Selected topic: Prehospital care
Compliance with a Morphine Protocol and Effect on Pain Relief in Out-of-Hospital Patients

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Abstract

This study was carried out to evaluate the compliance with a morphine protocol and its effects on pain relief in pre-hospital care. In this prospective study, pain intensity was evaluated by the Visual Analog Scale (VAS) from the beginning and every 5 min until hospital arrival (Tend). Group 1: No major deviation from the protocol (intravenous morphine as a first bolus of 0.05 mg/kg followed by repeated boluses every 5 min until VAS ≤ 30 mm). Group 2: Major deviation from the protocol. There were 216 patients included. The mean dose of morphine was 9.0 ± 5.7 mg. The morphine protocol was respected in 123 patients (57%). The mean VAS score was significantly better at Tend in Group 1 vs. Group 2 (27.8 ± 21.1 mm vs. 37.8 ± 22.1 mm, respectively), the degree of pain relief was significantly better (73% vs. 53%, respectively) and the initiation time for pain relief was significantly shorter in Group 1 vs. Group 2 (10 min [5–15] vs. 15 min [10–26], respectively). Satisfaction was significantly better in patients expressing pain relief than in unrelieved patients (94% vs. 61%, respectively). Out-of-hospital pain management using morphine depends on careful attention to dosage and the time interval between re-injections. Emergency teams may employ these data to improve the quality of pain relief in the field.

Introduction

A number of studies have shown that emergency physicians may not be giving adequate analgesia to patients in Emergency Departments or in the pre-hospital setting (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). Reasons for this insufficiency of analgesia are most often erroneous dogma and bad habits (2, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24). To improve analgesia in emergency situations, recommendations about analgesia have been made by emergency physicians, with proposals for appropriate use of morphine for severe acute pain (16, 25, 26, 27). Morphine sulfate has been studied in the pre-hospital setting and its benefit and its safety have been demonstrated in this context (25, 26, 27, 28). Nevertheless, there are few data about compliance with morphine pain control protocols or the initiation time for pain relief after intravenous morphine treatment in emergency care (29). This study was therefore carried out to evaluate the compliance with intravenous morphine protocol and its effect on the quality of pain relief in pre-hospital emergency medicine.

Section snippets

Study Design

This was a prospective cohort study conducted on consecutive patients transported by an ambulance crew during a 1-year period of observation.

Study Setting and Population

This study was carried out by the French Emergency Medical Services (EMS) system (Service d’Aide Médicale d’Urgence; SAMU), in a city of 290,172 inhabitants during a 12-month period. The EMS system in our country is based on a two-tiered approach: Emergency Medical technicians provide basic life support and physician-staffed ambulances provide advanced

Results

There were 216 patients studied during a 12-month period. The mean age was 49 ± 20 years. The gender ratio was 138 M:78 F (64% males). The mean VAS score at the beginning of medical management was 72.6 ± 19.1 mm. The mean SAPS was 2.6 ± 2.2 (0–11). No patient refused analgesics. The mean total dose of morphine was 9.0 ± 5.7 mg (2.0–35.0). Additional analgesics were administered in 79 patients (37%): intravenous paracetamol for 60 patients (28%) and inhaled nitrous oxide for 23 patients (11%).

Discussion

This study was done to evaluate the compliance with an intravenous morphine treatment protocol and its effects on pain relief in pre-hospital critical care medicine.

Our results underscore that the protocol for analgesia was often not respected (in about 40% of patients) despite training. This non-compliance with the protocol was associated with a greater rate of inadequate pain relief. In fact, fewer patients experienced pain relief and time for pain relief was significantly lengthened when the

Conclusion

Compliance with the pain protocol needs improvement in the pre-hospital setting, and may result in positive effects on pain relief. Emergency teams must pay attention to morphine dosage and interval time between re-injections of morphine to improve the degree and onset time of pain relief in the field. The implementation of a pain quality program is necessary to make emergency teams aware of the problem. Implementation of pain protocols is one step in a quality assurance program but is not

Acknowledgments

We thank all the physicians and nurses who took part in this study and Ms. F. Richardson for assistance in editing the manuscript.

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