chronic pain services - royal national orthopaedic hospital · nhs england in relation to...

Chronic Pain Centre 2015

Royal National

Orthopaedic Hospital

Chronic Pain Centre

Annual Report 2015 - 16

Financial Year 2015 / 2016

Authors: Roxaneh Zarnegar (Clinical Lead)

Tacson Fernandez (Neuromodulation Section)

Tajinder Manic (Data Collection & Research Officer)


Contents

Introduction 3

Key Achievements in 2014 – 15 Current Constraints & Limitations

Chronic Pain Service Structure 4

Definitions & Abbreviations 5

Service Provision 6

18 Week Waiting times

Referral Pathways

Case Load 7

Case Load in Adult Pain Clinics Case Load in Paediatric Pain Clinic Admission s for Residential Pain Management Rehabilitation Programs

Case Load 10

Case Load in Neuromodulation Clinics

Patient Related Outcome Measures Data

General information on PROMs data collection 11 Outcomes Data for Adult Pain Clinics (EQ5D-5L BPI, HEALTH VAS, PGIC,SE,PDI,PHQ-2,GIC)

Neuromodulation GP Satisfaction Survey 2014 – 2015 TF 25

Friends and Family Test for the Chronic Pain Service 28

Education & Training 29

Clinical Audit and Quality Improvement 30

Research Publications and Conference Abstracts 31


Introduction This is the second annual report for the RNOH Chronic Pain Centre (RNOH CPC). It should be considered in conjunction with the first report (2014-15).

Key Achievements in 2015 – 16

Appointment of a fourth substantive consultant, Dr Mihaylov

Commencement of formal Complex Case, Incidents & Risks Meetings

Presentation of the service at the RNOH Clinical Audit Meeting: “The chronic pain service,

benchmarking against the National Pain Audit and patient feedback on outcomes data

collection.”

Organisation of Evening Meetings on Chronic Pain for GPs in late 2015

Chronic Pain Centre Website updated including a section on the Neuromodulation Service

Improvements to POD data collection of electronic Patient Reported Outcome Measures

(PROMs) system.

Updating RNOH website for Chronic Pain & Neuromodulation completed

Personal Pages for Pain Consultants set up

Video for Neuromodulation “Patient care for Neuromodulation” uploaded to RNOH website.

GP Satisfaction Survey commenced 2015 – 16 in review

Commencement of Patient satisfaction Survey commenced 2015 – 16

The procurement of a new dashboard for POD to streamline service reporting

Current Constraints & Limitations

Over the course of the year, the Chronic Pain Service has been engaged in discussions with

NHS England in relation to recognition as a specialised centre for delivering care for patients

with complex musculoskeletal and neuropathic pain conditions. These discussions are on-

going although initial responses to the bid have been positive.

Demand for the RNOH Chronic Pain Service has continued to rise dramatically and meeting

the 18 week target has at times been difficult. Limited supply of space for clinical activity

continues to be a significant challenge to much needed expansion.


Chronic Pain Service Structure

Consultants in CP Roxaneh Zarnegar (Lead Consultant)

Rebecca Berman

Tacson Fernandez

Dan Mihaylov

Consultants in Psychiatry George Ikkos

Sara McNally

Clinical Nurse Specialists Julia Sach

Faustina Aikins

Michelle Lilley

Service Manager Rob Emmins

Secretarial & Administrative Sarah Jason

Victoria Brodie Smith

Sonia Brito

Data Collection & Research Tajinder Manic

Trainees

Advanced Pain Training Anthony Gubbay (Aug 15 – Feb 16)

Nicolas Varela (Feb 16 – current)

The service is supported by:

Specialist Physio- and Occupational Therapists in CP and Rehabilitation

Rehabilitation and Pain Specialist Psychology Service

Gill Thurlow, Nurse Consultant in Rehabilitation

RNOH Central Bookings Office particularly Ethal Sangasinha & Nadine Bourne

Pharmacy services particularly Drumita Pindora, Pain Management Specialist

Pharmacist


Definitions & Abbreviations

BPI: British Pain Inventory CP: Chronic Pain

IASP: International Association for the Study of Pain MDT: Multidisciplinary Team NPA: National Pain Audit PMP: Pain Management Programme

PROMs: Patient Reported Outcome Measures SCS: Spinal Cord Stimulation


Service Provision Waiting times

As of October 2015 the Referral to Treatment (RTT/ 18 week) rules were changed by the Department of Health (DOH) in relation to NHS targets. Historically we captured Non Admitted targets and Admitted targets. This has now been replaced and the RNOH has come into line with the NHS England to obtain a target of 92% of p[patients that are seen/treated under the 18 week policy.

Fig 1.1: RNOH RTT Target: 92 %

Referral Pathways, Referral Acceptance & Discharge Criteria

The 2014-15 report contains detailed information on referral pathways, acceptance and

discharge criteria. These have remained unchanged.


Case Load

Case load data 1st April 2014 – 1st April 2015 (Source: RNOH Insight)

Total number of first attendances (New)

Paediatric (< 18 years old) first attendances

First attendances to a neuromodulation clinic

849 7 0 – Data collection started 2015/2016

Case Load in Adult Pain Clinics

(Excluding neuromodulation clinics)

Adult new patient demographics (n = 702)

2015-16 2014-15

Gender Male 218

Gender Female 484

M:F Ratio 1:2.2 1:1.8

Average Age 52 54

Referral source

2015-16 2014-15

RNOH 524 598

GP (Primary Care) 133 201

Tertiary Care Centre 45 50

Total 702 849

Paediatric Pain Clinic (<18 years)

Case load (Source: RNOH Insight)

15 new patients were seen in paediatric pain clinic this year as new patients.

Table 3: New paediatric pain new patient demographics (n = 15)

RNOH Pain Centre RNOH GP (Primary Care) Secondary Care

Gender Male 2

Gender Female 13

Average Age 15.3

Referral Source 11 2 2


Waiting times

Paediatric referrals are prioritised by the service. The mean waiting time from referral to first appointment has

been 7.8 weeks in 2015-16 (median 7 weeks, range 3-18 weeks).

An analysis of paediatric referrals from April 2013 - end March 2016

Referral sources n

RNOH Spinal Surgery 11

PNI Unit 4

Shoulder & Elbow Unit 3

Paediatric Surgery 3

Joint Replacement Unit 1

GP or Community Paediatrics 3

GOS for transition 2

Total 27

Principle chronic pain problem

n

Musculoskeletal MSK axial 13

(MSK) MSK PWP* 1

MSK joint 5

MSK axial & radicular 3

MSK other 1

Neuropathic CRPS I 0

CRPS II 1

Peripheral neuropathic 3

Total 27 *PWP = Persistent Widespread Pain

Four of the above patients had persistent post-surgical pain, and five had an inherited or birth acquired MSK

condition that predisposed to the pain problem.

Treatments recommended* n Not used

Local measures TENS 15 2

Topical treatments 6

Versatis (Lidocaine 5%) 5

Medication advice Medication additions 14 2

Medication reduction 11 1

Therapy services 15

Pain procedure 5

RNOH Psychiatry** 2

Prepared for adult PMP 2

GOS referral for PMP 2

Total 27 *All patients are offered a variety of multimodal treatment options

**Patients already receiving successful treatment with CAHMS not included


Admissions for Residential Pain Self-Management Rehabilitation Programs (PMP)

1st April 2015 – 1st April 2016. This data does not include admissions under rheumatology and rehabilitation services

Number of admissions for pain rehabilitation: 69

Hotel programme: 34 Rehabilitation ward: 35 PMP patient demographics

RNOH Pain Centre

Gender Male 21

Gender Female 48

Ratio M:F 1:2.3

Average Age 49


Case Load in Neuro-modulation Clinics

Neuromodulation Activity April 2015 – April 2016

43 New patients referred to the Neuromodulation clinic.

17 were selcted for 2nd

stage full implant.

RNOH Pain Centre

New Patients 19

Number of Trials 19

Number of patient who have completed 1st Stage awaiting 2nd stage 17

Number of implants 2nd Stage 17

Number of implants 2nd Stage that completed POD outcomes 7

New Patients Fully Implanted 2015 – 2016 (n = 17)

RNOH Pain Centre

Gender Male 8

Gender Female 11

M:F Ratio 1.1.4

Average Age 50

Median Age 50

Note: 7 patients filled out Pre assessment and Post assessment Neuromodulation questionnaires.

{6 patients forgot to fill out there pre assessment from & 4 patients did not fill any from out.} The Neuromodulation

Service is moving from paper based questioners to electronic during 2016/2017 RNOH service to lower the impact of

missing outcomes for service reporting.

Age group (Average age)


Outcomes Data (Neuromodulation) 1st April 2015– 31st March 2016 (inclusive)

First Visit PROMS Data for Neuromodulation Clinics

A) EuroQol 5D-5L – Neuromodulation patients with SCS/PNS insertion (17)

Table: Data on Pre-Op visit to RNOH Pain Clinic (n = 7 of the 17 patients who completed proms)

EQ5D-5L health state Mobility (%)

Self-care (%)

Usual activities (%)

Pain (%) Anxiety/depression

(%)

No problems (1) 0(0%) 2(28.6) 0(0%) 0(0%) 0(0%)

Some impact (2) 0(0%) 1(14.3) 1(14.3) 0(0%) 1(14.3)

Moderate (3) 1(14.3) 3(42.9) 0(0%) 0(0%) 4(57.1)

Severe impact (4) 5(71.4) 1(14.3) 5(71.4) 3(42.9) 1(14.3)

Extreme impact/unable to do activity at all (5) 1(14.3) 0(0%) 1(14.3) 4(57.1) 1(14.3)

Table: Data on Post –Op visit to RNOH Pain Clinic (n = 7 of the 17 patients who completed proms)

EQ5D-5L health state Mobility (%)

Self-care (%)

Usual activities (%)

Pain (%) Anxiety/depression

(%)

No problems (1) 1(14.3) 3(42.9) 0(0%) 0(0%) 2(28.6)

Some impact (2) 0(0%) 2(28.6) 1(14.3) 1(14.3) 1(14.3)

Moderate (3) 1(14.3) 1(14.3) 1(14.3) 3(42.9) 2(28.6)

Severe impact (4) 4(57.1) 1(14.3) 5(71.4) 1(14.3) 2(28.6)

Extreme impact/unable to do activity at all (5) 1(14.3) 0(0%) 0(0%) 2(28.6) 0(0%)

Figure 6: EQ 5D-5L comparative profiles for before & after implantation in neuromodulation patients


(Smaller value indicates higher health status)


Table 7: EuroQol Index Value of Health Status Pre & Post implantation for neuromodulation.

(n = 7 of the 17 patients who completed proms)

Average (Mean)

Pre Implantation (n = 7) 3.7 Post Implantation (n = 7) 4.9

Table 8: EuroQol Health VAS Scores on Pre & Post implantation for neuromodulation


Median Mean

Interquartile range

Pre Implantation (n = 7) 40 45 61 – 70 Post Implantation (n = 7) 85 79 12 -18


(Higher value indicates Higher health status)


B) Brief pain inventory – Total patients (12)

Table 9: BPI – Pain severity score at Pre & Post implantation for neuromodulation

Pain ratings Pre Pain average Post Pain average

Minimum 0 0

1st quartile 61 27

Median 64 56

Mean 65.6 63.6

3rd quartile 70 59

Maximum 10 10

Table 10: BPI – Pain severity score at Pre & Post implantation for neuromodulation


Table 11: BPI – Pain interference profile at Pre Assessment visit to RNOH Neuro-mod Clinic

ITEM

Statistic General activity Mood

Walking ability

Normal work past 7 days

Relationships with other people Sleep

Enjoyment of life

BPI interference (mean)

Minimum 0 0 0 0 0 0 0 0

1st quartile 8 9 8 8 9 9 9 9.8

Median 10 10 10 10 9 10 10 10

Mean 9.3 9.6 9.4 9.3 9 9.4 9.6 9.4

3rd quartile 10 10 10 10 10 10 10 10

Maximum 10 10 10 10 10 10 10 10

Mean average pain severity

Pre Implantation (n = 7) 65.6 Post Implantation (n = 7) 45.4


Table 11: BPI – Pain interference profile at Post Assessment visit to RNOH Neuro-mod Clinic

ITEM

Statistic General activity Mood

Walking ability

Normal work past 7 days

Relationships with other people Sleep

Enjoyment of life

BPI interference (mean)

Minimum 0 0 0 0 0 0 0 0

1st quartile 4 4 3 4 3 5 3 3.7

Median 8 8 8 8 5 8 8 7.8

Mean 6.4 7 6.6 6.6 5.7 6.9 6.3 6.5

3rd quartile 9 9 10 9 8 9 8 8.9

Maximum 10 10 10 10 10 10 10 10

Table 12: Direct comparison of Pre & Post implantation for neuromodulation


BPI median average pain

Pre Implantation (n = 7)

9.4

Post Implantation (n = 7)

6.5



E) S-E Questionnaire – (Self-Assessment)



Questions Average

Pre Average

Post

Still enjoy things, despite pain 6.7 2.9

I can still do most of household chores despite pain 5.5 3.3

I socialise with friends/family despite pain 6 3.3

I can cope with pain in most situations 5.5 3.7

I can do some sort of work 6.7 4

I can still do my many hobbies despite the pain 15 5.5

I can cope with my pain without medication 7.5 4.6

I can accomplish most of my goals despite the pain 7.5 4.6

I can still live a normal life despite the pain 7.5 4

I can gradually become more active despite the pain 10 3.5

(Pain scores are out of a total of 60 – Higher number indicates lower health /confidence

status.)


F) PDI (Pain disability Index)



Questions Average

Pre Average

Post

Family Home Responsibility 1.1 1.4

Recreation 1.1 1.4

Social Activity 1.2 1.5

Occupation 1.3 1.6

Sexual Behaviour 1.3 2.3

Self-Care 1.6 2.3

Life Support Activity 1.9 2.6

(Pain scores are out of a total of 70 – Lower number indicates lower health /confidence

status.)


I) Patient Health Questionnaire PHQ-2 (17)

Table 1: PHQ-2 – Patient Health score at Pre & Post implantation for neuromodulation


Questions Average

Pre Average

Post

Little interest /pleasure in doing things 3.2 1.5

Feeling down, depressed or hopeless 3 1.7


status.)


K) Global impression of change Questionnaire – Total patients (17)

The GIC is broken down into 2 scales: Severity scaling & Improvement scaling.

GIC - Severity scales & Improvement scaling at Pre & Post implantation for neuromodulation.


Questions Average

Pre Average

Post

How bad is overall pain 6 4.3

Compare your health from admission to today, how has it changed. 5 2.4


status.)


Neuromodulation GP Satisfaction

Survey 2014 – 2015 TF


Selection of comments received:

‘Patient reports excellent experience’

‘The only drawback was the travel distance’

‘You are offering an excellent service’

‘Excellent result’

‘Continue to maintain the excellent standards of care provided’


Friends and Family Feedback for

the Chronic Pain Service

Fig 7: Inpatient friends & family scores for the Chronic Pain Service 2015-2016

Fig 8:Outpatient friends & family scores for the Chronic Pain Service 2015-2016


Education & Training

Advanced pain training

Written by Dr Nicolas Valera, Advanced Trainee, February 2016 for six months

RNOH is a nationwide center of excellence for the care of orthopaedic patients.

There is also a growing chronic pain service that currently has an advanced pain

trainee (APT) post. This is a 1 year post, with six months at RNOH and 6 months

take at National Hospital for Neurology and Neurosurgery (UCL).

As an APT my clinical duties included outpatients clinics (2 days each week),

interventional lists (between 2 and 2.5 days each week), inpatients review, MDT’s

and administrative time. All of my work was supervised, whether directly or

indirectly, and I had an excellent consultant support. It is to be noted that as

RNOH is a very specialised center, the patients seen in our clinics usually have

complex orthopaedic pathology (extreme scoliosis, multiple surgeries, etc.) and

are therefore challenging from a pain treatment point of view. Nevertheless, this

was much easier thanks to the fact that the consultants and Clinical Specialist

Nurses are always there to help the fellow.

The work at RNOH is intense, and throughout this six months I have seen almost

600 patients in clinic or theatre. Nevertheless this has not had a negative impact in

the teaching as I was encourage to attend different meetings with other

departments (Spine MDT, radiology MDT, psychiatry MDT) as well as clinics with

other specialists. The Advanced Pain Trainee attends one neuromodulation whole

day theatre list every other week, and at the end of the 6 months that means more

than 20 procedures (implants and trials).

Finally, I can’t finish without saying a word about the people that work here at

RNOH. During this six months everybody has been very pleasant as well as very

professional. This makes work much easier and there hasn’t been one single issue

with the rest of the people that work here. This is a huge help for the trainee who

will feel very confident since the very beginning. I have no doubt that I would

truly recommend this post to any trainee wanting to follow the pain medicine

pathway.

RNOH Pain Management Evening Educational Sessions – 17th November 2015, 24th November 2015

This was started as a new initiative in 2015 and organized primarily by Dr Mihaylov

with support from the RNOH Teaching Centre and collaboration with the RNOH


Rheumatology Department. The sessions were aimed mainly at GPs. Four sessions

were organized in two evening on 17th And 24th November:

‘Pain Management Programmes’, Dr R Zarnegar ‘Fibromyalgia: diagnosis & management’, Dr H Cohen ‘Inflammatory spondyloarthropathy: diagnosis & management’, Dr Gayatri Mittal ‘Opioids for persistent non – malignant pain’, Dr D Mihaylov Over 30 people attended the sessions and 26 feedback forms were collected.

Feedback from the sessions was very positive with all talks rated as good or very

good by all the participants in the categories of presentation content, speakers’

skills and general organization of the evenings. Further evenings are planned in

2016.

Clinical Audit & Quality

Improvement

The RNOH VTE Risk Assessment Audit

All admissions under the care of a CPC consultant are risk assessed for VTE on admission. The Trust’s performance in this area is steadily improving. The vast majority of our patients who are admitted for day case interventional procedures are not expected to have any reduction in mobility compared to their normal state and therefore do not need any prophylactic measures. Rehabilitation admissions usually have greater mobility than usual. Mechanical prophylaxis measures are used for patients who need more extensive procedures such as insertion of neuro-stimulator.

Audit of Referral Triage 2015-16

R Zarnegar

Referrals to the RNOH CPC are triaged by the service clinical lead according to the referral

acceptance criteria for the centre. During 2015-16, 92 referrals were sent back. Most were GP

referrals (70), 19 were from RNOH clinicians and 3 were from other sources.

The commonest reason for a referral not to be accepted is that the case is suitable for a local

secondary care service (52 cases). In 20 cases, referral to another service (not pain clinic) would

have been more suitable and in 4 cases another more suitable tertiary centre was suggested to the

GP, the reasons for the letter may have been geographical or clinical. Eleven letters were sent back

because there was insufficient information for triage. A number of these would subsequently be re-

referred and may or may not have got an appointment.

Overall 11% of referrals are sent back. Referrals from RNOH clinicians are in patients with more

complex physical or psychosocial problems and are less likely not to receive an appointment.


Policies & Procedures

In 2015, the following CPC documents were updated:

Patient information for nerve root injections (R Zarnegar & J Sach)

Research Publications, & Abstracts

Kalsi P, Turkistani W, Sykes C, Lucas A, Zarnegar R. "Work is a beautiful

thing...." Exploring attitudes towards employment in chronic pain (CP) patients

attending a pain management programme (PMP). Journal of Vocational

Rehabilitation 2015 44:97-107. DOI:10.3233/JVR-150783

Zarnegar R, Brown M D R, Henley M, Tidman V, Pathmanathan A. Patient

perceptions and recall of consent for regional anaesthesia compared with

consent for surgery. Journal of the Royal Society of Medicine 2015 108:451-456.

DOI: 10.1177/0141076815604494

Zarnegar R, Rajapakse D, Finch J. Managing Children’s Pain; Pharmacology and

Prescribing in Paediatric Pain Management. Pain management eLearning for

Royal College of Paediatrics and Child Health, 2015.

Ikkos, G., Psychiatric Expertise in 100 words. BJPsych 2015 207(5): 399

Carol Smyth, Marcantonio M Spada, Katherine Coultry-Keane & George Ikkos (2016): The Stanmore Nursing Assessment of Psychological Status:

Understanding the emotions of patients with spinal cord injury, The Journal of Spinal Cord Medicine, DOI: 10.1080/10790268.2016.1163809 Published 8 April 2016

Conference Presentations Prof G Ikkos: Key note speaker IASP Special Interest Group for CRPS International Congress, title of talk “Psychiatry and CRPS: From Somatisation to

Health Anxiety and beyond” Zurich, 1 Sept 2015

Prof G Ikkos: British Pain Society Conference Plenary Lecture: 21/22/23 Title of talk : "Pain and Psychiatry: body, brain, mind, self and clinical practice" Glasgow, April 2015

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