Quality of analgesia in physician-operated telemedical prehospital emergency care is comparable to physician-based prehospital care - a retrospective longitudinal study
Niklas Lenssen, Andreas Krockauer, Stefan K Beckers, Rolf Rossaint, Frederik Hirsch, Jörg C Brokmann, Sebastian Bergrath, Niklas Lenssen, Andreas Krockauer, Stefan K Beckers, Rolf Rossaint, Frederik Hirsch, Jörg C Brokmann, Sebastian Bergrath
Abstract
Acute pain is a common reason for summoning emergency medical services (EMS). Yet in several countries the law restricts opioid-based analgesia administration to physicians. Telemedical support of paramedics is a novel approach to enable timely treatment under the guidance of a physician. In this retrospective observational study, conducted in the EMS of Aachen, Germany, the analgesic quality and occurrence of adverse events were compared between telemedically-supported paramedics (July-December, 2014) and a historical control group (conventional on-scene EMS physicians; January-March, 2014).
Inclusion criteria: pain (initial numerical rating scale (NRS) ≥5) and/or performed analgesia. Telemedically-assisted analgesia was performed in 149 patients; conventional analgesia in 199 control cases. Teleconsultation vs.
Control: Initial NRS scores were 8.0 ± 1.5 and 8.1 ± 1.7. Complete NRS documentation was carried out in 140/149 vs. 130/199 cases, p < 0.0001. NRS scores were reduced by 4.94 ± 2.01 and 4.84 ± 2.28 (p = 0.5379), leading to mean NRS scores at emergency room arrival of 3.1 ± 1.7 vs. 3.3 ± 1.9 (p = 0.5229). No severe adverse events occurred in either group. Clinically relevant pain reduction was achieved in both groups. Thus, the concept of remote physician-based telemedically-delegated analgesia by paramedics is effective compared to analgesia by on-scene EMS physicians and safe.
Conflict of interest statement
J.C.B. and R.R. are shareholder of the Docs in Clouds GmbH. F.H. is a part-time employed (25%) tele-EMS physician at P3 telehealthcare. All other authors declare no conflict of interest.
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References
- Neugebauer EAM, et al. The treatment of patients with severe and multiple traumatic injuries. Dtsch. Arzteblatt Int. 2012;109:102–108.
- Jennings PA, Cameron P, Bernard S. Epidemiology of prehospital pain: an opportunity for improvement. Emerg. Med. J. EMJ. 2011;28:530–531. doi: 10.1136/emj.2010.098954.
- Pierik JGJ, et al. Pain management in the emergency chain: the use and effectiveness of pain management in patients with acute musculoskeletal pain. Pain Med. Malden Mass. 2015;16:970–984. doi: 10.1111/pme.12668.
- Albrecht E, et al. Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study. Br. J. Anaesth. 2013;110:96–106. doi: 10.1093/bja/aes355.
- Carr DB, Goudas LC. Acute pain. Lancet Lond. Engl. 1999;353:2051–2058. doi: 10.1016/S0140-6736(99)03313-9.
- Chambers JA, Guly HR. The need for better pre-hospital analgesia. Arch. Emerg. Med. 1993;10:187–192. doi: 10.1136/emj.10.3.187.
- Stork, B. & Hofmann-Kiefer, K. Analgesia as an important component of emergency care. Anaesthesist58, 639–48, quiz 649–650, doi:10.1007/s00101-009-1585-1 (2009).
- Nikolaou NI, et al. Part 5: Acute coronary syndromes: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015;95:e121–146. doi: 10.1016/j.resuscitation.2015.07.043.
- Priori SG, et al. ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC) Eur. Heart J. 2015;36:2793–2867. doi: 10.1093/eurheartj/ehv316.
- Roffi M, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC) Eur. Heart J. 2016;37:267–315. doi: 10.1093/eurheartj/ehv320.
- Benditz A, et al. Prospective medium-term results of multimodal pain management in patients with lumbar radiculopathy. Sci. Rep. 2016;6:28187. doi: 10.1038/srep28187.
- Brokmann JC, et al. Analgesia by telemedically supported paramedics compared with physician-administered analgesia: A prospective, interventional, multicentre trial. Eur. J. Pain Lond. Engl. 2016;20:1176–1184. doi: 10.1002/ejp.843.
- Friesgaard KD, et al. Efficacy and safety of intravenous fentanyl administered by ambulance personnel. Acta Anaesthesiol. Scand. 2016;60:537–543. doi: 10.1111/aas.12662.
- Jennings PA, Lord B, Smith K. Clinically meaningful reduction in pain severity in children treated by paramedics: a retrospective cohort study. Am. J. Emerg. Med. 2015;33:1587–1590. doi: 10.1016/j.ajem.2015.06.026.
- SQR-BW, B W. Available at . Accessed 22.05.2016 (2016).
- Wilson JE, Pendleton JM. Oligoanalgesia in the emergency department. Am. J. Emerg. Med. 1989;7:620–623. doi: 10.1016/0735-6757(89)90286-6.
- Bundesärztekammer. Indikationskatalog für den Notarzteinsatz: Handreichung für Telefondisponenten in Notdienstzentralen und Rettungsleitstellen. Dtsch Arztebl Int. 110, A–521 (2013).
- Bergrath S, et al. Implementation phase of a multicentre prehospital telemedicine system to support paramedics: feasibility and possible limitations. Scand. J. Trauma Resusc. Emerg. Med. 2013;21:54. doi: 10.1186/1757-7241-21-54.
- Bergrath S, Rossaint R, Lenssen N, Fitzner C, Skorning M. Prehospital digital photography and automated image transmission in an emergency medical service - an ancillary retrospective analysis of a prospective controlled trial. Scand. J. Trauma Resusc. Emerg. Med. 2013;21:3. doi: 10.1186/1757-7241-21-3.
- Brokmann JC, et al. [Potential and effectiveness of a telemedical rescue assistance system. Prospective observational study on implementation in emergency medicine]. Anaesthesist. 2015;64:438–445.
- Sanchez-Ross M, et al. The STAT-MI (ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction) trial improves outcomes. JACC Cardiovasc. Interv. 2011;4:222–227. doi: 10.1016/j.jcin.2010.11.007.
- Sejersten M, et al. Effect on treatment delay of prehospital teletransmission of 12-lead electrocardiogram to a cardiologist for immediate triage and direct referral of patients with ST-segment elevation acute myocardial infarction to primary percutaneous coronary intervention. Am. J. Cardiol. 2008;101:941–946. doi: 10.1016/j.amjcard.2007.11.038.
- Kim KM, et al. Efficacy of a New Medical Information system, Ubiquitous Healthcare Service with Voice Inception Technique in Elderly Diabetic Patients. Sci. Rep. 2015;5:18214. doi: 10.1038/srep18214.
- Rortgen D, et al. Comparison of physician staffed emergency teams with paramedic teams assisted by telemedicine–a randomized, controlled simulation study. Resuscitation. 2013;84:85–92. doi: 10.1016/j.resuscitation.2012.06.012.
- Fehn K. Strafbarkeitsrisiken für Notärzte und Aufgabenträger in einem Telenotarztsystem. MedR. 2014;32:543–552. doi: 10.1007/s00350-014-3766-4.
- Christian Katzenmeier & Stefania Schrag-Slavu. Rechtsfragen des Einsatzes der Telemedizin im Rettungsdienst. (Springer-Verlag, 2010).
- von Elm E, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4:e296. doi: 10.1371/journal.pmed.0040296.
- Felzen M, et al. Improved technical performance of a multifunctional prehospital telemedicine system between the research phase and the routine use phase - an observational study. J. Telemed. Telecare. 2016;23:402–409. doi: 10.1177/1357633X16644115.
- Middleton PM, et al. Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting. Prehospital Emerg. Care Off. J. Natl. Assoc. EMS Physicians Natl. Assoc. State EMS Dir. 2010;14:439–447. doi: 10.3109/10903127.2010.497896.
- Bendall JC, Simpson PM, Middleton PM. Prehospital analgesia in New South Wales, Australia. Prehospital Disaster Med. 2011;26:422–426. doi: 10.1017/S1049023X12000180.
- Walsh B, Cone DC, Meyer EM, Larkin GL. Paramedic attitudes regarding prehospital analgesia. Prehospital Emerg. Care Off. J. Natl. Assoc. EMS Physicians Natl. Assoc. State EMS Dir. 2013;17:78–87. doi: 10.3109/10903127.2012.717167.
- Reimann B, Maier BC, Lott R, Konrad F. Gefährdung der Notarztversorgung im ländlichen Gebiet. Notfall Rettungsmed. 2004;7:200–204. doi: 10.1007/s10049-004-0656-8.
- Schmiedel, R & Behrendt, H. Leistungen des Rettungsdienstes 2008/09. Analyse des Leistungsniveaus im Rettungsdienst für die Jahre 2008 und 2009. Bundesanstalt für Straßenwesen (Hrsg.): Berichte der Bundesanstalt für Straßenwesen. Mensch und Sicherheit (Wirtschaftsverlag NW, Bremerhaven, 2011).
- Corrigan M, Wilson SS, Hampton J. Safety and efficacy of intranasally administered medications in the emergency department and prehospital settings. Am. J. Health-Syst. Pharm. AJHP Off. J. Am. Soc. Health-Syst. Pharm. 2015;72:1544–1554. doi: 10.2146/ajhp140630.
- Jennings PA, et al. Morphine and ketamine is superior to morphine alone for out-of-hospital trauma analgesia: a randomized controlled trial. Ann. Emerg. Med. 2012;59:497–503. doi: 10.1016/j.annemergmed.2011.11.012.
- Bloemhoff A, et al. Solo emergency care by a physician assistant versus an ambulance nurse: a cross-sectional document study. Scand. J. Trauma Resusc. Emerg. Med. 2016;24:86. doi: 10.1186/s13049-016-0279-3.
Source: PubMed