title: The implementation and evaluation of an evidence-based statewide prehospital pain management protocol developed using the national prehospital evidence-based guideline model process for emergency medical services.
abstract: BACKGROUND
  In 2008, the National Highway Traffic Safety Administration funded the development of a model process for the development and implementation of evidence-based guidelines (EBGs) for emergency medical services (EMS). We report on the implementation and evaluation of an evidence-based prehospital pain management protocol developed using this model process.
  
  
  METHODS
  An evidence-based protocol for prehospital management of pain resulting from injuries and burns was reviewed by the Protocol Review Committee (PRC) of the Maryland Institute for Emergency Medical Services Systems (MIEMSS). The PRC recommended revisions to the Maryland protocol that reflected recommendations in the EBG: weight-based dosing and repeat dosing of morphine. A training curriculum was developed and implemented using Maryland's online Learning Management System and successfully accessed by 3,941 paramedics and 15,969 BLS providers. Field providers submitted electronic patient care reports to the MIEMSS statewide prehospital database. Inclusion criteria were injured or burned patients transported by Maryland ambulances to Maryland hospitals whose electronic patient care records included data for level of EMS provider training during a 12-month preimplementation period and a 12-month postimplementation period from September 2010 through March 2012. We compared the percentage of patients receiving pain scale assessments and morphine, as well as the dose of morphine administered and the use of naloxone as a rescue medication for opiate use, before and after the protocol change.
  
  
  RESULTS
  No differences were seen in the percentage of patients who had a pain score documented or the percent of patients receiving morphine before and after the protocol change, but there was a significant increase in the total dose and dose in mg/kg administered per patient. During the postintervention phase, patients received an 18% higher total morphine dose and a 14.9% greater mg/kg dose.
  
  
  CONCLUSIONS
  We demonstrated that the implementation of a revised statewide prehospital pain management protocol based on an EBG developed using the National Prehospital Evidence-based Guideline Model Process was associated with an increase in dosing of narcotic pain medication consistent with that recommended by the EBG. No differences were seen in the percentage of patients receiving opiate analgesia or in the documentation of pain scores.
authors.affiliation: from the Department of Pediatrics and Emergency Medicine, George Washington School of Medicine , Washington, DC (KMB) ; Emergency Department, Children's National Medical Center , Washington, DC (KMB) ; Maryland Institute for Emergency Medical Services Systems , Baltimore, Maryland (RA) ; Health Resources and Services Administration/Maternal and Child Health Bureau , Rockville, Maryland (TSW) ; Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, Maryland (BL) ; Baltimore City Fire Department , Baltimore Maryland (BL) ; Shock Trauma and Anesthesiology Research-Organized Research Center, University of Maryland School of Medicine , Baltimore Maryland (SH) ; Department of Pediatrics, Emergency Medicine, and Health Policy, George Washington University School of Medicine and Public Health , Washington, DC (JLW) ; Child Health Advocacy Institute, Children's National Medical Center , Washington, DC (JLW) ; and Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland , Baltimore, Maryland (JMH) .
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Brown
authors.forename: Jon Mark
authors.initials: JM
authors.lastname: Hirshon
authors.forename: Richard
authors.initials: R
authors.lastname: Alcorta
authors.forename: Tasmeen S
authors.initials: TS
authors.lastname: Weik
authors.forename: Ben
authors.initials: B
authors.lastname: Lawner
authors.forename: Shiu
authors.initials: S
authors.lastname: Ho
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Wright
mesh_terms: D059787:Acute Pain / Q000188:drug therapy* / Q000209:etiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000592:standards; D002056:Burns / Q000150:complications / Q000188:drug therapy*; D002985:Clinical Protocols; D004632:Emergency Medical Services / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D055416:Evidence-Based Emergency Medicine / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008396:Maryland; D008875:Middle Aged; D009020:Morphine / Q000008:administration & dosage* / Q000592:standards; D059408:Pain Management / Q000379:methods / Q000592:standards*; D010147:Pain Measurement / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic / Q000592:standards; D016730:Program Development; D015397:Program Evaluation; D017678:Sex Distribution; D014947:Wounds and Injuries / Q000150:complications / Q000188:drug therapy*; D055815:Young Adult
chemical_list: D000701:Analgesics, Opioid; D009020:Morphine