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Advancing pain services at SIVUH

Demand for pain services in Ireland continues to expand as knowledge increases of the specialty and how it can dramatically help sufferers.

About half a million people in Ireland suffer from chronic pain and there are more patients seeking specialist pain services nationally and internationally than ever before.

Staff at the Pain Medicine Unit at South Infirmary Victoria University Hospital (SIVUH) are keenly aware of the challenges in meeting demand and in the past five years, have helped thousands of patients. The unit recently celebrated its fifth birthday.

The last two-and-a-half years alone have seen a 38 per cent increase in patient throughput in terms of growth procedurally at the unit.

“That’s very significant and that’s still working with the same resources,” Ms Lisa Daly, Clinical Nurse Manager, told the Medical Independent (MI). 

“How we’ve achieved that…there are a number of ways — creative scheduling, streamlining every session, streamlining administration and we get the patients through because of the very positive and strong team dynamic here. I really think that’s at the core of it all and with the patient central to that.

“There is 100 per cent buy-in from every member of staff here…to get as many people through because we’re so acutely aware of the huge and growing demand that there is for our service.”

Demand

At SIVUH, 137 patients are awaiting inpatient care for pain, while 1,590 (the highest number of any site in the country) are awaiting an outpatient appointment, according to National Treatment Purchase Fund (NTPF) data for the end of February.

There are 13 public outpatient pain sites and 11 inpatient pain sites in Ireland, with SIVUH seeing both outpatients and inpatients.

Nationally, more than 7,600 patients are awaiting an outpatient appointment for pain, while 3,600 patients are awaiting inpatient care.

Last year, 3,515 patients (public and private) underwent procedures at the SIVUH pain unit. A number of patients had several procedures/multiple-site injections.

Dr Dominic Hegarty, Consultant in Pain Management and Neuromodulation at SIVUH, said the unit operates six sessions a week, which equals about 24 hours of actual procedure time. The rest of the time is dedicated to outpatients.

Some 2,700 outpatients were seen at the unit in 2016, including 417 new patients and 2,280 return patients. According to Ms Daly, the unit had a 27 per cent increase in referrals last year.

“That in itself shows we’re doing something right… The throughput is absolutely phenomenal but there is a growing need,” Ms Daly remarked.

“We are always trying new techniques and new approaches here. That shouldn’t be underestimated as to why we’re able to get patients through,” Dr Hegarty added.

Amid ongoing efforts to make the service more efficient, the unit has managed to radically reduce overall patient procedure time from when they enter the unit to when they leave, while still maintaining high-quality patient care. Up to 25 patients a day can undergo procedures at the unit.

“When someone comes in, it would have been two-to-four hours in the past but now we aim for one-to-two hours,” said Ms Daly.

The department is situated in a modular building with four outpatient offices, two procedural rooms and an eight-bed recovery room, all located within a few feet of each other on the same floor.

It was designed as part of the reconfiguration of hospital services in Cork city. The final part of the reconfiguration process will see pain services at Mercy University Hospital (MUH) eventually move to SIVUH.

The unit operates four days a week, has three secretaries, six nurses, one healthcare assistant and three consultants (one full-time and the other two half-time).

It is also supported on a sessional basis by radiography, catering, medical records and other staff, including NCHDs.

The total average patient treatment time, once they access the unit to when they leave, is two years. On average, each patient seen will undergo about seven procedures but others may not require a procedure.

“It’s a constant challenge maintaining the personal element given the numbers, but we are achieving that,” said Dr Hegarty.

According to Dr Hegarty, about 60-to-70 per cent of patient pain is related to the lower back.

The remainder may be upper limb, spinal pain, headache pain and trauma or limb injuries, as examples, Dr Hegarty explained.

Most patients are referred from the community but the unit sometimes works with other hospitals in the city in helping to treat urgent inpatients who would otherwise be waiting longer for treatment due to restrictions on acute services.

Services

The unit offers a number of procedures and services to patients, such as non-x-ray procedures, which may be ultrasound or non-ultrasound guided. Examples would be muscular injections, of which botox or steroids would be the most common, Ms Daly said. 

Examples of x-ray procedures would be epidurals, bone joint and facet joint injections, sacroiliac joint injections and more complex procedures. A small group of palliative patients also undergo pain procedures.

Dr Hegarty stressed that it’s not just about injections, but the style of techniques that are used.

“We use a technique called radio frequency denervation, where we use heat to actually burn the nerve fibres at high temperature… we also use other techniques, such as neurostimulation,” Dr Hegarty advised.

Neurostimulation involves the implanting of a device that helps to disrupt pain signals travelling between the spinal cord and brain and has proven highly effective in severe chronic pain patients.

The unit is leading the way in developing new treatment techniques for sacroiliac joint pain, complex regional pain and lower back pain.

“In 2016, we were the first pain unit to successfully implant the first Bioness devices outside Europe and this was a major achievement for the neuromodulation service,” Dr Hegarty noted.

The unit runs a specialist Neuromodulation Service, which is limited to one clinic a month and is supported by industry technicians.

It is the only centre outside of Dublin offering the service, which commenced about five years ago and has been growing ever since.

The implanting rate of the device is about 10 or 12 cases annually and the unit currently has about 45 implanted patients.

“This has great outcomes for these patients, who would otherwise be coming back to us every three months for injections,” Dr Hegarty stated.

The devices cost about €30,000 each and tight criteria exist to determine which patients can avail of the service.

“There is a long list of patients for this service at the moment,” Dr Hegarty said.

Separately, about 35 patients avail of an Intrathecal Refill Pump Service at the unit.

“It involves drugs that are delivered intrathecally and it may be for palliative pain treatment or multiple sclerosis patients, for example,” Ms Daly noted.

The pump costs between €15,000 and €18,000 and the service is operated by two pain nurse specialists who come to SIVUH from CUH. Patients are reviewed on average every 60 days, as refilling is required at this point.

Challenges

Despite the immense and highly-specialised work being undertaken by staff at the unit, a number of challenges remain.

The unit is allocated just two physiotherapy hours a week and discussions are ongoing to try and increase this.

Dr Hegarty stressed the importance of the biopsychosocial model of pain, which addresses psychological and social aspects in treating patients and expressed a wish to integrate the model more fully at the unit in the future.

“The downside is, we’re largely a procedural service and that is not necessarily where we want to be,” Ms Daly pointed out.

“At this point in time, we’re hopefully in the final stages of introducing a nurse-led yoga programme for patients. We’re also looking at the resource requirement to introduce a pain rehabilitation programme.”

Education for patients is another important part of the service and work on information leaflets is underway.

Monthly patient surveys show that patients are very satisfied with the service once they gain access.

 “Our patient feedback is fantastic. It’s overwhelmingly positive in terms of the service that is provided,” Ms Daly said.

“That is not to say there aren’t issues. If you are a patient and you are waiting three years to get in here, you’re not going to be happy. You’re suffering in the interim, so we can’t say it’s ‘all rosy in the garden’. We’re not forgetting about that person but we can only do what we can.

“I would like to think, ultimately, it’s all about bringing clinical improvement to patients and improving with that their quality of life. Ultimately, it’s about giving hope.”

The unit continues to be involved with research with the School of Medicine at University College Cork (UCC), ASSERT, Tyndall National Institute, the Faculty of Pain Medicine and industry in a whole variety of areas.

One study recently completed, of which Dr Hegarty partook, was a randomised, controlled trial of music for preoperative anxiety in patients with chronic pain undergoing day case procedures.

This year will also see the largest international pain meeting ever to take place in Cork in the area of complex regional pain.

Over 350 national and international delegates will attend and the event will contribute up to €1 million to the local economy. Further information about the event is available at www.crpscork2017.com.

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