Patterns and determinants of medication use by paramedics in German prehospital emergency care: a six-year multicenter analysis

Medication administration is a fundamental component of paramedic-provided prehospital emergency care within a physician-based EMS-System. In Germany, the Emergency Paramedic Act expanded pharmacological competencies and authorization pathways, yet real-world utilization of medications in routine EMS practice remains insufficiently described. This study aimed to quantify medication use, characterize medication categories and administration routes, and assess temporal and regional variation across three German EMS districts. We conducted a retrospective multicenter observational study of all paramedic-led EMS missions without on-scene physician involvement between 1 January 2019 and 31 December 2024. Electronic patient care records from three mixed urban–rural EMS districts were analyzed. Outcomes included the proportion of missions with medication administration, distribution of medication classes, administration routes, six-year temporal trends, and interregional differences. Statistical analyses included descriptive measures, chi-square tests, and Cochran–Armitage trend testing. Among 197,432 eligible missions, 22,340 involved medication administration (11.3%). Crystalloids (4.1%) and analgesics (3.2%) were the most frequently administered medications, followed by bronchodilators (1.4%), glucose (1.2%), and antiemetics (0.5%). Advanced medications were used in 0.9% of missions. Medication administration increased significantly from 9.4% in 2019 to 12.1% in 2024 (p = 0.02). Intravenous administration was predominant (76.3%). Districts with telemedical physician support demonstrated higher overall medication use compared to the district without tele-EMS (12.7% vs. 9.1%; p < 0.001). Medication use in German paramedic-led prehospital care remains concentrated on a narrow spectrum of frequently used medication categories despite expanded legal competencies and a comprehensive pharmacology curriculum. A system supervised by the EMS medical director (ÄLRD) is essential to ensure patient safety and to support the maintenance of pharmacological competencies.