term impact of the EI, to determine if a repeat EI was necessary, and to determine if the new pain management SOP was effective.

METHODS

RESULTS

There were 176 paramedics involved in the study. The population was 95% male, with a mean age of 38.7 years (range: 20–65) and 11.6 years of paramedic experience (range: 1–31). More than half (54%) of the paramedics received education beyond high school with 16% receiving associate’s degrees, 32% having bachelor’s degrees and 4% receiving master’s degrees. Twenty-six percent of the paramedics attended paramedic school in 2001 or later. On average, the paramedics reported receiving 4.6 education hours on pain, although 26% did not respond to this question. Only 21% of the paramedics stated that they had received the same EI in 2001, although 31% stated that they did not recall if they did or not. Paramedics completed 176 questionnaires before and after the intervention. This study also reviewed 283 EMS runs before the intervention and 155 after the intervention, for a total of 438 runs.

The basic knowledge of the paramedics regarding pain management is shown in Table 1 and Figure 1. There was a significant improvement between the baseline knowledge of the paramedics in 2001 and the baseline knowledge in 2007 (18.2; 95% CI 8.97%, 27.9%). However, in 2001 there were significant improvements of knowledge following the educational intervention, while in 2007 there were hardly any improvements. It is interesting that on the question of IV access, there was much more improvement in 2007 than 2001, even though the baseline scores were the same.

Paramedics were also asked about their perceptions of pain in transported patients. Details of their perceptions are shown in Table 2. In 2007 there were significantly fewer paramedics with incorrect perceptions of pain management. For example, in 2001 57% felt that EMS had a restricted role in pain relief, while in 2007 only 5% had this belief. However, perhaps because of these improved perceptions, there were hardly any significant changes following education in 2007. The one exception concerns patients’ unique perceptions of pain. Following education in 2007, many fewer paramedics felt that past experience or culture influenced pain perception, suggesting less cultural bias in 2007.

The effects of the EI on prehospital pain management practice by the paramedics are shown in Table 3 and Figure 2. As compared to 2001, in 2007, there were significant improvements in the baseline field management of pain prior to the EI. However, as opposed to the results on knowledge or perceptions, in 2007 there was almost as much further significant improvement following education as occurred in 2001.

DISCUSSION

Following our last study, we instituted a pain management SOP in our entire region made up of 4 EMS systems. Our goal in this study was to determine if the EI and pain management SOP had long-term effects for paramedics. We also wanted to collect data to determine if a regular EI was helpful to maintain baseline skills regarding pain management. Given that pain is the most common chief complaint of our patients, it must be assessed and managed adequately especially given the delays to treatment that take place on presentation to the ED. ^12,13 In this follow-up study, when we reviewed the paramedics’ run reports, we again saw significant improvements in baseline documentation and management of pain prior to the EI. There was, however, also significant improvement in prehospital documentation and management of pain following the EI in 2007.

Prior to the EI, in 2007 there were significant improvements in 9 of the 12 baseline knowledge questions. While in 2001 we saw significant improvements in knowledge following the EI, we did not see that in 2007. It is possible that because their baseline knowledge was already so high in 2007, there was little room for improvement. Additionally, the curriculum of current paramedic programs includes more material on the topic of pain. Twenty-six percent of the paramedics in this study may have had a better baseline knowledge base since they attended paramedic school in 2001 or later. With 1 question pertaining to the topic of IV access, we saw significant improvement following the EI.

Our results regarding paramedics’ perceptions followed a similar trend. There were significant improvements in 3 of the 12 baseline perceptions questions. While in 2001 we saw significant improvements in perceptions following the EI, we did not see that in 2007, again likely because they already had good perceptions of pain management. More commonly in 2007 paramedics understand the importance of applying pain management principles. Again, there was one question with a significant improvement following the EI on the topic of past or cultural experiences with pain. Cultural backgrounds can affect a person’s response to pain.^15,17 while those same cultural biases can affect a prehospital provider’s management of pain.^18,19

Given the noted findings regarding paramedic knowledge and perceptions of pain, we were surprised to identify a different trend in regards to the field management of pain. In addition to there being significant improvements in the baseline field management of pain, there were also further significant improvements following the EI in 2007. Paramedics not only improved their baseline field management of pain but we discovered through this study that further continuing education is effective.

The pain management SOP allows for the administration of MS. Since the institution of the pain management SOP we expected to see a significantly higher administration rate of MS. We did not see that 20% gave pain medication in 2001 prior to the MS protocol, while 27% (P = 0.069) gave pain medication in 2007 after the MS protocol. In a similar study where paramedics were allowed to administer MS according to written protocols, a higher percentage of patients were also not given MS after the protocol was implemented.²⁰ We, however, did see significant increases in the application of non-pharmacologic treatments for pain. These included the use of ice, splinting, repositioning, and communicative support to relieve pain. We believe that because of a more comprehensive understanding of pain management, the paramedics were able to obtain pain relief without the administration of a narcotic pain medication.

As demonstrated in this study, paramedics retained baseline knowledge, perceptions, and field management of pain. We also learned that we can further improve the prehospital management of pain by incorporating this topic into a QI project. This study demonstrates that a fully comprehensive CE program is still warranted to improve prehospital management of pain. It is unique in that we obtained this understanding through the diligent work of the paramedic medical officers who reviewed every completed run report pertaining to transported patients with pain during a 2-month timeframe before and after the EI. It is also the first follow-up study of its kind to evaluate the long-term effects of an EI focusing on the knowledge, perceptions, and documentation of pain in conjunction with the institution of a pain management SOP.

LIMITATIONS

We reviewed a large number of run reports within one large EMS system located in one geographic region. Expanding this study to the region made up of 4 EMS systems or expanding it statewide would help to reduce potential selection bias. We also reviewed a small number of run reports relative to a large number of paramedics in the system, which may not fully represent the EMS system. Since we retrospectively reviewed run reports and not actual paramedic practice, the same number of non-pharmacologic procedures may have been performed but better documented. The retrospective nature of the chart review also made it challenging to elucidate the specific factors that may have led to the changes in knowledge, perceptions, or documentation.

With the institution of the pain management SOP we studied the number of patients who received any dose of MS. We expected to see a higher number of patients receiving MS. While we did not see an increase in the number of patients receiving MS, we did not study the dose of MS that was given. As a result, the same number of patients may have received MS, but those same patients may have received a higher dose of MS to achieve more effective pain control.

CONCLUSION

In this follow-up study, paramedics’ baseline knowledge, perceptions, and management of pain have all improved from 6 years ago. Following a repeat educational intervention, paramedics further improved their field management of pain suggesting paramedics will still benefit from both initial and also ongoing continuing education on the topic of pain management.