Table 2.

Overview of included studies.

Author(s), year of publication	Study design	Study aim(s)	Study setting	Data collection period	Study sample	Results
						Pain assessment (initial and reassess)	Nonpharmacological management	Pharmacological management
Mulder, 2012 [40]	Mixed methods: sequential exploratory	To determine the factors contributing to the clinical decision-making process made by South African paramedics in their management of patients with acute traumatic pain	South Africa	Phase 1: quantitative (descriptive cross-sectional study)
				7 June–30 September 2010	N=57 participants (ALS), 22% response rate	Initial: analgesia initiated based on a comprehensive clinical picture Reassess: both decreased pain score and physiological indicator of change	Positioning and splinting	Morphine, ketamine, voltaren, NSAIDs, tramadol, benzodiazepines
				Phase 2: qualitative (in-depth interviews)
				2010	N=5 participants (ALS)	Initial: main determinant in decision-making around initiating analgesia was the patient's expression (verbal) of pain Reassess: participants rely on the patient's expression of pain relief rather than a numerical score in the decision-making process	Not reported	Morphine or ketamine (preferred when in scope) or alternatively a combination of morphine and ketamine
Matthews et al., 2017 [41]	Descriptive retrospective survey	To describe prehospital pharmacological analgesia practices in the city of Cape Town	Cape Town, South Africa	August 2013–July 2014	530 PCRs (ALS employees of WCEMS)	Initial: NRS assessed in 21% (n=111) of PCRs Reassess: 2nd NRS assessed in 6% (n=34) of PCRs	Not reported	Nitrates administered in 37% (n=197), morphine in 75% (n=278), and ketamine in 1.7% (n=9) of cases
Vincent-Lambert and De Kock, 2015 [42]	Prospective descriptive study: internet-based survey	To describe the use of morphine sulphate and compare paramedic practices to existing guidelines and literature	South Africa	One month in 2015	N=60 participants (ALS), 38% response rate	Initial: not reported Reassess: stop pain management partly based on decreased pain score	Not reported	Morphine
Cox et al., 2015 [43]	Descriptive cross-sectional study	To assess the community management of paediatric burns prior to admission to a burns centre against the current provincial policy guidelines and to identify areas for improvement	Cape Town, South Africa	August–October 2012 and June–August 2013	N=353 paediatric burn patients (aged 1 month to 14 years)	Initial: not performed Reassess: not performed	Cooling with water, ice or cooling agents like Burnshield® Burnshield® applied by EMS in 6.2% (n=22) children	Paracetamol, NSAID, tilidine, morphine, and ketamine
HPCSA, 2018 [44]	Adaptive CPG design	To review and update existing protocols for ECPs and create an evidence-based CPG which provides an evidence base for emergency care practice contextualised to the South African setting, is patient-centred, realistic, and enhances continuity of care throughout the emergency system, and is aligned to best practice and provide guidance to current practitioners and those envisioned by the draft NECET policy	South Africa	Searching: October 2015–January 2016	276 CPGs included	Initial: assess pain as part of general patient care Reassess: use age-appropriate pain assessment scale, reassess every 5 minutes Observe for evidence of serious adverse effects	Burns: cool and cover burns Fracture: effectively immobilise fracture No further recommendation specifically related to nonpharmacological pain management	Labour: inhaled nitrous oxide or opioids (IV or IM) Chest pain (dependent on the cause): sublingual or IV nitrates and/or opioids (IV or IM) Burns: paracetamol or NSAIDs, consider opioids for intermittent or procedural pain Trauma: narcotic analgesics (morphine IV or fentanyl IV/IN) for moderate to severe pain Procedural sedation and analgesia: ketamine: IV, if sedation inadequate, incremental IV doses Postresuscitation care: pain and discomfort should be controlled with analgesics and sedatives
Scott et al., 2017 [45]∗	Quasi-experimental: interrupted time series analysis	To compared five quality process measures recorded before and after the implementation of the CQI programme and aimed to determine the immediate impact of the CQI programme as well as the impact over time	Kigali, Rwanda	Pre-CQI: January 2013–February 2014 Post-CQI: April 2014–May 2015	N=1028 trauma patients >15 years	Initial: not reported Reassess: not reported	Splinting of long bone fractures: Pre-CQI: 87.5% (n=335) Post-CQI: 92.6% (n=393) p value: 0.019	Acetaminophen, ibuprofen, diclofenac, morphine, tramadol, fentanyl, pethidine and ketamine. Pain management for long bone fractures: pre-CQI: 85.1% (n=335) Post-CQI: 93.6% (n=393) p value: <0.001

^∗No formal prehospital care-certified programme was available, and thus, ambulances in Rwanda are manned by one driver, one anaesthesia technician, and one nurse. ALS: advanced life support; CPGs: clinical practice guidelines; CQI: continuous quality improvement; ECPs: emergency care providers; EMS: emergency medical services; IM: intramuscular; IN: intranasal; IV: intravenous; NECET: National Emergency Care Education and Training; NRS: numeric rating scale.