[Analgesia in the emergency medical service: comparison between tele-emergency physician and call back procedure with respect to application safety, effectiveness and tolerance].
Analgesie im Rettungsdienst: Vergleich zwischen Telenotarzt- und Callback-Verfahren hinsichtlich Anwendungssicherheit, Wirksamkeit und Verträglichkeit.
Algorithms
Legal aspects
Opioids
Pain therapy
Prehospital emergency medicine
Journal
Der Anaesthesist
ISSN: 1432-055X
Titre abrégé: Anaesthesist
Pays: Germany
ID NLM: 0370525
Informations de publication
Date de publication:
10 2019
10 2019
Historique:
received:
20
02
2019
accepted:
20
08
2019
revised:
19
08
2019
pubmed:
7
9
2019
medline:
21
10
2020
entrez:
7
9
2019
Statut:
ppublish
Résumé
Acute pain is a common reason for calling emergency medical services (EMS) and can require medication depending on the pain intensity. German EMS personnel feel strong pressure to reduce a patient's pain but are restricted by law. Currently, German federal law only allows the administration of opioid-containing drugs by or on the order of a physician, while in other European countries (e.g. Switzerland and The Netherlands) the administration of opioid-based analgesia by trained and certified paramedics is common practice. Consequently, a patient in Germany experiencing acute pain needs the attendance of an emergency physician in EMS missions. According to international standards pain reduction on the numeric rating scale (NRS) score by ≥2 or a NRS score ≤4 at the end of the patient transport is considered to be adequate. Comparison of two different algorithm-based concepts for analgesia with consultation of a physician analyzing the efficacy, tolerance and safety of application. In a retrospective cohort study in two different regions, two physician-supported algorithm-based analgesia concepts, a call back-supported concept (EMS Schleswig-Holstein: RKiSH) and a tele-EMS physician-based concept (EMS Aachen: RDAC), were compared over 2 years. The call back-supported concept is based on specific algorithms and certification of EMS personnel. In Aachen, the tele-EMS physician is integrated into the routine EMS system and includes immediate vital data transmission. Over a period of 2 years call back-supported analgesia was administered in 878 cases (2016: 428, 2017: 450) and telemedically assisted analgesia was used in 728 cases (2015: 226, 2016: 502). Call back vs. telemedicine: initial NRS scores were 9 (8-10) and 8 (6-9), respectively (p < 0.0001); NRS scores were reduced by 4 (3-5) and 5 (3-6), respectively (p = 0.0002), leading to mean NRS scores of 4 (3-6) vs. 3 (2-4), respectively (p < 0.0001) at patient handover/emergency room arrival. Clinically relevant pain reduction was achieved in both groups. Complete NRS documentation was conducted in 753 (85.8%) vs. 673 (92.4%) cases, respectively, p = 0. Severe adverse events did not occur in either of the groups. The administration of analgesia by EMS personnel with teleconsultation of a physician is effective and has a low rate of complications, particularly morphine. Overall, algorithm-based call back-supported as well as telemedically supported analgesia concepts based on regular training improve the management of pain in the prehospital setting. In addition, the resources of the emergency physician remain available for life-threatening emergencies. The training, certification and supervision of EMS personnel is very important in both systems to ensure the best pain management care and patient safety. Adjustments to the federal law on the administration of analgesics would facilitate the realization of algorithm-based concepts by paramedics as pain reduction could be performed with delegation by a medical director without consulting another physician.
Sections du résumé
BACKGROUND
Acute pain is a common reason for calling emergency medical services (EMS) and can require medication depending on the pain intensity. German EMS personnel feel strong pressure to reduce a patient's pain but are restricted by law. Currently, German federal law only allows the administration of opioid-containing drugs by or on the order of a physician, while in other European countries (e.g. Switzerland and The Netherlands) the administration of opioid-based analgesia by trained and certified paramedics is common practice. Consequently, a patient in Germany experiencing acute pain needs the attendance of an emergency physician in EMS missions. According to international standards pain reduction on the numeric rating scale (NRS) score by ≥2 or a NRS score ≤4 at the end of the patient transport is considered to be adequate.
OBJECTIVE
Comparison of two different algorithm-based concepts for analgesia with consultation of a physician analyzing the efficacy, tolerance and safety of application.
MATERIAL AND METHODS
In a retrospective cohort study in two different regions, two physician-supported algorithm-based analgesia concepts, a call back-supported concept (EMS Schleswig-Holstein: RKiSH) and a tele-EMS physician-based concept (EMS Aachen: RDAC), were compared over 2 years. The call back-supported concept is based on specific algorithms and certification of EMS personnel. In Aachen, the tele-EMS physician is integrated into the routine EMS system and includes immediate vital data transmission.
RESULTS
Over a period of 2 years call back-supported analgesia was administered in 878 cases (2016: 428, 2017: 450) and telemedically assisted analgesia was used in 728 cases (2015: 226, 2016: 502). Call back vs. telemedicine: initial NRS scores were 9 (8-10) and 8 (6-9), respectively (p < 0.0001); NRS scores were reduced by 4 (3-5) and 5 (3-6), respectively (p = 0.0002), leading to mean NRS scores of 4 (3-6) vs. 3 (2-4), respectively (p < 0.0001) at patient handover/emergency room arrival. Clinically relevant pain reduction was achieved in both groups. Complete NRS documentation was conducted in 753 (85.8%) vs. 673 (92.4%) cases, respectively, p = 0. Severe adverse events did not occur in either of the groups.
CONCLUSION
The administration of analgesia by EMS personnel with teleconsultation of a physician is effective and has a low rate of complications, particularly morphine. Overall, algorithm-based call back-supported as well as telemedically supported analgesia concepts based on regular training improve the management of pain in the prehospital setting. In addition, the resources of the emergency physician remain available for life-threatening emergencies. The training, certification and supervision of EMS personnel is very important in both systems to ensure the best pain management care and patient safety. Adjustments to the federal law on the administration of analgesics would facilitate the realization of algorithm-based concepts by paramedics as pain reduction could be performed with delegation by a medical director without consulting another physician.
Identifiants
pubmed: 31489458
doi: 10.1007/s00101-019-00661-0
pii: 10.1007/s00101-019-00661-0
doi:
Substances chimiques
Analgesics
0
Analgesics, Opioid
0
Types de publication
Journal Article
Langues
ger
Sous-ensembles de citation
IM
Pagination
665-675Références
Methods Inf Med. 2014;53(2):99-107
pubmed: 24477815
J Telemed Telecare. 2017 Apr;23(3):402-409
pubmed: 27080747
Am J Emerg Med. 2015 Nov;33(11):1587-90
pubmed: 26186993
Scand J Trauma Resusc Emerg Med. 2013 Jul 11;21:54
pubmed: 23844941
Anasthesiol Intensivmed Notfallmed Schmerzther. 2016 Feb;51(2):84-95; quiz 96
pubmed: 26949902
Sci Rep. 2016 Jun 16;6:28187
pubmed: 27305956
Eur J Emerg Med. 2016 Oct;23(5):370-4
pubmed: 25794114
Arch Emerg Med. 1993 Sep;10(3):187-92
pubmed: 8216592
BMC Anesthesiol. 2019 Jan 31;19(1):18
pubmed: 30704401
Dtsch Arztebl Int. 2017 Nov 17;114(46):785-792
pubmed: 29229039
Sci Rep. 2017 May 8;7(1):1536
pubmed: 28484212
J Telemed Telecare. 2011;17(7):371-7
pubmed: 21933897
Eur J Pain. 2016 Aug;20(7):1176-84
pubmed: 26914284
Ann Fr Anesth Reanim. 1997;16(8):945-9
pubmed: 9750642
Acta Anaesthesiol Scand. 2016 Apr;60(4):537-43
pubmed: 26612100
Prehosp Emerg Care. 2002 Oct-Dec;6(4):402-5
pubmed: 12385606