Inadequate pain management with opioids fentanyl and morphine by paramedics and emergency physicians in rural Germany: an observational study

BACKGROUND: Between 20% and 30% of patients in Europe receive inadequate prehospital analgesic therapy by emergency medical services. Current study investigated the group of patients with an NRS > 4 (Numeric Rating Scale) with regard to opioid dosages, leading diagnoses and changes in opioid applications following the removal of the requirement for an emergency physician callout. METHODS: The application protocols of 1147 patients (over 106 months) were evaluated. Missions were categorised according to opioids, symptom groups, diagnosis groups or accident mechanisms. Pain intensity, vital signs were evaluated before and after analgesia, as well as any adverse effects. RESULTS: The target NRS of ≤ 4 was not achieved in 26.5% of the cases. The average pain level of these patients upon admission to hospital was NRS 5.8 ± 1.2. No significant difference in the dose of fentanyl administered exclusively by paramedics was found between the groups (NRS ≤ 4: 0.155 ± 0.078 mg versus NRS > 4: 0.156 ± 0.082 mg). The majority of the patients with insufficient pain management were assigned to the symptom groups “trauma pain” (42.8%, NRS: 5.8 ± Ta1.2), “visceral pain” (22.0%, NRS: 6.1 ± 1.4) and “back pain” (17.8%, NRS: 5.8 ± 1.1), the injury pattern “fall” (27.6%, NRS: 5.7 ± 1.2), the diagnosis fields “acute abdomen” (26.0%; NRS: 6.1 ± 1.4) and “lumbago” (17.7%, NRS: 5.8 ± 1.1) were leading. The diagnosis group ‘visceral pain’ (p = 0.00024) was significantly more frequently associated with failure to achieve the target NRS. There was no increase in side effects in inadequately treated patients compared to patients with NRS ≤ 4. The proportion of inadequately treated patients increased significantly after the abolition of the requirement to call an emergency doctor to the scene (p = 0.045). CONCLUSIONS: Approximately one quarter of patients had excessive pain levels upon handover. We suggest insufficient titration and/or limited dose escalation of opioids by paramedics and emergency physicians to be the important contributor to inadequate treatment. TRIAL REGISTRATION: Not applicable.