Three nurse-led community pain management clinics in Lincolnshire have radically reduced waiting times and improved patient satisfaction.
All new services are motivated by a desire to improve some aspect of patient care. For Jenny Coen, now lead nurse, pain management at Pilgrim Hospital, part of the United Lincolnshire Hospitals NHS Trust, the motivation for setting up community pain clinics was simple: reduce waiting times and ensure patients have faster, more convenient access to pain relief.
Previously, patients with chronic pain were having to wait as long as a year to be seen and, because of the geographical nature of the area, often had to travel long distances to hospital appointments. 'These patients are in a lot of pain so they don?t take well to travelling 20 miles to the hospital in a bumpy ambulance and then back again,' points out Ms Coen.
The community pain clinics were launched two years ago (2004) and are run at three sites across Lincolnshire. A team of four nurses and one senior health care assistant, based in the acute hospital, go out into the community to run the clinics. One of the clinics has been set up in a community clinic, the other two in outpatient clinics in community hospitals. The sites were chosen to keep costs down, as GP surgeries can charge a fee for using clinic space.
The clinics in Skegness and Spalding are both 20 miles from the hospital. However, the third is only a mile from the hospital. 'Some patients just prefer to be seen in the community setting,' explains Ms Coen. 'They do not like visiting a large outpatients department, regardless of how close it is.?
The hospital consultant triages all the referrals for the service and decides which patients are suitable to be seen in the community. Two of the nurses attend the weekly clinics in each centre. Although the nurses meet regularly with the hospital consultants they do not have any contact with the medical team when out in the community.
At appointments they see new patients, take a history and work out a package of care which is followed through. Some patients are seen in the community clinic and then referred back to the hospital consultant for a specific procedure and then seen again in the community clinic by the nurse. A physiotherapist and occupational therapist are attached to the acute team and the nurses can refer patients to them.
The patients seen in the community present with a range of conditions including back pain, neck pain, facial pain, arthritis and pain following surgery. There are also a significant number of patients who have been injured at work, commonly landworkers as it is a rural area. Cancer patients are usually seen in the hospital but can be seen in the community clinic for a follow-up appointment. The patients are across the whole age range and include adolescents.
Ms Coen, who previously worked in theatre recovery, has been working in pain management at Pilgrim Hospital for the past ten years. The team has gradually expanded around her to now number five. All the team have some additional training in pain management. The lead nurse has an MSc in pain management while the three nurses in the team have studied for a module in pain management in adults.
Acupuncture treatment is proving increasingly popular with the patients. Ms Coen believes this is due to publicity about the treatment in the media and an increasing preference among patients to be treated drug-free. Team members are therefore also completed an acupuncture course for nurses course offered in the Trent region. The course takes five days and has follow-up study and practice. Nurses are also trained and experienced in using TENS machines.
Ms Coen herself is also a nurse prescriber. However, until recently, the majority of analgesia was not part of primary nurse prescribing but she is hopeful that the recent extension to the formulary will help. The rest of the nurse team use secondary prescribing for dose adjustments of medication.
Ms Coen says that counselling and education are a big part of the work.
Patients who attend the community clinics are given a 45 minute appointment at their first visit. 'These patients have had a lot of investigations, scans and other appointments. We are the end of the road. We discuss the options with the patients. Sometimes we cannot help the pain to any great degree but what we are trying to do is to improve quality of life. Most patients are realistic and realise that having had pain for a length of time they are not necessarily going to get rid of it completely.?
A patient audit on the community pain clinics has shown very positive results. In the first nine months from April 2004 to the end of the year, the nurses saw 135 new patients in the community clinics and carried out 609 follow up appointments.
The first 60 new patients who attended from April 2004 were given a questionnaire, of which 55 per cent were returned, a total of 33 patients. The results showed that the majority were happy to be seen by a specialist nurse rather than a doctor with only five of the patients saying they were uncertain. Three out of four of the patients were very much in favour of the location of the clinics, finding the community setting more convenient.
Two-thirds of the patients reported that their pain had improved since their appointment with well over half of the patients also reporting an improvement in quality of life. Four out of ten of the patients reported an improvement in their mobility.
The caseload of the pain clinics remains high as it is hard to discharge patients, a common aspect of all pain management services. Even if a successful therapy is found, such as acupuncture or an injection therapy, the patients still need to return for a top-up treatment.
The community clinics have had a significant impact on waiting times which are now down to 12 weeks with a wait for follow-on treatment of just a week or two. The team is looking to the future and are currently carrying out another audit of the service. The nurses are thinking about extending their skills by undertaking training in simple injection techniques and the number of community pain clinics looks set to increase.
Case study (names changed)
Samantha, a 13yr old girl, was first seen by a nurse specialist in the community pain clinic following referral by her GP with a two-year history of headaches associated with nausea. Her symptoms had been fully investigated by her GP and consultant paediatrician without a clear diagnosis. During this time, various therapies had been tried without success. The headaches were severely disrupting her education and she was keen not to fall behind.
At the first appointment, it was decided that acupuncture could help and she was booked for a course of treatment. Samantha was a little apprehensive but the session went well. At the second treatment, Samantha reported that she had only had one headache in the week between treatments. At the six week follow-up appointment Samantha reported that her headaches had considerably reduced and she had not lost any school time since her acupuncture commenced. Her mother reported an improvement in Samantha?s mood, saying she seemed happier and was socialising more with friends.
She now has acupuncture top-up treatments at regular intervals which have subsequently lengthened in time. She does still have some headaches. However, these have considerably reduced both in number and severity.