Prehospital Emergency Nurse Competence and Pain Management for Acute Abdominal Pain

Key Takeaways

• Adults with acute abdominal pain transported in a Swedish nurse-staffed EMS system had higher documented rates of pain assessment, analgesia, and reassessment when a PEN was involved.
• Among patients with moderate-severe pain, analgesia was documented more often in PEN encounters than in non-PEN encounters.
• Mild pain at the last documented assessment was reported more often in PEN encounters, as an end-of-encounter documentation measure rather than proof of treatment effect.

Acute abdominal pain can be difficult to manage during a short ambulance encounter, when assessment, treatment, reassessment, and documentation all shape what is visible before hospital arrival. Within one Swedish regional emergency medical services (EMS) system staffed by nurses, clinicians wanted to know whether encounters involving a Prehospital Emergency Nurse (PEN) differed from those without that competence in how prehospital pain care was captured. Investigators analyzed adult abdominal pain transports in that setting.

In the study, investigators conducted a retrospective observational secondary analysis of adult EMS patients with acute abdominal pain in one Swedish region using full electronic patient record (EPR) review. Of 840 sampled records, 816 were included; median age was 64 years, and median prehospital interval was 38 minutes. The comparison focused on PEN versus non-PEN encounters and also examined sex, age, and prehospital interval, with age and interval dichotomized at the median. Primary outcomes were documented pain assessment, analgesia administration, and any documented reassessment, while secondary outcomes included documented Numerical Rating Scale (NRS) use, analgesia among patients with moderate-severe pain, reassessment after analgesia, and mild pain at the last documented assessment.

Across the cohort, only about half of encounters had a documented pain assessment, fewer than half received analgesia, and most assessed patients had moderate-severe pain. PEN encounters were more likely than non-PEN encounters to include documented pain assessment, at 67% versus 53%, and analgesia administration, at 50% versus 37%.

Documented follow-up measures also differed by clinician competence. Any documented reassessment was reported in 31% of PEN encounters versus 17% of non-PEN encounters, and among patients with moderate-severe pain, analgesia was documented in 81% versus 58%. Mild pain at the last documented assessment was also reported more often in PEN encounters, while younger patients and cases with longer prehospital intervals showed higher rates of assessment, NRS use, analgesia, and reassessment. Sex differences were not significant.

Clinician Questions

How was moderate-severe pain defined in the Swedish EMS acute abdominal pain analysis?

In the Swedish EMS acute abdominal pain analysis, moderate-severe pain meant an initial NRS score of 4 or higher at the first documented pain assessment, or an equivalent qualitative free-text description when no NRS score was recorded; if neither was available, the severe-pain triage identifier was used. This classification applied only to encounters with a documented initial pain assessment.

What did mild pain at the last documented assessment mean in prehospital acute abdominal pain records?

In prehospital acute abdominal pain records, mild pain at the last documented assessment meant an NRS score of 3 or lower, or equivalent qualitative documentation, at the final documented pain assessment during the prehospital encounter. Encounters without any documented pain assessment could not be classified as mild, and the authors treated this outcome as a proxy for end-of-encounter status rather than a direct measure of treatment effectiveness.

Which EMS acute abdominal pain encounters were included in the Swedish regional analysis?

The Swedish regional analysis included adult primary EMS assignments coded as abdominal pain by the EMS clinician within one regional system. It excluded patients younger than 18 years, inter-facility transports, assistance to another ambulance, and assignments that did not result in transport.

What remained unresolved about PEN competence and pain relief in acute abdominal pain care?

What remained unresolved was whether the higher documented rates of assessment, analgesia, and reassessment in PEN encounters reflected a causal effect of PEN competence on pain relief. The authors noted that the chart-review design depended on documented information, reassessment documentation was limited, and further research using designs better suited to causal inference was still needed.