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8/19/2019 British Pain Society
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Abstracts
British Pain SocietyAnnual Scientific Meeting
Bournemouth, United Kingdom
16 – 19 April 2013
BJP0010.1177/2049463712444364AbstractsBritishJournal ofPain
8/19/2019 British Pain Society
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British Pain Society Scientific/Abstract Committee were:
Professor Gary Macfarlane (Chair) University of Aberdeen
Professor Mike Bennett University of Leeds
Professor Candy McCabe University of the West of England
Dr Beverly Collett Leicester Royal Infirmary
Professor Roger Knaggs University of NottinghamProfessor Maria Fitzgerald University College London
Professor Stephen Morley University of Leeds
Professor Kate Sears University of Warwick
Professor Paul Watson University of Leicester
Support for the Abstract Committee and for the production of this British Journal of Pain supplement was
provided by Ken Obbard, Jenny Nicholas and Rikke Sussgard-Vigon.
Editorial remarks
The opinions or views expressed in this abstract book are those of the authors and do not necessarily reflect the
opinions or recommendations of the British Pain Society or the publisher. The published abstracts have been type-
set from electronic submission. Every effort has been made to reproduce faithfully the abstracts as submitted.
Dosages, indications and methods of use of products that are referred to in the abstract book by the authors are
not necessarily appropriate for clinical use and may reflect the clinical experience of the authors or may be
derived from professional literature of other clinical sources.
The investigators of these abstracts have stated in their submission documentation that prospective studies wherepatients are involved have institutional and Ethics Committee approval and informed patient consent.
The British Pain Society. A company registered in England and Wales and limited by guarantee. Registered
address: Third Floor, Churchill House, 35 Red Lion Square, London WC1R 4SG. Registered No. 5021381.
Registered Charity No. 1103260. A charity registered in Scotland No. SC039583
8/19/2019 British Pain Society
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Registration Programme
Annual Scientific Meeting
Liverpool
24 - 27 April 2012
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Contents
Acute Pain 5-11
Assessment & Measurement 11-19
Cancer Pain 19-21
Education 21-25
Elderly 25
Epidemiology 25-27Evidence & Guidelines 27-30
Experimental (Basic) Science 31-32
Interventional Pain Management 32-40
Management (Audit) 40-48
Management (Research) 48-49
Neuropathic Pain 49-53
Non-Pharmacological Pain Management 53-58
Other 58-61
Paediatric 61-64
Primary Care 64-66
Psychology 66-75
Reviews 75
Translational Pain Research 75-76
Index 77-86
Volume 7 Supplement 1 April 2013
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British Journal of Pain7(2) Supplement 1 5–76© The British Pain Society 2013
Reprints and permissions:sagepub.co.uk/ journalsPermissions.navDOI: 10.1177/2049463713481587bjp.sagepub.com
001
A FOLLOW-UP PILOT STUDY LOOKING AT PAIN MANAGEMENTAFTER DISCHARGE, FOLLOWING MAJOR SURGERY
Category: ACUTE PAIN
Charlotte Halmshaw, Carsten Bantel, Stephen Ward, Tanya Carr,
Sarah ThomasChelsea and Westminster Hospital, London, UK
Background
Information received after surgery is essential for each patient in fa-
cilitating the transition from hospital to home (Suhonen et al, 2005;
Williams, 2008). Recent research has shown shorter recovery times
(Kehlet, 2009), reduced anxiety (McDonald et al, 2004), and improved
satisfaction of hospital care (Walker, 2007) when information was pro-
vided. However, studies so far have only looked at specific patient co-
horts, such as orthopaedic or colorectal patients. There is limited data
available about the effect of leaflets on a generalised patient population
after major surgery. In addition, data is lacking on how patients manage
pain after discharge. Specifically, only scarce information is available
about patterns of analgesic consumption and weaning at home.This pilot study aimed to explore whether providing an informa-
tion leaflet on pain management after surgery, provided benefits to
patients. Secondly, it aimed to introduce a follow-up interview to
obtain evidence on general pain management after discharge.
Methods
A structured questionnaire-based interview was developed and tri-
alled with initially 3 patients. The leaflet was subsequently revised to
its final version, which was then handed out to 20 patients. A random
sample was selected by reviewing day 1 post-operative patients after
major surgery. Verbal consent was obtained from 20 patients who
had been given the leaflet prior to discharge (leaflet group- LG), and
20 further patients who had not been given the leaflet (non-leaflet
group- N-LG). Epidemiological data and information about eachpatient was taken from the patients’ notes. The period selected was
6th August 2012 to 17th September 2012, and the exclusion crite-
ria was age
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6 British Journal of Pain 7(2) Supplement 1
Methods
A one-page survey and a self-addressed stamped envelope were sent
through the postal system to the acute pain services of the 323 acute
care NHS hospitals in the United Kingdom. Respondents were
asked to answer to the questions raised above.
Results
146 surveys were returned, giving a response rate of 45%. Out of
the returned surveys, 70 acute pain services (48%) stated that their
hospital used a form of SSCA. The Painbuster system was used by
18 of the hospitals (26%), while 12 hospitals (17%) used an epidural
catheter and pump. 57% of respondents used Bupivacaine as the
local anaesthetic.
SSCA was used by 47% of respondents for orthopaedic cases and
by 44% for general surgical operations. Most patients (81%) were
looked after on the ward, while 17% were looked after in high depen-
dency or intensive care unit.
The acute pain service was involved with looking after 80% of pa-
tients using SSCA, whereas the anaesthetist on-call was involved in
46% of cases. 66% of hospitals using SSCA had a protocol in place,
while another 10% of respondents stated that they were in midst of
implementing one.
Conclusion
Our survey shows that almost 50% of acute hospitals in the NHS
that responded are using a form of SSCA, using an elastometric sys-
tem such as Painbuster or adapting the pumps used for epidural or
PCA systems. It is interesting to note that the acute pain service was
involved in looking after most of these patients, further showing the
need of the service in hospitals. A majority of patients with SSCA
were looked after the ward highlighting the safety and simplicity of
the delivery system.
003
IMPROVING THE QUALITY OF ANALGESIA AFTER SHOULDERARTHROPLASTY USING AN ANALGESIC PATHWAY.
Category: ACUTE PAIN
Nigel Chee1, Elaine O’Shea1, Sav Wijesingha1, James Dinsmore2
1Royal Bournemouth Hospital, Bournemouth, Dorset, UK, 2Queen
Alexandra Hospital, Portsmouth, Hampshire, UK
Background
Royal Bournemouth Hospital performs approximately 60 shoulder
arthroplasties each year. In 2011 a service improvement project
was undertaken, examining the type of anaesthesia provided for
shoulder arthroplasty, postoperative pain scores and analgesia pre-
scribed. As a result of this project, a standardised analgesic pathway
was developed with the aim of improving pain relief and to enable
patients to fully participate in rehabilitation exercises. Periopera-
tively anaesthesia is provided by an interscalene nerve block and
general anaesthesia with regular paracetamol and a non-steroidal
anti-inflammatory (NSAID). Postoperatively regular paracetamol
and ibuprofen are prescribed. Oxycontin® is prescribed regularly,
with the first dose given at 20.00 on the day of surgery and con-
tinued 12 hourly for the first two postoperative days. Oramorph®
is administered as required. Data was collected 12 months after
initiation of the pathway.
Methods
Between April 2011 and March 2012, 52 shoulder arthroplasties
were performed and the patient notes were analysed. Details of
anaesthetic and postoperative pain management were recorded.
Data collected included type of arthroplasty, type of anaesthetic, an-
algesia prescribed, pain scores at rest and on mobilisation, length of
inpatient stay and causes of delayed discharge from hospital.
Results
All patients (n=52) had an interscalene nerve block and general an-
aesthetic.34 (65%) patients received a NSAID. 11 (21%) had a significant
contraindication to NSAID. 37 (71%) patients received Oxycon-
tin®, 5 (10%) patients were already prescribed an alternative opiate
medication preoperatively and this was continued.
9 (17%) patients had a pain score ≥9 on mobilisation on Day 1
compared with 10 (33%) n=30 before introduction of the pathway.
The mean length of stay was 2.9 days (range 1-12 days) compared to
3.4 days (range 2-9 days) pre pathway.
Conclusion
This shoulder arthroplasty pathway is now routinely used within the
trust. Whilst it was a local service improvement project with relatively
small numbers, it has demonstrated how the use of a pathway incor-
porating regional anaesthesia and multimodal analgesia can benefitpatients. There has been a 48% reduction in the number of patients
who had severe pain on mobilisation day one. We feel that the provi-
sion of improved analgesia has contributed to a shorter in-patient
stay. We would fully support expanding such pathways for other pro-
cedures and feel that by reducing variation within practice we can
improve patient experience.
004
USE OF TARGINACT (OXYCODONE AND NALOXONE) IN THE MANAGE-MENT OF ACUTE POST-OPERATIVE PAIN: A PRELIMINARY CASE SERIES
Category: ACUTE PAIN
Arun Bhaskar, Shyam Mantha, Gemma Beirne, Sharon Cundy
The Christie NHS Foundation Trust, Withington, Manchester, Greater Manchester, UK
Background
Post-operative pain is often undertreated due to poor assessment of
the pain as well as the reluctance to use strong opioids due to the mis-
conception that this would delay discharge from the hospital due to
side-effects like constipation, nausea and vomiting. Patients are often
treated with weak opioids like codeine and tramadol even from day
three after being on an epidural following laparotomy. This not only
resulted in inadequate pain control and at higher doses patients were
not only complaining of constipation and nausea, but also found that
post-operative physiotherapy and mobilisation was being negatively
affected. We started using Targinact (Oxycodone-Naloxone combina-
tion) that is proven to reduce the incidence of opioid-induced con-
stipation for the management of acute post-operative pain. We are
presenting the preliminary case series of patients who had undergone
surgery for cancer at The Christie NHS Foundation Trust.
Methods
We looked at patients undergoing major surgery including lapa-
rotomies for colo-rectal, gynaecological and urological malignan-
cies as well as major reconstructive surgery following mastectomy
for breast cancer. Patients already on strong opioids and those with
prolonged post-operative stay in the critical care unit were excluded.
Data collected included pain scores (BPI) at rest, on coughing, on
movement and on straining for bowel movement. Patient satisfac-
tion scores, time of first bowel movement, drinking and eating and
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Abstracts 7
removal of nasogastric tube was recorded along with bowel func-
tion index. Mobilisation parameters like tolerance to physiotherapy,
walking to toilet and climbing stairs were noted. Side-effects like
constipation, nausea, vomiting, sedation and respiratory depres-
sion were also recorded till the day of discharge and any identi-
fiable cause for discharge. The use of concommitant drugs like
paracetamol, anti-emetics, laxatives and neuropathic pain agents
were documented and patients had telephone follow-up to ascertain
analgesic usage and side-effects.
Results
In the preliminary series of 45 patients, all of the patients reported
significant reduction in their pain scores over days three to five as
compared to the previous standard, which was Tramadol at a dose
of 50-100 mg four times a day. Three of the patients had reported
constipation at day 5 and six patients had symptoms of nausea and
vomiting during their peri-operative period. Patients were using
less of oxynorm for rescue analgesia and had better satisfaction
scores. Bowel function index were favourable for ease of defecation
and for completion of evacuation, but were less reliably recorded
for rating of constipation as patients were finding it difficult to
quantify it. Patients also recorded better satisfaction scores about
their overall peri-operative experience. Patients gave varying dura-
tion of use of post-discharge analgesics. One patient died during
the observation period.
Conclusion
The use of adequate dose of a strong opioid was better in controlling
post-operative pain following major surgery compared to tramadol.
The addition of naloxone has effectively reduced the troublesome
side-effects of constipation and is an alternative to conventional opi-
oids. The combination of oxycodone and naloxone (Targinact) has
been accepted by the surgeons as it effectively addresses the issue
of opioid-induced constipation that often delays discharge planning
and is currently incorporated in the Enhanced Recovery Pathway
as the opioid of choice for the management of post-operative pain.
More randomised controlled studies are required to validate thefindings of this audit.
005
ACUTE NEUROPATHIC PAIN: HOW PREVALENT IS IT IN HOSPI-TALISED PATIENTS?
Category: ACUTE PAIN
Mae Johnson, Lenny Ng, Melissa Mellis, Jeremy Cashman
Acute Pain Service, Department of Anaesthesia, St George’s Healthcare
NHS Trust, London, UK
Background
Acute neuropathic pain (ANP) is defined as “pain arising as a directconsequence of a lesion or disease affecting the somatosensory sys-
tem” (1). It is a condition that is under-recognized, under-treated
and can progress to chronicity and disability.
ANP has been previously reported in approximately 2% of inpatients
reviewed by an acute pain service in a tertiary referral hospital in
Australia (2). It is not as common as nociceptive pain in the hospital
setting. The challenge is therefore to identify high-risk patients for
the development of ANP. There is evidence that the risk of progres-
sion to persistent neuropathic pain is high and that early intervention
may prevent this from developing (5).
The aim of this survey was to define the prevalence of neuropathic
pain at St George’s Hospital, a tertiary referral and major trauma
centre in the UK.
Methods
A retrospective survey of all in-patients reviewed by the Acute Pain
Service (APS) at St George’s Hospital between April 2012 and Oc-
tober 2012 was done. Detailed information was collected via the
APS patient electronic database.
Data collected included: age, gender, specialty, operation, pain as-
sessment, number of visits, type of pain, pain scores, side effects of
pain medication, medication started by the APS and patient satisfac-tion with their treatment.
Patients with a history of chronic pain were excluded. As this was
an observational study, no formal statistical analysis was under-
taken.
Results
Over the six month period, 1318 patients were reviewed by the APS.
80 patients were excluded. Consequently, 1238 patient records were
analyzed.The mean age of the patients was 50 (range 5- 92) years.
52% of patients were male and 48% female.
123 out of 1238 patients were diagnosed with ANP, an overall preva-
lence of 11%. Out of the 123 patients with ANP, 120 were from
surgical specialties and 3 from medical specialties. The percentage of
ANP from surgical specialties was 10% (120/ 1222). The percentageof ANP from medical specialties was 19% (3/16).
The four highest surgical subspecialties with ANP were: vascular
24% (8/34), neurosurgery 19% (9/47), trauma and orthopaedics
16% (40/ 253) and plastics 12% (7/ 60).
Conclusion
The prevalence of ANP in this survey was 11%, a higher percentage
than previously reported (2). ANP was more common in those surgi-
cal specialties with a predominant trauma case mix. The number of
medical patients was small, making it difficult to draw conclusions
on ANP rate. Thoracic surgery, perceived to be high risk for ANP,
had a low rate of 6%.
To our knowledge, this is the first report of the prevalence of ANP
in the UK.We have ascertained the high-risk groups for the develop-ment of ANP, this will help in the identification, recognition and
treatment for these patients.
006
NATIONAL INPATIENT PAIN STUDY -USING REAL TIME DATACOLLECTION TO MEASURE THE QUALITY OF INPATIENT PAINSERVICE TECHNIQUES AND IDENTIFY VARIATIONS IN PRACTICE
Category: ACUTE PAIN
Fiona Duncan1, Ruth Day2, Olga O’Neill3, Jeremy Nightingale4,
David Counsell5
1 Manchester Metropolitan Universi ty, Manchester, UK, 2South Devon
Healthcare NHS Foundation Trust, Torbay, UK, 3Belfast Health and
Social Care Trust, Belfast, UK, 4Portsmouth Hospital NHS Trust,Portsmouth, UK, 5 Betsi Cadwaladr University Health Board, Wrex-
ham, UK
Background
Pain management for patients in hospital is a major problem. Evi-
dence of pain service impact has been lacking, there is significant
variation in care provision. Evidence is needed about the ways in
which pain services are organized in order to understand whether
these are linked to important differences in what happens to patients.
The National Inpatient Pain Study group (NIPPS) is a voluntary
collaborative venture of inpatient pain specialists working towards
building a national prospective research database.
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8 British Journal of Pain 7(2) Supplement 1
Methods
The long-term aim is to improve the quality of pain management for
patients in hospital. The objectives are (1) to describe the case mix
of the inpatient pain population (2) to define and monitor the qual-
ity and side-effects of different techniques and identify variations in
practice.
The pilot clinical dataset is divided into six main sections and in-
cludes demographic data, surgical details if relevant, the primarytechnique used to control pain (e.g. epidural, intravenous Patient
Controlled Analgesia, nerve block, intramuscular/subcutaneous and
oral analgesia), pain scores, adverse events, and a measure of effec-
tiveness. We use ASA physical status as a general measure of comor-
bidity. Routine data is collected by members of the pain team using
handheld devices, and downloaded to a central site.
The pain service website is live, recording information about service
provision including staffing, hours of work, and the drugs and equip-
ment used.
Results
Results indicate that staffing varies widely from 0.5 to 8 nurses per
hospital site. 12% of hospitals do not routinely collect data. The main
workload is orthopaedic and general surgery based on data from 13hospitals and 29,080 patients in 2011. 37% of patients reported a
pain score of moderate to severe pain on the first assessment, and
21% reported severe pain. Nausea and vomiting was the most fre-
quent adverse event reported. Sixty-nine major adverse events were
logged, of which 64 documented respiratory depression. 29% of epi-
durals were reported as being stopped earlier than planned due to a
variety of technical reasons.
Conclusion
We continue to develop and refine our outcome measures, and have
a rapidly growing accurate and meaningful database. This is an im-
portant step towards reducing variation and improving effectiveness.
Prospective longitudinal data has the potential to improve our un-
derstanding of variation in outcomes and establish future researchpriorities.
007
EXAMINING THE EFFECTS OF PERIOPERATIVE PAINMANAGEMENT ON PAIN AT FIRST WAKING IN THE RECOVERY ROOM
Category: ACUTE PAIN
Stephen Ward, Charlotte Halmshaw, Dushyanth Gnanappiragasam,
Carsten Bantel
Imperial College, London, UK
Background
Pain outcomes immediately following surgery may be the result of
standardised approaches to preemptive and preventive analgesia,
risk factors associated with postoperative pain, or a combination of
both.1
However, it still remains unclear how these factors influence pa-
tients’ pain intensities in the ‘real life’ scenario of busy theatres in
a major hospital and whether multimodal approaches are used suf-
ficiently enough.
The primary aim of this study was to determine the quality of intra-
operative pain management as assessed by pain-intensity scoring
on first waking in recovery. Royal College guidelines were used as
benchmarks.2
The second aim was to define predictors for the observed pain-
scores on first waking through analysis of intra-operative manage-
ment practice and determination of genuine patient factors.
Methods
After institutional approval between April 2012 and June 2012
n=100 patients’ scheduled to have elective or emergency trauma and
orthopaedic surgery, or general surgery were randomly selected for
service evaluation. Pain intensity was assessed with a 5-point verbal
rating scale (VRS) and recorded immediately on first waking. Co-
variables thought to influence this outcome were determined from
analysis of anaesthetic, operation and recovery room charts includ-ing the patients’ healthcare records. Co- variables for preemptive and
preventive analgesic approaches were pain scores at first waking in
relation to; total morphine dose, total morphine boluses and total
number of preventive analgesics administered. Co-variables for risk
factors were; age, gender, previous history of pain, previous history
of surgery and open versus closed surgical procedures.
To determine how the independent variables predict the outcome
variable logistic regression was applied for the main analysis. A P -val-
ue of P
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Abstracts 9
recovery, post operative pain was more problematic if the PCA was
not connected before arrival in CCU compared to those who arrived
with the PCA connected. Therefore we retrospectively examined the
CCU electronic database (IntelliVue Clinical Information Portfolio
(ICIP)) to examine this question.
Methods
After gaining approval from our local Clinical Audit Committee,data was collected retrospectively from ICIP on all post operative pa-
tients having an abdominal procedure (31/10/11 to 17/2/12) return-
ing to level 2/3 critical care, who were prescribed an opioid PCA.
Pain numerical rating scores (NRS) at rest and on movement on first
arriving in CCU/overnight recovery were recorded and expressed as
means. The next NRS documented in ICIP was recorded to assess
the impact of pain management in CCU/overnight recovery. Con-
nection (or not) of PCA prior to CCU/overnight recovery was docu-
mented. Results were also expressed as percentage of patients being
‘analgesed’ which was defined as a NRS of ≤2 at rest, and ≤4 on
movement. Prior PCA connection (‘before’ group) was compared to
connecting the PCA in CCU/overnight recovery (‘after’ group) for
pain scores (Mann-Whitney U) and if patients were ‘analgesed’ or
not (Chi squared).
Results
91 patients were identified. Of those, 45 were connected before ar-
rival and 46 after arrival. Overall, pain scores on arriving in CCU/
overnight recovery were 2.7 (rest) and 3.4 (movement). Pain scores
after intervention were 1.5 and 2.4.
NRS pain scores were significantly less if the PCA was connected
before arrival (‘before’ group) than if connected ‘after’, at rest (1.5
compared to 3.3, P
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10 British Journal of Pain 7(2) Supplement 1
Background
There is interest in predicting patients likely to have a poor post-
operative pain experience. Instinctively those with chronic pain and
opioid tolerance will present challenges. Identification of these would
allow pre-operative formulation of pain management plans and early
involvement of the inpatient acute pain service (APS). In Torbay,
all elective patients undergo nurse-led pre-operative assessment and
this is entered into a computer record. In the routine questionnairewe included four questions thought to be predictive of a poor pain
experience. Data is collected on the Acute Pain Database (TIPPS) of
all patients seen by the APS. The two databases allowed us to com-
pare whether the post-operative pain experiences of the patients seen
by the APS could have been predicted by the pre-operative questions
and if so, which questions, and whether 1, 2, 3 or 4 questions were
required. Data for 12 months of elective patients was retrospectively
reviewed.
Methods
The records of 908 patients assessed pre-operatively were reviewed.
Based on the Salford pain team questions (which were later incorpo-
rated in RADAR) the pain predicting questions were:-
1. Significant anxiety over post-operative pain
2. Previous experience of post-operative pain
3. Established chronic pain syndrome
4. On long-term opioid therapy
In patients regularly taking opioids, oral morphine dose equivalence
was calculated and the patient banded into high (>150mg), medium
(100-150mg) and low dose (
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Abstracts 11
disparities in the methods of delivering TAP blocks in our institution
and those used by Carney et al. were identified however, prompting
development of a departmental guideline to optimise the procedure.
It includes adopting a posterior ultrasound approach similar to that
used by Carney et al. and performing the block preoperatively. It
highlighted that not performing a TAP block does not necessarily
mean providing an inferior standard of care.
012
PARACETAMOL DOSAGE - ARE WE PRESCRIBING CORRECTLY?AN EXPERIENCE FROM A DISTRICT GENERAL HOSPITAL
Category: ACUTE PAIN
Ravi Kare, Kate O’Callaghan, Heather Lynes, Udi Akhigbe, Coralie
Carle, Subhash Kandikattu
Anaesthetic Department, Peterborough and Stamford Hospitals NHS
Foundation Trust, Peterborough, Cambridgeshire, UK
Background
Paracetamol is widely used as an analgesic and antipyretic. Its rec-
ommended dose is weight dependent (BNF). Following reports of
accidental overdose of paracetamol the MHRA issued guidance on‘Drug Safety Information’ in May 2010. The National Reporting
and Learning System identified 206 paracetamol related incidents
(44 neonates and 162 children) of them 2 had severe harm and 14
had moderate harm (NPSA Signal, Nov 2010).
These incidents were attributed to ‘lack of awareness among vari-
ous healthcare professions of neonatal and paediatric drug dos-
age regimens’, ‘poor documentation resulting in double dosing’,
‘confusion between oral and IV Paracetamol drug doses’ and
‘calculation and prescription errors of IV Paracetamol’.
This motivated us to review the paracetamol prescribing practices
within our hospital. This review involved three components: first
looked at anaesthetists’ understanding of paediatric dosing; second
focussed on peri-operative prescription (adults) and the third assessed
the knowledge of paracetamol prescribers in the wider hospital.
Methods
With appropriate audit permission, the initial component of our
review was carried out in June 2010. This involved a written ques-
tionnaire sent to all anaesthetists. We sought to establish the cur-
rent practice of paracetamol prescribing in paediatric patients (dose,
dosing interval, maximum daily dose, errors). The results were
presented locally and the anaesthetists updated on key elements of
paracetamol prescribing.
We then re-audited Peri-operative paracetamol prescribing in July
2012.The notes, drug chart and anaesthetic chart of patients pass-
ing through the post anaesthesia care unit (PACU) were reviewed.
Details relating to paracetmol prescribing, including potential and
actual errors, were collected on a proforma. The findings were pre-
sented locally, the medical and nursing staffs were re-educated andthe audit repeated in September 2012.
The final component of our review involved a written survey estab-
lishing paracetamol prescribing practices of the hospital’s physicians,
surgeons and paediatricians. This was carried out in August 2012.
Results
Our initial survey received a 70% response rate. The notable results
include: children < 10kg, 50% of anaesthetists stating an incorrect
treatment dose and 83% stating an incorrect maximum dose;
children 10-50kg, 50% of anaesthetists stating an incorrect max
dose; children >50kg, 70% of anaesthetists stating both an incorrect
treatment dose and incorrect maximum dose.
The PACU audit most significant finding was that in 50% of pa-
tients there was the potential for a second IV dose to be administered
within 4 hours. This error occurred in 6% of patients. Following staff
education, the re-audit revealed a reduction in both actual and po-
tential errors.
Our survey of other specialities received a 20% response rate. The
notable results include: 70% doctors were not aware of the MHRA
guidance; 30% made no dose alteration for adult patients under
50kg; 20% stated an incorrect paediatric dose and; 15% stated an
incorrect adult dose.
Conclusion
The three components of our review highlight that errors in
paracetamol prescribing for both adult and paediatric patients is
widespread throughout the hospital. Despite improvements in
practice following staff education, 100% compliance with BNF and
MHRA guidance is not being achieved. It is important for us to be
vigilant while prescribing paracetamol doses and dosage intervals.
To prevent potential and actual errors we should communicate and
hand over carefully during the perioperative period. We should con-
tinue the cycle of education and re-audit to help in improving our
practice
013
DOCUMENTATION OF PAIN OBSERVATIONS FOLLOWING IMPLE-MENTATION OF THE NEW UHBRISTOL OBSERVATION CHART
Category: ASSESSMENT & MEASUREMENT
Ben Welham2, Steven Lindley1, Nilesh Chauhan3
1Royal United Hospital, Bath, UK, 2University of Bristol, Bristol, UK,
3University Hospitals Br istol, Bristol, UK
Background
In 2008, the Chief Medical Officer advised that a pain score should
become part of the vital signs that are monitored routinely for all
inpatients . Previously at UHBristol NHS Trust, following the in-troduction of the early warning observation system, pain recording
did not feature on this form. A separate (Pain Observation Forms
(POF) was disseminated to encourage the recording of pain. An au-
dit in 2009 found that there was poor uptake of this form and many
patients were left without adequate pain documentation. Following
this audit, space for pain observations was included as part of the
redesigned UHBristol Observation Chart (UOC). This form also in-
cluded the Abbey Pain Scale for patients with cognitive impairment
and an ‘action report’ for the recording of intervention of moderate
to severe pain.
Methods
Five patients were randomly sampled using a random number gen-
erator from each ward at UH Bristol. The Emergency Department,
ENT and Maxillofacial wards and the Intensive care unit were ex-
cluded as these wards used alternative charts to assess pain. Five
questions were asked of the form: 1. Is the UHBristol Observation
chart (UOC) used? 2. Is pain assessment filled in correctly 3? Is the
patient verbally able to communicate their pain? 4. Is the Abbey Pain
Scale employed? 5. Has an action report been recorded if pain is
documented as moderate or severe?
Results
A total of 132 patients were sampled which was similar to the initial
audit of 152 patients. Uptake of the UOC was 96%. 100% of pa-
tients with UOC documentation had pain recorded, compared to
only 50% (1% patients on medical wards 64% on surgical wards)
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12 British Journal of Pain 7(2) Supplement 1
in the previous audit. 99% of patients had more than half correctly
entered pain recordings, compared to less than 40% on POF. There
was a very small take up of the Abbey Pain Scale with only 0.8% of
patients having this employed which likely represents a fraction of
patients with cognitive impairment (likely 1/3 of inpatients). 38%
of patients reported moderate to severe pain at some point, of these,
only 26% had ‘action reports’
Conclusion
The uptake of UOC compared well with the previous EWS observa-
tion chart. The use of the UOC for recording pain assessment was
exceptional, with the quality of entries representing an improved
chart. However, improvements can be made to the utilisation of the
Abbey Pain Score and freetext action-reporting.
This audit has shown the importance of pain assessment documen-
tation on the same chart as an early warning system, we have shown
that by having two separate charts pain assessment is poor. With
the introduction of the ‘National Early Warning Chart’, which has a
minimal amount of pain assessment, this is threatened.
014
THE ASSESSMENT OF CHRONIC PAIN AFTER KNEE REPLACE-MENT: A SYSTEMATIC REVIEW
Category: ASSESSMENT & MEASUREMENT
Vikki Wylde1, Julie Bruce2, Andrew Beswick1, Karen Elvers1, Rachael
Gooberman-Hill1
1University of Br istol, Bristol, UK, 2Univers ity of Warwick, Coventr y, UK
Background
Total knee replacement (TKR) is a successful operation for re-
lieving pain for the majority of patients. However, approximately
20% of patients experience chronic pain after TKR. Despite the
prevalence of this condition, there is no agreement in the research
literature about which measures should be used to assess chronic
pain after TKR. For clinical trials investigating efficacy of chronicpain treatments, IMMPACT recommends that the assessment of
pain should encompass measurement of pain intensity, pain medi-
cation usage, pain quality and the temporal aspects of pain. The
aim of this systematic review was to determine which pain instru-
ments and broader health-related measures incorporating pain
items were used in all original epidemiological and experimental
research articles published over a 10-year period. Within this lit-
erature we explored geographical and contemporaneous trends in
the use of pain-related outcome measures, and compared the pain
domains assessed within the measures to the recommendations
from IMMPACT.
Methods
Searches identified 8,486 articles with 1,164 eligible for inclusion.MEDLINE, Embase, PsycINFO, Cochrane Library and CINAHL
databases were searched for research articles published in all lan-
guages between January 2002 and November 2011. Articles were
eligible for inclusion if they assessed pain at a minimum of 3 months
after TKR. Studies were excluded if they were case studies, confer-
ence abstracts, PhD theses, recruited less than 10 participants or did
not present original primary data. Abstracts or full text articles were
screened to determine if the article met the eligibility criteria. Data
extracted included study design, country, timings of assessments,
and outcome measures that contained pain items. For 184 articles
only accessible as abstracts, authors were contacted. Of 84 authors
with contact details, 36 provided full text articles or verified data
extraction.
Results
Studies used a variable number of measures that incorporated pain
items (range 1-14), with 17% of studies using three or more mea-
sures. A wide variety of composite and single-item measures were
used to assess chronic pain after TKR, with the American Knee So-
ciety Score being the most common. Other commonly used multi-
item measures included the WOMAC, Hospital for Special Surgery
Knee Score, SF-36 and Oxford Knee Score (OKS). Comparison ofpain domains assessed within the measures to those recommended
by IMMPACT revealed that many measures failed to capture the
multi-dimensional nature of pain. Of measures commonly used, the
WOMAC and OKS provided the most comprehensive assessments
of pain. Geographical trends were evident, with nation-specific pref-
erences for particular measures. Comparison of temporal trends
identified recent reduction in the use of clinically-administered tools
and an increase in the use of patient-reported outcome measures.
Conclusion
This systematic review found extensive variation in the outcome
measures used to assess chronic pain after TKR. A key finding was
that, despite a growing interest in investigating this condition, assess-
ment has been inconsistent and predominantly orientated towardspain severity, with little consideration of other key aspects of pain,
such as temporality and quality, as recommended by IMMPACT.
The review also highlights the presence of nation-specific preferenc-
es and conservatism in pain assessment within orthopaedic studies.
Standardisation and improvements in assessment has the potential
to enhance the quality and generalisability of research and facilitate
the establishment of a core outcomes set.
015
THE COLOUR OF PAIN: CAN PATIENTS USE COLOUR TODESCRIBE OSTEOARTHRITIS PAIN?
Category: ASSESSMENT & MEASUREMENT
Vikki Wylde, Victoria Wells, Sam Dixon, Rachael Gooberman-Hill
University of Br istol, Bristol, UK
Background
Pain assessment is fundamental to management of osteoarthritis
(OA) pain and evaluation of the effectiveness of clinical interven-
tions. While the subjective nature of pain means that self-report is
appropriate, some people experience difficulties in completing stan-
dardised numeric or descriptive pain measurement tools. This may
be because it can be challenging to define and explain pain experi-
ence through pre-defined questions and response options. In a clini-
cal setting, patients’ ability to describe pain is a key component of
successful communication between patients and clinicians. Optimal
and diverse methods of pain assessment may help to facilitate com-
munication and shared-decision making about treatment and man-agement strategies. The aim of this qualitative study was to explore
patients’ views about the acceptability and feasibility of using colour
to describe OA pain, and whether they thought that colour was an
appropriate means of communicating about pain in clinical settings.
Methods
Seventeen patients with knee OA took part in one of six group in-
terviews, each comprising 2-3 participants; groups were stratified by
gender. In each interview, participants were first asked to describe
living with OA, experiences of pain and management strategies, and
thoughts about using colour to describe pain. Next, 10 loose circles
of coloured card were placed in the centre of the table. Participants
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Abstracts 13
were asked to describe and discuss whether they could relate the
coloured circles to OA pain, and if so how those colours related to
pain qualities and changes in pain intensity. Participants then used
coloured pencils to depict their pain on a body diagram, and were
encouraged to describe their choice of colours. Group sessions con-
cluded with participants’ views about the potential to use colour in
conversations with healthcare professionals. Anonymised transcripts
were imported into NVivo© version 9 and analysed using methods
of constant comparison.
Results
The group interviews revealed that while the idea of using colour
was generally acceptable, it did not suit all participants as a way of
describing pain. The majority of participants chose red to describe
high intensity pain; reasons given were its symbolic association with
inflammation, fire, anger, and its connection with a traffic light sys-
tem. Colours used to describe absence of pain were those associ-
ated with positive emotional feelings, such as purity, calmness and
happiness. A range of colours was chosen to represent changes in
pain intensity. When describing aching pain, participants consistently
identified colours such as grey or black. In comparison, sharp pain
was described using a wider range of colours including yellow, white,
red and purple. The majority of participants thought that they would
be able to use colour to describe their pain to healthcare profession-
als, although issues around the interpretability and standardisation of
colour were raised.
Conclusion
This study suggests that presenting patients with a range of colours
and asking how they would use these colours to describe their chron-
ic pain may be a useful communication tool. As evident from this re-
search, this would not be appropriate for everyone, but some people
may find that engagement with colour provides a comfortable way to
initiate discussions around pain. Although not explored in this study,
colour symbolism varies between cultures and any such tool would
need to allow for diversity. Further research could establish the util-
ity and possible impact of a colour-based communication tool in aclinical setting.
016
IS CONFIDENCE THE KEY TO ACCURATE PAEDIATRIC PAINASSESSMENT OR IS THERE MORE WE NEED TO LEARN?
Category: ASSESSMENT & MEASUREMENT
Laura Angco1,2, Mansimran Cheema1,2, Carsten Bantel1,2, Helen
Laycock1,2
1Imperial College London, London, UK, 2Chelsea and Westminster
Hospital, London, UK
Background
Children and infants experience pain1. Inadequate analgesia and the
experience of pain in children can lead to physical, psychological
and behavioural consequences in the short and long term2,3. Despite
the importance and moral obligations of healthcare professionals to
ensure a patient’s comfort, pain in hospitalised paediatric patients is
often poorly managed4,5.
Accurate pain assessment is key to pain management, both as a
screening tool and also a measure of effectiveness of analgesia. Pain
assessment in children should be completed with tools appropriate
for age, clinical situation and the child’s ability to self-report6.
A previous hospital audit demonstrated over 75% children were not
assessed for pain using hospital recommended tools and 50% had
inaccurate pain assessments7. We aimed to explore, how nursing staff
evaluate their practice in pain assessment and its importance, to help
address the above discrepancy.
Methods
Over a two-week period, 20 paediatric nurses were approached on a
general medical and surgical paediatric ward in a Central Lon-
don Teaching Hospital. No prior introduction to subject matter was
given and each was asked to complete a qualitative Likert scale ques-tionnaire with additional areas for free text.
Questions were constructed to evaluate nurses’ confidence levels in
assessing pain and previous training. Additionally they were asked
about how to conduct pain assessments, the frequency with which
they perform them and average time taken to complete an assess-
ment on the ward. They were also asked to list their top 3 respon-
sibilities on the ward to assess the importance of pain / pain assess-
ment.
Results
95% responder rate, 5% refusal. 84% felt confident or very confident
in their accuracy in assessing pain, with none feeling unconfident or
worse.
Only 42% felt children could accurately report pain, although84% identified ability to do so was age related. There was a wide
range in average time spent assessing pain (3 seconds to 10 min-
utes, mean 2.6 minutes) and nurses were inconsistent in frequency
of pain assessment. Most identified that frequency depends on the
patient, but average frequency ranged from every 30 minutes to
once daily. Hospital guidelines recommend frequency should be
every 4 hours.
16% of nursing staff felt assessing pain was one of their top three
responsibilities. They found patient care, supporting family, running
the ward, managing staff, and keeping safe, clean environments more
important. Only 53% had received training in pain assessment, with
only 30% of those having received more than a one-day study course.
Conclusion
Despite previous evidence that pain assessments are inaccurate,
most staff were confident in their ability to assess pain. Many felt
children were unable to self report accurately and illustrated large
ranges of frequency and time take to complete assessments. This
suggests lack of training, which was confirmed by the questionnaire.
It is likely they exist in the “unconscious incompetence” stage of the
competency model of learning8 and a more standardised format of
pain assessment training could address this issue, leading to more
accurate assessments and a better standard of care.
017
COLLECTING PATIENT REPORTED OUTCOME MEASURES (PROM)USING SMART PHONE TECHNOLOGY WITHIN A CLINICAL SETTING
Category: ASSESSMENT & MEASUREMENT
Andrew Vitiello, Dave Newell, Ahmet Ulusan, Maja Bjorn
Anglo European College of Chiropractic, Bournemouth, UK
Background
Mobile health (mHealth), and the use of mobile technology to en-
hance care, is an emerging debate. The model of the ‘doctor knows
best’ has been questioned, whereas the involvement of the patient in
their care and management, including ongoing treatment decisions
and the development of a ‘partnership’ between physicians and their
patients has been shown to impact outcomes and cost, particularly
in chronic conditions. 1,2
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14 British Journal of Pain 7(2) Supplement 1
However, engaging patients in monitoring their health care and
managing their condition has remained a challenge.3 With the emer-
gence of mobile technology considerable scope for innovation4,5 has
arisen with opportunities to improve patient self management and
experience of care, as well as potentially reducing unnecessary and
costly health seeking behaviour.6
We have developed a smart phone app7 that provides validated
PROMs on the patient’s phone together with the ability to provide
these outcomes to both the patient via a secure server to the clinician.
Methods
Code was written to enable the presentation of 2 validated PROMs
(Roland Morris Disability Questionnaire8 and Bournemouth Ques-
tionnaire9), in an appropriate format for smart phone screens as
well as web site to display PROM data to the clinician. The apps
were tested for face validity using a number of students and faculty
and feedback as to the ease of use, both as a potential clinician and
patient was obtained. A further pilot study was then carried out to
ascertain the experience, utility and practicality of 10 non specific
low back patients over the course of 7 days following the initiation
of treatment. Feedback concerning the use of the app and patients
experience was collected using a short questionnaire and in a smaller
sample, a semi structured interview.
Results
A smart phone app able to present two validated questionnaires with
daily notifications to the patients has been created along with a web-
site to display PROM data from individual patients to their clinician.
The details of the app along with the results of the face validity and
pilot study will be presented at the conference.
Conclusion
The use of smart phone technology is an emerging area and has po-
tential to impact favourably both in terms of providing valuable pa-
tient data concerning symptomatology as well as providing a platform
for feedback to the patient in attempts to encourage and support selfmanagement. We have developed a patient friendly smart phone app
that enables the recording of PROMs directly from the patient’s phone
providing direct feedback to the patient as well as uploading this in-
formation to a secure central server for review and use by the clinician
018
DOES THE START BACK TOOL SHORTLY AFTER THE INITIAL VISIT COM-PARED TO BEFORE BETTER PREDICT OUTCOMES IN LBP PATIENTS
Category: ASSESSMENT & MEASUREMENT
Dave Newell1, Jonathan Field1,2
1 Anglo European College of Chiropractic, Bournemouth, UK, 2Back-
2Health, Petersfield, UK
Background
Low back pain is common and costly 1. Most LBP is non-specific in
nature and identifying those individuals likely to respond to inter-
vention has proved problematic. Research has attempted to identify
prognostic groups2 through the development of screening methods. 3
Hill et al 4 have developed the STarT Back, which has proved to add
utility beyond physiotherapist choice alone in determining treatment
for LBP patients by categorising into low, medium and high-risk
groups, with low risk given advice, medium, physical therapy and
high-risk physical therapy with a CBT component.
Recently5 we investigated whether the SBT could predict outcomes
in nsLBP patients undergoing chiropractic care and found no sig-
nificant association between SBT risk groups and outcomes. Previ-
ous work in this population indicates early change may be associated
with favourable outcomes and we hypothesized that the SBT post
the initial visit as opposed to before may provide better prognostic
information.
Methods
Consecutive patients aged over 16 presenting with nsLBP to one of
six chiropractic clinics in the south of England are asked to completethe SBT at baseline and within 2 days of their initial visit online, via
a web page. A Patients Global Impression of Change (PGIC) was e
mailed at 14, 30 and 90 days following their initial visit.
For this study, the primary outcome was the PGIC. Patients were
categorised into the three SBT risk groups using the method as de-
scribed by Hill et al4. For each of the follow up points, all outcomes
were dichotomized with poor outcome defined as a score of
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Abstracts 15
task. The Bath Adolescent Pain Questionnaire (BAPQ); is an
assessment tool designed specifically for use with adolescents
who experience chronic pain, developed by the Bath Centre for
Pain Research. The BAPQ offers a comprehensive way to assess
the widespread deleterious impact of adolescent chronic pain in
both a research and clinical setting. However, it is currently only
in paper version. New online technologies mean it is possible to
produce an online version, which is quick and easy to access any-
where and allows for immediate access of data for a distributed or
remote clinical team.
Methods
The questionnaire was replicated in full using standard web input
controls (free text entry, drop-down lists etc). Efforts were made
however to use each type of input mechanism appropriately in order
to sensibly limit the range of possible response to minimise ambiguity
wherever possible - e.g. if the range of possible answers are known,
a fixed drop-down list was used. It is thought this resulted in no loss
of resolution.
There was also a design decision to repeat the labels for each of the
likert-scale questions on each question (as opposed to just present-
ing them in a table with the labels shown only once at the top. This
was done to prevent the need for the user to scroll to the top to check
their response (e.g. ‘1’ : never) and two, to allow for more physical
space between questions (mostly to increase selection accuracy on
touchscreen based devices).
Results
The online BAPQ is an HTML5 website that has been designed
to be usable in multiple environments. Efforts have been made to
ensure cross-browser and (more importantly in this day and age)
cross-device compatibility (website automatically adjusts for mobile
phone / tablet use / interface is usable on touchscreen-based devices
etc). All participant data is validated and verified before submission.
Data is non-personally identifiable and is stored securely on a UoB-
based database.
A great advantage of the online BAPQ is that scores are calculatedautomatically. The clinician is provided with these results immedi-
ately, which they can then print for further discussion with their pa-
tient. In addition, subject to ethical approvals, researchers can get
immediate access to the aggregate / anonymised data in a usable
form (MS Excel), with the BAPQ calculations already complete.
Conclusion
The online BAPQ is currently being tested with clinicians in the
Royal National Hospital for Rheumatic Diseases in Bath. If deemed
useful in service settings, it will be being rolled out for wider clinician
and patient feedback.
020
SERVICE EVALUATION- ADEQUACY OF ASEPTIC TECHNIQUES INPAIN CLINIC BASED PROCEDURES
Category: ASSESSMENT & MEASUREMENT
Monica Chogle, Michael Stafford, William Campbell, David Miller
Ulster Hospital, Belfast, UK
Background
Asepsis plays an important role in any pain procedure. Operator
hands can be a significant source of bacterial contamination before
patient contact. In our Pain Clinic, where procedures are performed
in a dedicated treatment room on an outpatient basis, the role of
following strict aseptic precautions is of utmost importance. The
aseptic techniques need to be at par with what are followed in an
operating theatre environment.
In our Pain Clinic treatment room, we follow RCOA guidance
for performing central or peripheral nerve blocks. Operators wear
cap, mask, gown & gloves as a rule. Procedure site is cleaned with
Chlorhexidine 0.5% in ethanol spray & draped with sterile drapes.
This project was a quality assurance process to evaluate the adequa-
cy of various aseptic techniques we routinely follow in the pain clinic
treatment room and improve or modify our techniques if deficiencies
were observed.
Methods
Service evaluation was approved by local research and ethics depart-
ment. Microbiology department supported the project. Patients and
staff were consented for sampling. All patients received standard care
in the pain clinic. Staff were instructed to follow standard aseptic
precautions.
There were4 areas for evaluation:
Area 1: Swabs were taken from staff hands on 3 occasions (on
arrival from home, after 1st and after 2nd hand washing)
Area 2: Epidural injection group, where swabs were taken before,
during and post procedure from patients skin)
Area 3: Ultrasound guided procedures, where swabs were taken
before & after application of gel.
Area 4: Ultrasound gel (samples from sterile single use pouches
and refilled bottles)
As this project only aimed at quality assurance, only 4 sets of samples
were obtained from each area of interest. Microbiologic assessment
was performed to identify organisms and quantify as colony forming
units (CFUs)
Results
Area 1 Clinicians Hands: Two out of 4 samples from clinicians
hands grew pathologic organisms on arrival to the clinic. And after
1st Hand wash, only normal skin flora were cultured form the same
hands. No flora was cultured after subsequent hand washes.
Area 2 Epidural procedure: Two out of the 4 samples collected from
patients skin grew pseudomonas (opportunistic pathogens). But af-
ter cleaning with Chlorhexidine 0.5% (in 70% v/v ethanol) spray all
four samples showed no growth. Spraying the back with Chlorhexi-
dine 0.5% eliminated all organisms.
Area 3 Ultrasound Blocks: One skin sample out of 4 grew non
staphylococcal gram positive cocci. No organisms were cultured af-
ter cleaning the same site with Chlorhexidine 0.5% & application of
ultrasound gel from refilled bottles.
Area 4 Ultrasound gel: Both gel from sachets and gel from refillable
bottles were cultured. Both did not grow organisms of any clinical
significance.
Conclusion
Microbiological snapshot data showed that adequate asep-
tic techniques were followed in our treatment room. In view
of results obtained from swabbing staff hands, importance of
regular hand washing needs to be emphasized to all staff in all
clinical areas. We obtained local data to show that ‘seven step
hand washing’ is of utmost importance on arrival to a clinical
area from home. The microbiological data also reinforced that
Chlorhexidine 0.5% skin spray is an acceptable cleaning tech-
nique for a regional or central neuraxial procedure in an office
based environment.
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16 British Journal of Pain 7(2) Supplement 1
021
RASCH ANALYSIS OF THE FATIGUE SEVERITY SCALE AND ANEXAMINATION OF THE RELATIONSHIP BETWEEN PAIN ANDFATIGUE IN PEOPLE WITH KNEE OSTEOARTHRITIS
Category: ASSESSMENT & MEASUREMENT
Bryan Moreton, Maggie Wheeler, David Walsh, Nadina Lincoln
Arthritis Research UK Pain Centre, University of Nottingham, Notting-ham, UK
Background
There is growing evidence that fatigue interacts with pain experience in
osteoarthritis (OA) of the knee. Several questionnaires are available to
evaluate fatigue in musculoskeletal conditions such as the Fatigue Se-
verity Scale (FSS). This questionnaire is composed of nine items which
assess the impact of fatigue (e.g., Fatigue is among my three most disabling
symptoms), and it uses a seven-point response scale where higher values
indicate stronger agreement. The FSS has been shown to exhibit good
measurement properties in other patient groups, but has not been fully
evaluated with people with knee OA. Rasch analysis permits an evalu-
ation of a measurement scale. It can be used to refine a questionnaire
to improve its ability to measure variables of interest. We aimed to con-duct Rasch analysis of the FSS with knee OA patients and to explore
the relationship between pain and fatigue in this condition.
Methods
Participants were recruited from hospital clinics and a group of peo-
ple that had taken part in previous research. All participants had OA
of the knee, which was confirmed by examination of X-ray records,
and reported pain on most days for at least the past month. The ex-
clusion criteria were another known arthritic condition (e.g., rheuma-
toid arthritis), knee joint surgery within the last three months and an
inability to understand English. Potential participants were sent an
invitation letter. Those interested in taking part were asked to com-
plete a set of questionnaires, including measures of pain and fatigue.
Only data from the FSS and the Intermittent and Constant Osteo-arthritis Pain (ICOAP) scale are reported. The questionnaires were
completed at home and returned by pre-paid envelope. Rasch analy-
sis was conducted on the FSS and regression was used to determine
whether pain predicted fatigue controlling for potential covariates.
Results
Data from 171 participants were available for analysis. There were 89
women (52%) and the mean age of the group was 67 years (standard
deviation = 10). The FSS initially misfit the Rasch model (χ2 = 41.62,
df = 18, p = .001). One item had disordered response thresholds,
which means that the response options were not being used as they
should be. In addition, 14 participants and several items (1, 2, and 8)
deviated from the predictions of the model. Removal of items 1 and 2
considerably improved the fit statistics. The revised 7-item FSS exhib-ited good measurement properties. Data from this analysis was then
used to explore the relationship between pain and fatigue. Controlling
for age and gender, OA knee pain significantly predicted self-reported
fatigue accounting for just over twenty percent of the variance.
Conclusion
The study supported previous evidence that suggests an association
between OA knee pain and fatigue. There is a tendency for those
with more severe OA knee pain to report higher levels of fatigue,
which may be due in part to the impact that pain has on sleep. It is
therefore important that fatigue is considered when measuring pain
experience in this condition. The FSS offers a candidate measure to
capture fatigue in OA. It is brief, easy to understand and administer,
and it can be adapted to meet the requirements of the Rasch model
which has statistical advantages.
022
ELECTIVE MAJOR JOINT REPLACEMENT- A COMFORTABLEJOURNEY
Category: ASSESSMENT & MEASUREMENTMei Foong Yeoh
Aintree Universit y Hospi tal NHS Foundation Trust, Liver pool,
Mersey, UK
Background
Effective pain and nausea and vomiting management in the periop-
erative period improves patient outcome, reduces hospital stay and
prevents unnecessary distress. Pain and post- operative nausea and
vomiting (PONV) should be evaluated in partnership with patients
themselves and management tailored to individual experience. Pa-
tient satisfaction is the key indicator of efficient pain and PONV man-
agement. Our audits attempt to capture patients’ pain and PONV
experience in the first 24 hours post elective major joint replacement.
Methods
Data collection of the initial audit stretched from 15/11/2011 to
18/12/2011. Sample size was 56 patients. Patients were sampled
from the daily orthopaedic list at Aintree University Hospital. Pa-
tient questionnaires were used to evaluate patients’ satisfaction with
their pain management. A recovery proforma was used to identify
pain score on first eye opening, pain score at 30 minutes after eye
opening and management of pain in recovery. Data on choice of
perioperative analgesia, use of antiemetics and any surgical compli-
cations, if present, were obtained from patients’ notes. The results
were presented and change was implemented. A reaudit was car-
ried out from 01/07/2012 to 31/07/2012. Sample size was 19 pa-
tients due to the reduced number of surgeries that month. The same
methodology was used with the addition of evaluating patients’ sat-isfaction with their PONV management using the questionnaire.
Results
Comparing the reaudit to the former, 94% (vs 89%) of patients had
a pain score of < 2 on first eye opening and 94% (vs 87%) of patients
had a pain score of < 2 at 30 minutes after eye opening. One hundred
percent (vs 92%) of patients were prescribed both regular and break-
through analgesia and antiemetics prior to discharge to the ward. One
hundred percent (vs 89%) of patients felt that hospital staff did every-
thing they could to control their pain while 10% (vs 16%) of patients
would opt for an alternative method of pain relief. In both audits, all pa-
tients received preoperative information on pain management and only
one patient from each sample was not satisfied with the information
received. However, only 73% of patients were warned about PONV.
Conclusion
There has been significant improvement with patients’ pain man-
agement during the perioperative period. Other areas of improve-
ment were reflected in the judicious prescription of both regular
and breakthrough analgesia and antiemetics for the post operative
period and the prompt response to patients’ complaints of pain. An
area that still needs addressing is informing patients about PONV
and treatment available post operatively. Suggestions made included
warning patients about PONV and discussing antiemetic regimes.
The audit should be repeated after the Aintree University Hospital’s
elective joint replacement perioperative analgesia and antiemetic
protocol commences.
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Abstracts 17
023
NURSES’ VIEWS ABOUT ASSESSING PAIN IN NONVERBALPATIENTS BY USING BEHAVIOURS PARAMETRIC PAIN SCALES INTHE INTENSIVE CARE
Category: ASSESSMENT & MEASUREMENT
Nai-Huan Hsiung1,2, Graeme Smith1, Jennifer Tocher1
1The University of Edinburgh, Edinburgh, UK, 2Tzu-chi College of Tech-nology, Huailien, Taiwan
Background
The inadequate treatment of pain in adults with speech impairments
could be due to professional caregivers’ failure to assess and manage
pain effectively. It is recognized that effective pain assessment would
lead to more satisfied patients and families. Despite the availability of
the evidence to guide pain management practices, practices are often
suboptimal with patients experiencing from moderate to severe pain
in critical care. Limited theoretical knowledge and lack of objective
instruments for assessing pain have been suggested reasons for this.
This study, then, is to explore nurses’ views on the use of pain assess-
ment tools in an intensive care (ICU) setting.
Methods
This paper present data from three modified focus groups undertak-
ing as part of a large study by exploring pain assessment practices in
five hospitals in Taiwan. The researcher first introduced various pain
assessment scales for measuring pain in patients with communicative
difficulties, such as the BPS (Behavioural Pain Scale), the CPOT
(Critical-care Pain Observation Tool), and the FRPS (Facial Rating
Pain Scale). Before the study, twenty two nurses were taught how to
appropriately assess patients by using the three scales. After practic-
ing with them for more than half a year, fifteen nurses took part in
the focus groups and were asked questions about their views on the
satisfaction and remarks of using three instruments in pain assess-
ment within the ICU.
Results
The regional Research Ethic Committee in Hualien, Taipei, and
Chiayi approved the study (approval no.IRB100-23, B10002014,
00-IRB-006-M). All participated nurses agreed that the introduction
of pain assessment tools would improve documentation. Nurses also
felt full theoretical knowledge on overt expressions of pain behaviours
is necessary to objectively explore pain in patients with speech im-
pairment. Therefore, almost three-quarters of nurses preferred BPS
for assessing pain in their clinical practices. When nurses were asked
how much time they need and how easy they felt for completing these
tools, all of them agreed that each patient assessment was the easiest
and took minimal time to use FRPS. However, eighty percent consid-
ered that the most effective pain reactions during nociceptive proce-
dures had been assessed by using BPS. Even though all stated CPOTprovides a detailed item-description about pain behaviours, there is
also main obstacle to use because of its ambiguous indicators.
Conclusion
The variety of pain assessments used by nurses in this study opens
an avenue for further investigating through the linkage between
underlying conceptions of pain behaviours and the effectiveness of
nurses’ assessments of pain in patients without verbal communica-
tion by using an objective pain measurement. The inconsistencies
in these replies could reflect the conflicting demands between the
need to use a validated measures of pain for nonverbal patients while
managing a heavy workload in ICU.
024
PAIN CLINIC - PATIENT SATISFACTION SURVEY
Category: ASSESSMENT & MEASUREMENT
Arindam De, Nick Roberts
Kettering General Hospital, Kettering, UK
Background
Pain Clinic - Patient Satisfaction Survey was developed as a unique
patient centered reflective feedback loop at Kettering General Hos-
pital Pain Clinic. More than 3000 chronic pain patients were seen in
clinic last year and offered consultation for over 1000 new referrals
in last one year. We offer the best available management for Chronic
Pain based on recent advances and available evidences. But effectiv-
ity of our service was only endorsed recently by patients following
this survey.
Methods
Prospective survey recruited 100 new patients over 3 months, who were
requested to fill the questionnaire.The questions covered the following:
The reason for consultation and their expectations from the clinic,choices include -
Someone to listen
Diagnose the problem
Further Investigations
Medication
Injections
Acupuncture
Alternative therapies (TENS)
Cure
Coping skills
Improve quality of life
They were also asked where would they like the consultation - either
at the hospital or at the GP / PCT and how far they were prepared
to travel for this.The duration of the consultation and the information given were
satisfactory or not.
Patient understanding of the management plan and professionalism
of both the doctors and the nurses were in the questionnaire.
Finally they were requested to value their appointment by putting
a number between 0 to 10; 0 being waste of time to 10 being most
satisfactory. Patients were also requested to add comments regarding
consultation.
Results
Out of 100, 6 refrained from valuing, 3 did not reply.
> 70% patients expected someone to listen, diagnose a problem, in-
vestigate and offer medications and injections.
Majority did not expect cure but wanted a better quality of life.
80% expect consultation at local hospital.
90% were happy with timing of referral and the length of consulta-
tion where they understood the given information, except for the
leaflets. Patients rated doctors and nurses as professionals.
Value of the appointment mostly had high scores, which then plotted
in Net Promoter Score (NPS) chart.
NPS is a customer loyalty model of Harvard Business School to
improve services, which correlates with revenue growth. NPS seeks
votes on a scale 0-10 for a service; where 0-6 detractors, 7-8 passives
and 9-10 are promoters. NPS is calculated as (% promoters) - (%
detractors). NPS maximum score can be 100 (everyone promoter),
NPS +50 is excellent. Our survey yields NPS of 82.
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18 British Journal of Pain 7(2) Supplement 1
Conclusion
Patients highly valued the service provided. NPS should be included
as a regular feedback programme at all patient care delivery level.
In reflection of this survey we concluded that the patients still want
the services to be delivered at secondary care level and chronic pain
consultants were most valued among the team. Long waiting time
remained as a challenge. But overall pain clinic based delivery of
the chronic pain management programme was highly valued by thispatient endorsement survey.
025
THE INTERMED SYSTEM: AN EXPLORATION OF CHANGES INCASE COMPLEXITY FROM 2008-2012 AT WIRRAL UNIVERSITYHOSPITALS NHS TRUST PAIN MANAGEMENT CLINIC
Category: ASSESSMENT & MEASUREMENT
Emma Bain, Peter Williams
Wirral University Teaching Hospitals NHS Foundation Trust, Upton,
Wirral, UK
Background
There is concern about the increasing complexity of cases present-
ing to the Chronic Pain Management Clinic over time, and there is
indeed need to assess this and allocate resources accordingly. The
ageing population is one of the factors contributing to an increase
in presentation of patients with complex medical, psychological and
social needs to Pain Management Services.
The INTERMED system provides a simple and rapid assessment of
case complexity based upon patient interview. It includes an assess-
ment of history (past 5 years), current state and prognosis. It involves
the evaluation and scoring of biological, psychological, social and
health care needs. There is a maximum score of 60 and an overall
score of greater than the cut off of 21 is considered significant and
deemed as a complex case.
Methods
From 2008 to 2012, the INTERMED score of 804 patients present-
ing to the Chronic Pain Management Service was collected. Scoring
was performed at interview on clinic assessment. The total number
of patients scoring greater than 21 per quarter of each year was re-
corded and mean INTERMED score per quarter were calculated.
Results
There was an increase in the number of patients presenting with
INTERMED score of greater than 21 over time and an increase in
mean INTERMED score from 18.4 in the first quarter of 2008 to
21.1 in the third quarter of 2012. The percentage of patients present-
ing with INTERMED score of more than 21 had increased from
32.9% to 42.9% in 2012. Mean INTERMED score had risen over
time to above the cut off of 21.
Conclusion
There has been an increase in case complexity presenting to the
Chronic Pain Management Service as scored by the INTERMED
system from 2008 to 2012. This has significant implications for
allocation of resources needed to manage these increasingly complex
patients. In particular psychosocial comorbidities are known to affect
outcome and prognosis of medical and psychiatric disorders. The
need for access to integrated care with medical specialities, psychi-
atric services, physiotherapy and occupational therapy will increase
over time. An increase in allocation of resources to Pain Management
services will be required in order to manage these cases effectively.
026
IS THE BRIEF PAIN INVENTORY (BPI) A USEFUL PATIENTREPORTED OUTCOME MEASURE (PROM) TO ASSESS CHANGE INPATIENTS WITH CHRONIC PAIN FOLLOWING INPUT FROM A SPE-CIALIST PAIN MANAGEMENT PHYSIOTHERAPIST?
Category: ASSESSMENT & MEASUREMENT
Christopher Carter, Kevin Dewell, Gary Ferguson, Richard Hughes,CRD Laird
County Durham and Darlington NHS Foundation Trust, County Dur-
ham, UK
Background
The National Pain Audit has been set up to look into pain manage-
ment around the UK over the next 3 years. The BPI is one PROM
being used and consists of a simple, short, self-administered ques-
tionnaire that uses 0 to 10 numeric rating scales (NRS)to measure
pain intensity as well as the degree to which pain interferes with
function.Since pain can be quite variable over a day, the BPI asks
patients to rate their pain at the time of responding to the question-
naire (pain now), and also at its worst, least, and average over the
previous week. Evidence for the validity and reliability of the BPIcomes from several studies using the instrument with cancer patients
and patients with other diseases who had pain (Cleeland & Ryan
1994; Keller et al 2004).It has several applications, including efforts
to assure the quality of pain management.
Methods
The BPI has been used as part of a service evaluation to investigate
the impact of specialist pain management physiotherapy on patients
with chronic pain attending the University Hospital of North Dur-
ham (UHND). Specialist physiotherapy intervention consisted of
education,acupuncture,graded exercise, class based exercise, problem
solving and progressive goal setting.Significant change was deemed to
be any change of two points or more on the NRS (Farrar et al 2001;
Farrar et al 2009; Salaffi et al 2004). Over a 6-month period a total of126 patients were asked to complete a BPI pre and post physiotherapy
intervention. The data was then compared and any significant change
in any of the domains on the BPI noted. The working hypothesis was
that specialist physiotherapy intervention would have more impact on
the more physical domains as it aims to restore normal movement and
reduce fear avoidance (Main, Sullivan & Watson 2008).
Results
The pre and post data on the 126 patients showed nearly a third,
29% of patients with chronic pain showed significant improvement in
worst and least pain experienced.Just over a quarter, 27% showed sig-
nificant improvement in the average pain experienced. Exactly a third
of patient’s, 33% showed a significant reduction in their pain at that
exact moment in time (pain now). The physical domains on the BPIthat were expected to change significantly following specialist phys-
iotherapy input included general activity, walking and normal work
(including housework), these improved significantly in 44%, 37%
and 34% of patients with chronic pain respectively. Interestingly the
BPI domains that showed significant improvement in most patients
following specialist physiotherapy were not the physical domains as
expected, but indeed the patient’s mood and enjoyment of life which
significantly improved in nearly half of the 126 patients, 46% and
49% of patients respectively.
Conclusion
The results show that the BPI can be used as a PROM to as-
sess change in patients with chronic pain following input from
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Abstracts 19
a specialist pain management physiotherapist. Although the results
did not prove the working hypothesis, nearly 1 in 3 patients showed
significant improvement in the physical domains on the BPI directly
associated with physiotherapy intervention. These results must be
interpreted with caution as pain management is not uni-modal and
other interventions from within the wider multidisciplinary team
(MDT) may have taken place during this same period, therefore a
further study is needed to address this issue.
027
PERCUTANEOUS CERVICAL CORDOTOMY FOR CANCER RELATEDDEAFFERENTATION PAIN
Category: CANCER PAIN
Manohar Lal Sharma, Heino Hugel, Manish Gupta
Walton Centre NHS Foundation Trust, Liverpool, UK
Background
Percutaneous cervical cordotomy is accepted treatment for mesothe-
lioma related medically refractory cancer pain. Its role is also estab-
lished for nociceptive cancer pain which is refractory to conventional
medical management. However, there is some controversy relating touse for this neuroablative technique for cancer related deafferenta-
tion pain.
Methods
We describe three cases of brachial plexus infiltration related can-
cer pain treated by Percutaneous cervical cordotomy. All patients
derived excellent reduction in pain and analgesics consumption
after this procedure. All of these patients had numb, painful and
paralysed upper limb. This was related to spread of cancer to axilla
and impaired function of brachial plexus. All patients were treated
by application of radiotherapy and chemotherapy to control the
spread of cancer. Pain was difficult to control with combination of
strong opioids, anticonvulsants, antidepressants and conventional
analgesics. All patients were assessed by Joint Palliative and Painteam. Patients were usually admitted at Woodlands hospice for pre
and post procedure care and procedure was carried out at Walton
Centre.
Results
All patients reported excellent analgesia post cordotomy. There
were no major complications. Usual side effects of headache, neck
pain and general malaise were noticed for 2-3 days. There was con-
siderable reduction in analgesic use post cordotomy. Another use-
ful observation during sensory stimulation while undertaking cor-
dotomy was that all patient felt spinothalamic sensation in numb
and paralysed limb (sensation of heat and cold). Before undertak-
ing Cordotomy, authors were not sure whether this will be possible.
Perception of spinothalamic sensation in painful area on sensorystimulation is positive predictor of success from percutaneous cer-
vical cordotomy.
Conclusion
In our opinion and experience, percutaneous cervical cordotomy has
useful role in medically refractory cancer related deafferentation type
upper limb pain caused by infiltration of brachial plexus. However,
we understand that our results cannot be extrapolated to all patients
suffering from this type of cancer pain. This though remains a possi-
bility if the pain was to be poorly controlled with conventional medi-
cal management.
028
PAIN SCREEN AND TREAT: A RANDOMISED CONTROLLED TRIALTO ASSESS THE EFFECT AND COST- EFFECTIVENESS OF ROUTINESCREENING AND TREATMENT OF PAIN IN CANCER PATIENTS
Category: CANCER PAIN
John E. Williams1, Janet Peacock2, Anthony Gubbay1, Rose Ellard1,
Julia Riley1
, Odile Sauzet3
, Joy Ross1
1Royal Marsden Hospital, London, UK, 2Department of Primary care
and Public Health Sciences, Kings College London, London, UK, 3Depart-
ment of Statistics, University of Bielefeld,, Bielefeld, Germany
Background
Cancer pain remains a major public health problem affecting as many as
one in two patients attending oncology outpatients departments (1,2,3).
Reports from the American and British Pain Society’s have recom-
mended a proactive approach to pain management, including regu-
lar assessment of pain and use of evidence-based treatment proto-
cols, integrated into routine oncological practice.
We aimed to explore whether a new ‘ proactive screening and treatment
system’ for pain, which incorporates these recommendations, is effec-
tive and cost effective when compared with ‘usual care’.
Methods
We screened patients routinely attending outpatients for pain using
a single question. Patients scoring >4 on the BPI-NRS ‘worst pain
in past 24 hours’ were approached for inclusion and randomised to
intervention or ‘usual care’.
Intervention included immediate (on-the-day) access to pain treat-
ment advice according to individualized protocol algorithms, follow
up, reassessment and patient education.
The primary outcome was difference in pain scores (BPI) at one, two
and three months.
Secondary outcomes included pain interference with activities
(BPI), adequacy of pain management (PMI), quality of life (EQ-
5D), patient satisfaction (0-6 Likert scale) and anxiety or depression(HADS).
Data was prospectively collected to evaluate healthcare costs.
Results
From January 2011-July 2012 we screened 1087 patients (2212 visits).
We recruited 156 patients, mean age (SD) 58.1 (10.6) years, 64.7% male.
The most common diagnoses were thyroid 18.6%, tongue 17.9%,
tonsil 10.9%, and parotid cancer 7.1%. Average (SD) pain scores at
baseline were 6.4 (1.6).
Conclusion
Final data will be available March 2012 and full results presented at
this meeting.
029
INVASIVE NEURODESTRUCTIVE PROCEDURES IN CANCER PAIN(INPIC): DEVELOPMENT OF A CORDOTOMY REGISTRY.
Category: CANCER PAIN
Nicholas Campkin1, Matthew Makin2, on behalf of INPiC pilot study
group3
1Portsmouth Hospitals Trust, Portsmouth, UK, 2The Marie Curie Pallia-
tive Care Institute, Liverpool, UK, 3INPiC pilot s tudy group, INPiC, UK
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20 British Journal of Pain 7(2) Supplement 1
Background
The Marie Curie Palliative Care Institute Liverpool Pain Group
and NRCI Palliative Care Studies Pain Group established a work-
ing party to examine the role of Invasive Neurodestructive Proce-
dures in Cancer Pain (INPiC). The initial focus has been on cor-
dotomy (INPIC Pilot study) The aims and objectives of the INPiC
Pilot study were:
• To produce national guidelines for the use of cordotomy in me-
sothelioma-related pain management
• To provide a benchmark for the availability of cordotomy for
mesothelioma-related pain in the UK
• To establish a National Registry for cordotomy
• As a pilot, if successful, to be repeated in oth