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Pain management

Why is this important?

Pain is the leading complaint among individuals presenting to emergency departments, with up to 70 per cent of emergency department (ED) patients having pain as part of their chief complaint [1]. McLean et al [2] found that at least 20 per cent of patients transported by emergency medical services (EMS) had moderate to severe pain. Multiple other studies [3-7] have also demonstrated that pre-hospital care providers and emergency physicians fail to adequately recognise, assess, and treat pain. Identifying these inadequacies in pre-hospital pain management has resulted in recommendations to incorporate assessment scales and treatment protocols, and to undertake further pain research [6-8].

Pre-hospital pain control/management of patients has provided significant clinical benefit by reducing time to pain relief [7]. Efficient analgesia reduces both physiological and psychological stress, during transport in the pre-hospital setting [9]. Provision of analgesia is an integral part of modern EMS. It has been reported that two third of ambulance patients complaining of moderate to severe pain receive an analgesic agent, and the reported effectiveness of analgesia ranges from 49 per cent to 70 per cent [10-11]. Control of pain is important not only for humanitarian reasons, but also because it may prevent deterioration of the patient and allow better treatment outcome.

Analgesia should be administered (where appropriate), as soon as clinically possible after arriving on scene, although this can be done en route so as not to delay time-critical patients. It is important to remember that the pain a patient experiences cannot be objectively validated in the same way as other vital signs. Clinicians should therefore seek and accept the patient's self-report of their pain. All patients with pain should have a pain severity score undertaken and repeated after each intervention (the timing of the repeat score depends on the expected time for the analgesic to have an effect). The NSW Ambulance recommends that a simple 0-10 point verbal scale is used (where 0= 'no pain' and 10= 'the worst pain imaginable'). This section has presented information about pre-hospital administration of analgesia for patients to whom an ambulance was called in NSW.


[1] Cordell WH, Keen KK, Giles BK. The high prevalence of pain in emergency care. Am J Emerg Med 2002; 20(3):165-9.
[2] McLean SA, Maio RF, Domeier RM. The epidemiology of pain in the prehospital setting. Prehosp Emerg Care 2002; 6(4):402-5.
[3] DeVellis P, Thomas SH, Wedel SK. Prehospital and emergency department analgesia for air-transported patients with fractures. Prehosp Emerg Care 1998;2:293-6.
[4] Basket PJ. Acute pain management in the field. Ann Emerg Med 1999; 34(6):784-5.
[5] McEachinDD, McDermott JT, Swor R. Few emergency medical service patients with lower extremity fractures receive prehospital analgesia. Prehosp Emerg Care 2002; 6:406-10.
[6] Alonso-Serra HM, Wesley K. National Association of EMS Physicians position paper: prehospital pain management. PrehospEmerg Care 2003; 7(4):482-8.
[7] Abbuhl FB, Reed DB. Time to analgesia for patients with painful extremity injuries transported to the emergency department by ambulance. Prehosp Emerg Care 2003; 7(4): 445-7.
[8] Fullerton-Gleason L, Crandall C, Sklar DP.Prehospital administration of morphine for isolated extremity injuries: a change in protocol reduces time to medication. Prehosp Emerg Care 2002; 6(4):411-6.
[9] Chambers JA, Guly HR. The need for better pre-hospital analgesia. Arch Emerg Med 1993; 10:187-92.
[10]Galinski M, Ruscev M, Gonzalez G, et al: Prevalence and management of acute pain in prehospital emergency medicine. Prehosp Emerg Care 2010;14: 334-339.
[11] Middleton PM, Simpson PM, Sinclair G, Dobbins TA, Math B, Bendall JC: Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting. Prehosp Emerg Care 2010;14(4): 439-447.


The proportion of Electronic Medical Records (for patients who received analgesia) that had an initial and final pain score recorded declined marginally from 94.3 per cent in 2012-13 to 93.5 per cent in 2013-14. A similar trend was observed across all ambulance sector and divisions (Chart AM02). The rate was slightly lower in regional operational sectors, compared to metropolitan operational sectors.


Pre-hospital pain management has led to significant improvements in pain relief and treatment outcomes. Appropriately measuring and documenting the intensity of pain provides important feedback to the Paramedic about the quality of pain relief. Variations in how pain scores are documented in rural/metro regions indicate the need for a re-emphasis on the standardised approach to recording this important observation. Pain scoring is a subjective experience, and initial and final pain scores must be recorded for it to be used to guide clinical care, or to assess quality of pain management.

What we don't know

NSW Ambulance has measured this KPI to establish base-line performance levels. Further analysis is being conducted to establish the cause of the discrepancy between metropolitan and regional performance.

AM02 (Analgesia): Per cent of patients administered analgesia

Per cent of patients administered analgesia who had initial and final score recorded by Ambulance zone/sector in NSW July 2012 to January 2014

Source: NSW Ambulance.

End Matter

Drafted by: NSW Ambulance and eChartbook team, CEC eChartbook team

Data analysis by: CEC eChartbook team
Reviewed by: NSW Ambulance
Edited by: CEC eChartbook team

Suggested citation
Clinical Excellence Commission [access year]. eChartbook Portal: Safety and Quality of Healthcare in New South Wales. Sydney: Clinical Excellence Commission. Available at: Accessed [insert date of access].

© Clinical Excellence Commission 2013
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Chart: AM02 (Analgesia)

Admin Status: Current

Indicator Name: Analgesia administration to Ambulance patients

Description: Per cent out of hospital ambulance patients administered analgesia those who had an initial and final pain score recorded by Ambulance Zone in NSW July 2012 to January 2014

Dimension: Patient safety: Pre-hospital care (Ambulance patients)

Clinical Area: Initiatives in safety and quality health care: Pre-hospital care (Ambulance patients)

Data Inclusions: All transported patients to hospital with MI age 16 years and older by Ambulance sectors

Data Exclusions: None

Numerator: Total number of patients received aspirin administered ambulance para-medic

Denominator: Total number of ambulance patients with suspected MI

Standardisation: None (crude rate per 100 was calculated)

Data Source: NSW Ambulance