Evolution of analgesia in EMS: A comparison of narcotic analgesia pre and post standing orders

Background: Historically, New York State has required on-line medical control for the administration of morphine analgesia. Paramedic providers felt that this was a barrier to morphine administration, leading to inadequate treatment of patients who were in pain. In June 2007, the pre hospital pain management protocol was changed to standing orders for patients meeting protocol parameters within Monroe County, New York.

Methods: A survey was developed and distributed to 10 EMS agencies to compare narcotic administration during the year after the introduction of standing orders for morphine and the same time period one year prior. Agencies provided information on morphine administration, call volume, and numbers of paramedic providers during those time periods. Qualitative semi-structured interviews were conducted with 25 paramedics to assess how the introduction of standing orders has changed their practice treating pain.

Results: The quantitative survey had a 40% response rate encompassing >65% of call volume in Monroe County, NY. The total number of morphine administrations increased from 277 times (pre standing orders) to 350 times (post standing orders) (p 0.034), while total milligrams of morphine increased from 1569 mg to 2211mg (p 0.009) with similar call volume. Qualitative themes included changes in paramedic practice, decreased “hassle” in administering morphine, and improved patient care without adverse events.

Conclusion: This study showed a statistically significant difference in aggregate morphine usage. Qualitatively, paramedics in Monroe County, NY felt that standing orders have changed practice in paramedic pain management and will continue to improve pre hospital patient care.