Factors affecting paramedics’ assessment and judgement about pain experienced by patients in a community based health setting
thesisposted on 26.05.2017, 07:44 by Lord, William Anthony
Objective: This study aims to locate, analyse and understand data relating to the management of pain by paramedics in a community emergency health setting in Australia, and to compare this with contemporary standards of care. An analysis of patient care records was performed to gain evidence of the incidence of pain in cases attended by paramedics and current practice regarding the paramedic management of pain. Focus groups involving paramedics were subsequently undertaken in order to understand factors affecting pain management. This enabled the analysis of paramedics’ attitudes and beliefs relating to their role in pain assessment and pain management and their potential influence on practice. Methods: This retrospective cohort study of paramedic patient care records included all adult patients with a Glasgow Coma Score (GCS) >12 transported to hospital by ambulance in a major metropolitan area over a seven-day period in 2005. Data collected included demographics, patient report of pain and its type and severity, provision of analgesia by paramedics and type of analgesia provided. The outcomes of interest were gender differences in the provision of analgesia. Data analysis was by descriptive statistics, χ2 test and logistic regression. A qualitative study was also undertaken to identify paramedics’ and student paramedics’ beliefs, attitudes and experiences regarding pain and the assessment and management of patients reporting pain. Data was obtained through the involvement of paramedics and student paramedics in focus groups that discussed the concept of pain and paramedic pain management practice. Grounded Theory methodology was used to enable the development of theories that account for variables that influence paramedics’ clinical judgements in cases involving a patient reporting pain. Results: Of the 3357 patients transported by paramedics 1766 (52.6%) had pain. The mean initial pain score using a 0-10 numeric pain scale was 5.5. The proportion of patients with pain that did not receive analgesia was 44.8% (n=791). Logistic regression analysis found that patients with cardiac pain were more likely to receive analgesia than those with trauma related pain (OR 4.14; 95% confidence interval [CI], 2.37 to 7.23; P < 0.001), after adjusting for age, gender, initial pain score, cause of pain and duration of pain. Patients with duration of pain >24 hours and <1 week were less likely to receive analgesia than patients with pain duration <6 hours (OR 0.60; 95% CI, 0.38 to 0.94; P = 0.026). Gender was a predictor of the type of analgesia administered, with males more likely to receive morphine (17%, 95% CI 15-20%) than females (13%, 95% CI 11-15%); p = 0.01. The difference remains significant when controlled for type of pain, age and pain severity (OR 0.61, 95% CI 0.44-0.84). Focus group analysis found a dominant theme relating to paramedics’ willingness to believe the patient’s report of pain, particularly where the patient’s behaviour was inconsistent with the paramedic’s expectations of pain-related behaviour. The patient’s motives in reporting pain were also found to influence paramedics’ clinical judgements. Conclusion: Duration of pain and cause of pain are associated with significant differences in rates of paramedic-initiated analgesia. Consideration should be given to educating paramedics to identify subgroups of patients who might otherwise not receive adequate analgesia, and to recognise the effect that personal beliefs and attitudes have on clinical reasoning and decision making. However, organisational factors have a significant effect on paramedic practice and organisations employing paramedics have an obligation to identify barriers to effective pain management and develop strategies that enable paramedics to make unbiased judgements about care for patients reporting pain.