Undertreatment of acute pain (oligoanalgesia) and medical practice variation in prehospital analgesia of adult trauma patients: a 10 yr retrospective study.
BACKGROUND
Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia.


METHODS
Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR).


RESULTS
A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant.


CONCLUSIONS
Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.
Department of Anaesthesiology, Lausanne University Hospital, Bugnon 46, 1011 Lausanne, Switzerland.
E
E
Albrecht
P
P
Taffe
B
B
Yersin
P
P
Schoettker
I
I
Decosterd
O
O
Hugli
D059787:Acute Pain / Q000188:drug therapy* / Q000453:epidemiology* / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000401:Aircraft; D000698:Analgesia / Q000706:statistics & numerical data; D000701:Analgesics, Opioid / Q000627:therapeutic use; D004632:Emergency Medical Services / Q000379:methods*; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use; D015600:Glasgow Coma Scale; D006301:Health Services Needs and Demand; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D059408:Pain Management; D010147:Pain Measurement; D012372:ROC Curve; D012189:Retrospective Studies; D012737:Sex Factors; D014193:Trauma Centers; D014947:Wounds and Injuries / Q000150:complications / Q000628:therapy*; D055815:Young Adult
D000701:Analgesics, Opioid; D005283:Fentanyl