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PORTRAIT OF PAIN: A MANAGEMENT APPROACH IN AN AMBULATORY CANCER CENTRE.

Nancy Doyle*. Kathy D. Beattie* (SPON: R. Needs) Toronto-Sunnybrook Regional Cancer Centre, Toronto, ON, M4N 3M5 Canada

Aim: To explore ways of meeting the challenge of providing pain and symptom management and coordinating care for patients in a large ambulatory oncology setting. Toronto-Sunnybrook Regional Cancer Centre is a freestanding outpatient cancer centre assessing approximately 7900 new patients per year. This centre, along with one other, services a metropolitan region of 4.5 million population. The cancer centre is associated with a university affiliated tertiary care centre as a host hospital.

Methods: Patient demographics were compiled and analyzed by diagnosis, pain classifications and modes and numbers of pain management interventions utilized.

Results: Patient referrals occur internally within the ambulatory centre e.g., for chemotherapy, radiation, and externally to the host hospital for nerve blocks, epidural infusions or neuroablative surgery. In addition referrals are made to the community for supportive care in the home. Interventions include opioid, non-opioid and adjuvant therapies, as well as psychosocial and community support.

Conclusions: The arena of pain management is coming into clear focus. Currently teams are more cognizant of pain's multidimensional nature and are utilizing a broad spectrum of resources. The interdisciplinary team, members' roles and the various resources available to them have been identified. Within this framework, oncology caregivers are meeting the challenge of improved cancer pain management.

A QUALITY PROGRAM FOR ACUTE PAIN MANAGEMENT.

Francoise M.Bardiau , Monique M.Braeckman' , Laurence Sei-del²', Adelin Albert²', Jean G. Boogaerts'" (SPON: H. Adriansen) Depts of 'Anesthesiology, CHU Charleroi, ^lostatistics, CHU Liege, Belgium

Aim of Investigation: The objective was to compare pain management quality before and after the introduction of a Quality Program (QP) in a general hospital. The phases were: Assessment, Actions, Reassessment.

Methods: The study material consisted of 1304 surgical patients in pre-QP and 671 surgical patients in post-QP. Visual Analogue Scale (VAS) pain scores were measured every 4 hours for 72 hours in the postoperative period. Time related VAS data were summarized using pain indicators as described elsewhere [1]: AUC (Area Under the VAS-time Curve); Mean VAS; VAS max (peak of VAS); Tmax (time of VAS Max); persistence PVAS-3: the time period during which VAS was above the critical threshold of 3. The analgesic consumption were recorded. Pre- and post-QP results were compared using Student t-test.

Results show improvement in pain management as reflected by the significant decrease of pain indicator levels.

Conclusion: Efficacy of the QP is demonstrated in the study.

PAIN THERAPY SERVICE OF HOSPITAL ALEMAO OSWALDO CRUZ: A BRAZILIAN PROPOSAL FOR SPECIALIZED TRAINING.

Lucimara D. Chaves. Ana Luiza H. M. Heise*, Ruth Locking*, Sandra S. Destro*. Hospital Alemao Oswaldo Cruz. Pain Therapy Service, Rua Joao Juliao, 331, Paraiso, Sao Paulo, Brasil, CEP:01323-903

Aim of Investigation: The organization of the Pain Therapy Service (PTS) of Hospital Alemao Oswaldo Cruz (HAOC) had the purpose of offering a specialized attention to operated patients in the control of postoperative acute pain.

Methods: In 1994, a multi-disciplinary team was formed with doctors, pharmacists and nurses, whose first activity was reviewing the existing theory. Then it developed a work plan which set goals and priorities. Patient attention strategies were developed through daily visits. Through continuous work the team was able to prepare and re-evaluate specific instruments for anamnesis, prescription, pain assessment and measurement. PTS nurses conducted a work of training and updating hospital nurses in relation to pharmacology, analgesic administration routes, and peridural catheter and infusion pumps handling for patient-controlled analgesia

Results: PTS implementation was a result of the definition of specific protocols for prescription, evaluation and monitoring of patients submitted to peridural analgesia and patient-controlled analgesia through infusion pumps. Another important result was the performance of an updating and training program for nurses.

Conclusions: Since its implementation, PTS has already attended t( 1.020 patients in HAOC's postoperative acute pain control. The results related to analgesia will be presented in August, 1999.

ARE WE MAKING THE RIGHT DECISION TO TERMINATE IV-PCA?

PP Chen. PT Chui, MML Ma, Dept of Anaesthesia & Intensive Care, The Chinese Univ of Hong Kong, Shatin, Hong Kong SAR

Aim of Investigation: Intravenous patient-controlled analgesia (iv-PCA) is often terminated according to clinical decision based on acute pain service guideline. This prospective study examines the patients' preference 24 hours after stopping iv-PCA

Methods: With ethics committee approval and patient consent, we recruited all patients who had iv-PCA for postoperative analgesia over a three-month period. Twenty-four hours after termination, w< asked patients whether they wish to re-start iv-PCA, and his/her reason. Patients' data, opioid consumption, side effects and VAS pain both at and 24-h after termination ofiv-PCA were collected.

Results: Of 115 patients recruited, 38 (33%) patients would like to re-start iv-PCA, 97.4% because of better analgesia with iv-PCA. Seventy-seven patients did not want iv-PCA restarted, because of minimal pain (51.9%), cumbersome PCA-device (15.6%), ineffective iv-PCA (11.7%), side effects (11.7%), and the wish to put up with pain (7.8%). Both groups of patients were similar with respect to age, sex, operation, duration of iv-PCA, reasons for iv-PCA termination, side effects and VAS pain at and 24 hours after iv-PCA termination. The total morphine consumption in the restart group (79.7 ± 50.6mg) differed from the non-restart group (57,1 ± 53.2mg), (p=0.037). Morphine consumption in the 24 hours prior to stopping iv-PCA was also different (21.1 ± 14.8mg compared to 15.1 ± 15.1mg, p^{^:s}0.044). The restart group required more rescue analgesia after stopping iv-PCA (36.8% compared to 11.7%), (p=0.001).

Conclusions: Pain score does not predict patient preference to restart iv-PCA, although morphine consumption may be useful. Other non-clinical reasons also influence patient's decision.

THE USE OF A QUALITY ASSURANCE FORM FOR THE REPORTING OF CRITICAL INCIDENTS ON AN AN-ESTHESIOLOGY BASED PAIN SERVICE.

K.Holritz. D. Tundis, S. Datta, A. Racolin (SPON: S. Jain) Dept of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021.

Aim of Investigation: The purpose of this investigation was to review the incidence of critical events on an Anesthesiology based Pain Service that resulted in actual or potential harm to the patient.

Methods: Over a 12 month period, the attendings, fellows and nurses on an anesthesiology based pain practice at a major cancer center were asked to record specific events using a quality assurance form with established criteria. The major categories for the incidents were the following; drug related, personnel related, equipment related, technique related, patient related, Dept responsible for the incident, outcome, and if timely action was taken. The Anesthesia Pain Service saw 2048 patients on the inpatient service during the year that the data was collected. A total of 95 incidents was recorded.

Results: Of the categories listed, incidents that were personnel related (35%) and equipment related (35%) were ranked first. Drug related incidents (15%) was second, technique related (13%) was third and patient related had no incidents (0%). The ranking of Dept responsible for the incidents ranked as follows: Anesthesiology Pain Fellow (24%) and the nurse (24%), other staff (27%), surgical staff (22%), and pharmacist (2%). Outcomes for patients were as follows: no change in hospital stay (63%), inadequate pain control (26%), other (8%), severe side effects (2%), severe pain crisis (1%), and death (0%). Timely action was taken most of the time (79%) as compared to not (21%).

Conclusion: The reporting of 95 incidents is low, and most did not result in any adverse affect to the patient or an extension in their hospital stay. In reviewing the data it was determined that the QA instrument was not specific or sensitive enough in its categorization of incidents. There is a need to revise the form to be more descriptive about the complications being reported and the reasons for personnel making mistakes for it to be useful as a monitoring and educational tool to improve patient outcomes.

A THREE SITE COMPARISON OF SURVEYS FOR PATIENT SATISFACTION, PHYSICIAN AND NURSING KNOWLEDGE ABOUT PAIN MANAGEMENT.

Tim J. Lamer, Yvonne D'Arcy*, Dept of Anesthesiology, Mayo Clinic Jacksonville, Jacksonville, FL 32224. USA

Aim of Investigation: To compare patient satisfaction with pain management and the pain management knowledge base of physicians and nurses in three institutions.

Methods: A valid tool was used to survey 410 patients for satisfaction with pain management and 744 health care professionals for pain management knowledge at 3 acute care sites.

Results: In all three institutions greater than 95% of patients surveyed reported pain. Patient survey results: 28% expected to have significant pain but only 41% were told how much pain to actually expect. 17% of the patients had problems with pain management and 55% were completely satisfied with their pain management. Healthcare professional surveys results: 79% of the respondents did not fear opioid addiction in cancer patients treated with opioids, while 77% feared addiction in chronic pain patients treated with opioids. 95% knew that the patient was the best judge of pain intensity, but 54% thought that a placebo trial was a good way to test for true pain. Only 16% recognized normeperidine as a harmful metabolite ofmepcridine 25% knew the duration of IV morphine, and 34% were able to convert morphine to an equianalgesic dose of meperidine.

Conclusions: The survey findings were remarkably similar in all 3 sites. The identified knowledge deficits potentially affect the quality of pain management care that patients receive while hospitalized. The results of these surveys support the need for more pain management education for staff and patients as an ongoing process.

PAIN AND SATISFACTION WITH ANALGESIA IN POSTOPERATIVE CARE

Luciana M.M.Martins*: Cibele A.M. Pimenta, Prof. Edmundo Vasconcelos Hosp., Univ. ofSao Paulo, Sao Paulo, S.P., 05422-970, Brazil.

Aims of the Investigation: to identify the incident and characteristics of the postoperative pain and the disability resulted from the pain process; to characterize the analgesic prescriptions; to verify the patients' satisfaction with the analgesia; to compare the characteristics of the analgesic schedule, the disability that can result from pain as well as the satisfaction with the analgesia, according to the extent of the surgery.

Methods: Data collection identified patients according to the intensity of the pain; the pain's interference in the five daily activities; analgesic prescription; extend of the surgery; and the patients' satisfaction with the pain control.

Results: 110 patients were observed during the first 3 postoperative days and 85,5% experienced pain. In the Large surgery group (37,3%), the prescriptions were written "as necessary" scheme in 58,4% of the cases; 67,4% were dissatisfied with the analgesia. In the Medium surgery group (51,8%), 95% of the 173 analgesics were antiinflammatories; 12% of patients were unable to comfortably move in bed and in 10%, sleep was disturbed secondary to pain. In Small surgery group, 12,5% of the patients had severe pain.

Conclusions: We observed a high frequency of pain in postoperative days. In the Large surgeries the pain was more frequent, more intense and the disabilities connected to pain were more important. The antiinflamatones, were the analgesic more prescribed in the three groups. About half of prescriptions were "as necessary" scheme. Bigger dissatisfaction with pain control was referred by patients who were submitted to Large surgeries.

THE 1MPLEMENTATAT10N OF A PED1ATRIC POSTOPERATIVE PAIN PROTOCOL.

M. Puylaert. K. Vissers, M. Judong, C. De Deyne*, J. Van Canneyt*, R. Heylen*, Pain Service, Dept of Anaesthetics, ZOL, Schiepse Bos 6 3600 Genk, Belgium

Introduction: An adequate postoperative pediatric pain management may reduce postoperative morbidity in children. Our institution consists of a 840 beds regional teaching hospital with 2 pediatric wards. We implemented a pediatric postoperative pain protocol for: standardization of prescriptions, improvement of postoperative pain rating scales, fine adjustments of individual pain treatment by the Nursing Dept and prevention of postoperative pain by a regular NCA (Nurses Controlled Analgesia) scoring system.

Aim of the Study: In our pediatric protocol for postoperative pain management we used a multimodal medication scheme, which is based on the WHO analgesic stepwise approach. The base of the protocol is a peripheral acting analgesic (propacetamol and/or NSAID) administered on a regular basis. Using an algorithm that includes the pain score, the degree of sedation, the respiratory function and the circulatory state, the pediatric nurse can decide on an independent, but safe medicolegal method to administer an opi-oid if pain rating scores become too high. By scoring the patients on a regular basis we can prevent severe postoperative pain.

Method: Evaluation of "postoperative pain" (incidence, characteristics) by interviewing postoperative patients before and after implementation of our pain protocol:

- Phase I (October 97-January 98): interview of 50 randomly selected postoperative patients before implementation

- Phase II (February-April 98): interview of 50 randomly selected postoperative patients after implementation Results: Generally, there was an improvement of postoperative care since the implementation of our pain protocol. In phase I 58% and phase II 68% of patients arrived on the pediatric ward with a painscore(VAS)<5/10.

- In phase I 76% and phase II 85% of patients had a painscore < 5/10 after 24h or discharge of the ward.

- In phase I 72% and phase II 100% of parents were satisfied with the postoperative pain treatment.

Conclusion: Good pediatric postoperative pain management has to rely on the implementation of a routine pain protocol, supported by medical and nursing staff.

THE ESTONIAN PATIENTS' PAIN EXPERIENCES AFTER SURGERY.

Ulla Raid. Univ ofKuopio, Dept of Nursing Sciences, Finland; Katri Vehvilainen-Julkunen, Univ ofKuopio, Dept of Nursing Sciences, Finland; Anna-Maija Pietila, Univ ofKuopio, Dept of Nursing Sciences, Finland

Background: Since 1991 when Estonia become independent, reforms have significantly changed the Estonian economic and health care system. Due to the present situation the topical themes for the research are needs for the development of the nursing and health care services. Estonians value good health highly. Generally, they only become concerned about the risks of their health when they already have a health problem. The main reason when they are looking for help is the pain.

Purpose of this Study: was to describe the pain experiences after surgery among Estonian patients. The main object of this study was to explain how the patients experience the pain and pain management after surgery and to clarify what kind of expectation of pain and pain management they had before surgery and after that. Subjects and Methods: The data were collected for two months in June - August 1998 from two universities and a local hospital.The questionnaire for this study is modified based on the earlier investigations and theories. The following criteria for the patients: patient had an operation and his condition was good enough to answer this questionnaire, age over 18-years, good knowledge of Estonian language. Measuring instrument was a semi structured questionnaire with 68 items. The responses (n=233) to questions have been analysed using quantitative statistical methods (frequencies, percentages and cross-tables)

The results and the conclusions: are expected to be finished in the spring of 1999 and will be presented at the conference. The results will be used to develop knowledge based nursing and also in nurse education in Estonia.

VALIDATION OF SIAARTI MONITORING SHEET OF POSTOPERATIVE PAIN TREATMENT

Savoia G.. Gravino E.*, Scibelli G.*, Maio L.* Dept of Anaesthesia and Intensive Care, "Buon Consiglio" Hospital - Via A. Man-zoni 220 - 80100 Naples, Italy.

Aim of Investigation: SIAARTI (Italian Society for Anaesthesia, Analgesia and Critical Care) has recently proposed a national recommendation for treatment of postoperative pain control, founded on 3 different levels of care intensity. We have validated the feasibility of the proposed postoperative monitoring sheet (fig.1) for anaesthesiologists, nurses and patients by realizing a 350 consecutive patients data-base.

Methods: We have evaluated the filling feasibility of the proposed postoperative monitoring form by using a simple questionnaire (Scale of0=no problems - 100 = extremely difficult for data collection).

Results: A data-base of 350 patients was evaluated: 200 patients received I level procedures, 120 patients II level procedures and 30 patients III level procedures, respectively. Feasibility score per each group was: 15 ± 8 for anaesthesiologists, 25 ± 12 for nurses and 30 ± 13 for patients.

Conclusions: Feasibility of proposed data sheet results optimal for anaesthesiologists, but requires an adequate training of other staff members and an effective information of patients.

SURVEY OF POSTOPERATIVE PAIN IN A SINGAPORE COMMUNITY HOSPITAL.

CSYoong. Dept of Anaesthesia, Changi General Hospital, Singapore 529889

Aim of Investigation: To investigate benefits and risk of providing an Acute Pain Service in a new medium-sized community hospital.

Methods: 507 patients on the Acute Pain Service were interviewed twenty-four hours following surgery to assess quality of pain relief They were asked to [1] rate quality of pain relief experienced at rest and on movement - using a Verbal Descriptor Scale (Nil; Mild; Moderate; Severe) and [2] describe their satisfaction with pain relief obtained. Incidence of side-effects and major complications arising from pain management were also investigated.

Results: The commonest type of surgery performed were abdominal (67%), genito-urinary (13%) and orthopaedics (12%) Modes of analgesia consist mainly ofepidural analgesia (75%) and intravenous patient controlled analgesia (23%). Overall, 92% of patients had nil to mild pain at rest. On movement, 6% of patients had severe pain. Only 6% of patients were dissatisfied with their pain relief. When abdominal operations were considered (n=340), severe pain at rest was present in 2% of patients but increased to 7% for movement pain. In this group, 6% of patients were dissatisfied with their pain management. There were no significant differences in resting pain, movement pain and patients' satisfaction rate between patients given epidural analgesia and those given intravenous PCA. Common side-effects were nausea / vomiting (11) and pruritus (5%). There were no serious complications of note.

Conclusions: The Acute Pain Service provides a safe and effective means of providing pain relief to postoperative patients.

GOAL-BASED DEVELOPMENT OF A PAIN-FREE HOSPITAL.

Ruth Zaslansky. Elliot Sprecher, Benno Rosenberg*, David Yamit-sky, Depts. of Neurology, Anesthesiology, Haifa Pain Research Group, Rambam Medical Center and Technion Medical School, Haifa, Israel

Aim of Investigation: Devise and test a multidisciplinary program to establish a "pain-free hospital" (VASes 0-3), by applying evidence-based medical guidelines for treatment of acute pain.

Methods: Development of a 4 stage goal-based Acute Pain Service program, where the primary goal is significant reduction in pain throughout a tertiary care facility: 1) Compilation of general pain treatment guidelines from the IASP, American Pain Society, AHCPR, WHO. These guideline cover pain measurement, phar-macological methods, treatment, monitoring, and PCA and other technological application. 2) Revision and application of guidelines to suit local conditions. These include adaptation to available resources, teaching and skill transfer, and distinctions of theory vs. practice. 3) Quality control examination. This involves statistical program evaluation, and assessment of whether goals are achieved. 4) Updating and maintenance of the program based on the quality control. Ongoing development and research, in order to enhance and correct the guidelines and their application.

Results: 16 months of activity in 3 hospital Depts, Emergency, Orthopedics, and Plastic Surgery, have provided the basis for the pain treatment program. We produced a local handbook of pain treatment guidelines; Dept patient forms now include pain-relevant data; staff awareness and treatment practices are being assessed; statistical quality control methods are being developed and implemented; and PCA and other pain-relevant resource purchases were made.

Conclusion: Our model represents a framework for achieving the goal of a pain-free hospital. Continued development and research will reveal whether this goal is possible; we already know that it is desirable.

ANALGESIA TOTAL QUALITY PROGRAM: THE FIRST BRAZILIAN EXPERIENCE IN ACUTE PAIN EDUCATION FOR NURSES IN HOSPITAL SETTINGS

Bemardo CL. Chaves LD, Oliveira AS, Moraes TM, RHODIA-CREMS, Av. das Nacoes Unidas 22428, SP-SP, Brazil, 05477-000

Aim of Investigation: To offer a basic education program in acute pain management for nurses in hospital settings of principal hospitals in Sao Paulo, in order to improve the quality of nursing care of patients who suffer from acute pain.

Methods: This program is being offered for the first time during 1998, by the RHODIA CREMS to 16 hospitals (4 public, 6 private, 6 teaching). Our nursing team provided 4 hours training to 974 nurses. Our course objectives included: current theories of the anatomical, physiological basis of pain and analgesia; psychosocial and environment factors which contribute to the pain experience: assessment of pain and efficacy of therapeutic strategies; roles of pharmacological and non-pharmacological approaches; responsibilities of nurses in acute pain management.

Results: 318 (32.6%) of nurses answered the questionnaires. Most of them, 88%, considered the subject of acute pain very important. Concerning the place of the course the majority, 98% of nurses, reported the advantages of having training in the same place of work. To 80% of nurses the theoretical material was considered excellent. Duration of the course was considered appropriate.

Conclusions: Experience to date suggests that this program is a powerful strategy for educating nurses in a hospital setting about acute pain management.

ADVANCED PRACTICE NURSE ROLES IN PAIN MANAGEMENT: THE CANADIAN EXPERIENCE.

S. Musclow'. M. Sawhney²*, J. Watt-Watson³, 'Scarborough General Hospital; ²The Toronto Hospital; ^niv of Toronto, Toronto Ontario, Canada

Aim of Investigation: To describe the qualifications and responsibilities of advanced practice nurses (APN) working in acute pain management in Canada.

Methods: APNs from across Canada were mailed a 6-page self-administered questionnaire consisting of fixed choice and open-ended questions. An initial pilot study was conducted with 10 APNs working in acute pain management in adult and pediatric settings in the Toronto area.

Results: Pilot data indicated that all APNs had a minimum nursing baccalaureate degree and 70% had a graduate nursing degree or were completing graduate education. Most graduate content included formal pain content. All APNs worked in Univ affiliated hospitals. Most nurses identified a dual reporting responsibility to both nursing and anaesthesiology and proposed that there were both benefits and challenges with this arrangement. Role responsibilities varied related to the inclusion of research expectations and anaesthesia and sedation therapies. Independent decision-making was valued by all nurses although interdisciplinary collaboration, particularly with the anaesthesiologist was also important.

Conclusion: Pilot data showed that most APNs working in acute pain management had graduate education that included pain content. Common role expectations included administrative, clinical, educational and research and/or quality improvement monitoring responsibilities. The pilot study confirmed the reliability and validity of the methodology and questionnaire. The larger study is now in progress and results from the completed study will be presented.

IMPLEMENTING EVIDENCE BASED PAIN MANAGEMENT: A RANDOMISED CONTROLLED TRIAL TO ASSESS THE EFFECT OF INTRODUCING AN ORAL ANALGESIC LEAGUE TABLE ON PATIENT OUTCOME AND STAFF KNOWLEDGE

Kate Seers. Dawn Carroll, Sarah Richards*, Nicola Crichton*, RCN Inst, Radcliffe Infirmary, Oxford, 0X2 6HE UK

Aim of Investigation: To determine whether introducing an oral analgesic league table based on systematic reviews as part of an evidence based practice (EBP) approach to pain management can reduce patients' pain and improve staff knowledge.

Methods: Randomised controlled trial. Baseline scores for postoperative pain, pain relief and analgesics were obtained via interview and chart review of 120 patients on four surgical orthopaedic wards. Forty nursing staff on these wards were interviewed to assess knowledge and views about EBP and pain management. Wards were then randomised to either continue with normal care 01 participate in an intervention, which included four interactive teaching sessions outlining the principles of EBP and discussing the analgesic league table. Research on the best way of implementing this evidence was utilised. Outcomes will be reassessed three months after the intervention by a researcher blind to treatment allocation,

Results: Patients' baseline scores showed pain control was similar across the four wards. Mean "worst" pain on a 0-10 scale was 6.1 (SD 2.9). There were 22 different types/doses of oral analgesics administered, some with a high Number Needed to Treat. Staff interviews suggested they were unclear about EBP, and felt knowledge on this and pain management could be enhanced.

Conclusions: There were areas of pain management that staff wanted to develop and they were keen to implement the oral analgesic league table. Details of the intervention and its effect on outcomes will be presented.

Acknowledgments: Funded by RCN Institute

MULTIDISCIPLINARY TREATMENT OF NON-ONCOLOGIC CHRONIC PAIN

Sara Bistre. Margarita Araujo, Pain Clinic. The American British Cowdray Medical Center, Mexico City, 01120 Mexico.

Aim of Investigation: To present the results ofmultidisciplinary treatment of a group of 140 patients suffering from non-oncologic chronic pain at the Pain Clinic of Mexico City's American British Cowdray Medical Center.

Methods: The analysis is based on the systemic examination of medical files of 140 patients that attended our Pain Clinic. The entire group had suffered pain for over three months, previously diagnosed and treated, without success. All of them were evaluated by the different specialties of our clinic: Psychiatry, Internal Medicine, Anaesthesia, Neurology, Neurosurgery, Traumatology, Family Medicine, Psychology and Physical Therapy. Results: Chronic pain affected both women and men of all ages, socio-economic level, occupation, religion and marital status, predominating in high income, catholic, married housewives. The group's average intensity of pain (measured by VAS) was 7.7. An overwhelming majority of patients, 90%, were diagnosed and treated for pain caused by organic factors, predominantly back pain. The other 10% was related to psycho-somatic factors. We found depression in 57% of the group. The majority had taken NSAIDs. Some of them had undergone surgery, blocks, physical therapy and alternative medicine.

Conclusions: Integral, multidisciplinary treatment yielded positive results in 50% of the patients. The combination of various therapeutic approaches proved successful. Therapy was based on the simultaneous application ofetiologic treatment with analgesic support, the most frequently prescribed were opioids and antidepres-sants. Also different types of physical therapy, blocks, psychological support and in some cases surgical interventions.

A DAY-CARE PAIN CLINIC - FIRST RESULTS

Ingrid Gralow. Albert Hurter*, Cilly Schwerdt*, Pain Clinic, Dept ofAnaesthesiology and Operat. Intensive Care Medicine, Univ of Munster, Albert-Schweitzer-Str. 33, 48129 Munster, Germany

Aim of Investigation: The first day-care unit for pain patients in Germany provided a multidisciplinary treatment program for 3 weeks, based on a psychosomatic concept. The clinical experiences were described.

Methods: During the first two years 155 patients with chronic pain have been treated. Bio-psycho-social data were assessed with in- ! terviews and questionnaires. Psychodynamic relevant biographic j and actual stress factors and the style of conflict solving were j specified. Outcome criteria were assessed at discharge and at fol-,' low-ups after 6 and 10 months. Statistical analysis used the independent samples t-test.

Results: Patients, 46 years old on average, 66% of them female, were mainly suffering of low back pain and headaches. The classification for chronicity showed 72% as being in advanced chronic stages, in former studies correlated with poor prognoses. More than 80% of them showed psychogenic stress factors and most frequently a depressive style of conflict-solving. At discharge there was significant change in the severity of pain, but more considerable improvements in somatic and psychic well-being. Follow-ups showed changes in improvements in accordance to the stages of chronicity.

Conclusions: The first initial clinical experiences show that the day-care unit provides a noticeable improvement in patient care and constitutes an excellent link between the out- and inpatient therapeutic possibilities. But problems of defining long-term outcome criteria for efficacy of pain treatment in a bio-psycho-social concept needs further discussion.

Acknowledgments: Supported by the Federal Minister of Health.

TAPED CONSULTATIONS IN THE PAIN CLINIC

John Lamberty*. Beatrice Sofaer and Dympna Copley*. Pain Management Unit, Hove Polyclinic, Brighton NHS Trust, BN3 7HY UK.

Aim of Investigation: To evaluate the use of taped consultations with patients in the pain clinic during the first appointment with the consultant.

Method: Following the taped consultation with each new patient, the audio tape was taken home by the patient. A questionnaire was sent to each patient to assess their (a) understanding of their condition,^) interpretation of the meaning and implications of the diagnosis, (c) knowledge of possible treatments and (d) attitude in relation to future activities.

Results: 77 questionnaires were analysed. For 97% of respondents this was their first experience of a taped consultation. Of the total sample 80% felt it enhanced communication. Only 8% didn't listen to the tape at home, 35% said they were unclear about the diagnosis before coming to the pain clinic and over 50% said the tape had made some difference to their understanding of the pain. The majority recommended the use of the tape. There was a reduction in pain scores on average following the visit but this may have been due to pain treatments being instigated.

Conclusions: On an individual basis patients obviously appreciated having the consultation taped. It is not possible to attribute pain reduction to this, but it is speculated that in the long-term "being understood" by the physician would be beneficial to patients' well-being.

TELEPHONE FOLLOW-UP OF PATIENTS WITH CHRONIC PAIN.

Susanne Samuelsen* (SPON: Niels-Henrik Jensen), Multidisciplinary Pain Centre, Herlev Univ Hospital, 2730 Herlev, Denmark

Aim of Investigation: To describe and analyse the verbal nursing care by telephone follow-up and the consequences these may have for the patient.

Methods: Qualitative study divided into 2 parts: 1) Fieldwork fo-cussing on the verbal communication of the nurse doing telephone follow-up; and 2) Qualitative semi structural interviews with the nurses involved and with 6 patients.

Results: Three nurses, 3 patients with malignant pain and 3 patients with non-malignant pain entered the study. Temporary results indicate that the verbal nursing care by telephone is based on professional active listening and exchange of most possible information. The nurse poses questions to the patients in a careful and structured manner. The topics of the telephone follow-up are typically pain, pain control, administration of the medication and its side-effects, activities, sleep, obstipation, nausea, nutrition and fatigue. Conclusion: The investigation indicates that professional nursing telephone follow-up is an important supplement to the treatment at the Pain Centre. The quality of care is improved by telephone follow-up and is used by the nurses to clarify and relieve different problems for the patient related to living with chronic pain. The study doesn't yet answer whether the patient's compliance to the treatment and self-management in daily life with pain is improved.

Acknowledgments: Supported financially by Novo Nordisk Foundation.

RECENT ADVANCES OF PAIN CLINIC IN CHINA

Li Sheng Zhang, Journal of Pain, 4th Affiliated Hospital, Hebei Medical Univ, Shijiazhung, Hebei, 050011, P.R.China

Aim of Investigation: To introduce the recent history of pain clinic and its new development in China.

Method: Collect all of the articles published in my journal of pain and review the new development.

Results: Since the first national congress held in 1988 many pain clinics have been set up by anesthesiologists. The nerve blocks we used are trigger point, epidural sacral, stellate ganglion, paraverte-bral trigeminal, coeliac plexus successively. Drugs used for injection are lidocaine or bupivacaine and prednisolone, dexamethasone or limethasone. Total dose must be limited to the minimum. The effect of vitamins is unconfirmed. As an adjuvant to three step analgesic ladder neurolytic drugs are sometimes used if the effect of analgesics is not enough or its dose is too high. Epidural methyl-ene blue is used recently but rare, with which pain relief lasted 14 hrs. Oral or hypodermic ketamine is also used. Nerve block with mitomycine is effective for cancer and intractable pain. Acupuncture and Chinese medicinal herbs are very popular for treating pain. Angina pectoris with epidural block is also reported in China.

Conclusion: Combinative method for pain relief is the best choice.

PREPARING TO IMPLEMENT CLINICAL GUIDELINES FOR THE ASSESSMENT AND TREATMENT OF PAIN IN THE ELDERLY: FINDINGS FROM A CHRONIC CARE FACILITY

Nancy Bol*. Heather Whittle*, Maggie Gibson, David Keast*, Luis Viana*, Jill MacLean*, Parkwood Hospital site, St. Joseph's Health Centre, 801 Commissioners Rd E, London, Ont., Canada N6C5J1

Aim of Investigation: To establish a baseline for current pain assessment and management practices within a 370 bed chronic care facility serving elderly Canadian war veterans.

Methods: 45% of hospital charts were audited for pain-related information. The clinical audit tool was derived from the Clinical Practice Guidelines/or Managing Chronic Pain in the Elderly published in 1998 by the American Geriatrics Society (AGS). Charts contain the past month's interdisciplinary team (1DT) progress notes, in addition to admission and consultation reports. All charts include the Medication Administration Record (MARS) and geriatric assessment data collected using the government-mandated Minimum Data Set (MDS).

Results: 165 charts were audited, representing 158 male, 7 female residents aged 65-95 years (M=79; s.d.=5.6). Pain diagnosis and/or conditions associated with pain (e.g., osteoarthritis) were recorded in 76% of charts. MDS data documented daily pain in 24% of charts, pain less than daily in 19%. 27% of charts included formal pain assessment reports, authored by a variety of IDT members (Physicians, Nurses, Behaviour Therapists, Occupational Therapists, Physiotherapists, and the Pharmacist).Treatment plans were recorded in Nursing Cardexes (10%) and/or the IDT plan of care (22%). 16% of residents were receiving opioid therapy. Few non-pharmacological pain control interventions were documented.

Conclusions: Audit results indicate congruence between current practices and the AGS Clinical Practice Guidelines in principle: practice deficiencies only (no practice discrepancies) were identified. Practice deficiencies will be addressed from a continuous quality improvement perspective, targeting processes that impede compliance. Our experience highlights the value of clinical audit in preparing for implementation of clinical practice guidelines within an established service venue.

COST ANALYSIS OF OPIOID ADMINISTRATION IN THE LONG-TERM CARE SETTING

Robert J. Chaponis*. R.K. Elswick, Jr.*, Barbara Chamberlain* (SPON: Ming Gao Shi), Center for Health Information, 3101 American Legion Rd, Chesapeake, VA 23321, USA

Aim of Investigation: To determine the labor time and costs associated with administering and completing controlled substance records of selected solid oral opioid agents in the long-term care setting.

Methods: Trained observers measured the time required to complete administration and documentation pathways for solid oral opioids in one nursing facility. The average compensation for nurses at the site was combined with the time-motion analysis to determine the cost per administered dose. The costs of selected opioids were obtained from 1998 Redbook® average wholesale prices for unit-dose preparations. The daily and monthly costs of administering and completing requisite documentation were computed for a controlled-release (CR) formulation ofoxycodone (OxyContin®) dosed Q12h and selected short-acting combinations, oxycodone-acetaminophen (Percocet®) and hydrocodone-acetaminophen (Lortab®, Vicodin®), dosed 1 or 2 units Q6h. Results: Total daily and monthly costs for nursing administration and documentation were as follows:

Conclusions: The application of time-motion research to determine total costs of opioid administration and associated documentation demonstrated an advantage for a Q12h regimen ofCR oxycodone 10 and 20mg tablets over several short-acting opioid agents.

Acknowledgments: Support for this study provided by Purdue Pharma L.P., Norwalk, Connecticut.

EVALUATION OF THE PRESENCE OF PAIN IN HIV/AIDS PATIENTS IN SPECIALIZED PUBLIC UNIT

M.L. Nobrega. M.J. Teixeira*, M.H.0. Leite*, B.A.D. Gasparini*, D.E. Uip*, H.A. Ashmawi. Divisao de Anestesia, Clinica de Molestias Infecciosas, Clinica Neurologica Hospital das Clinicas-FMUSP, Sao Paulo, SP, Brazil

Aim of Investigation: At the end of the twentieth century it is anticipated that 40 to 100 million people be infected with HIV and 10 million will develop AIDS. The aim of this work was to find the pain incidence in HIV/AIDS patients treated in a specialized unit for the disease.

Methods: 300 patients were interviewed. A questionnaire evaluated pain occurrence and characteristics, use of analgesics in the two weeks previous to the interview. The Institute Gustave Roussy Questionnaire was used.

Results: Pain occurred in 44.33%. Pain characteristics: burning, shooting, tingling and boring pain and numbness. Pain locations: lower limbs, lumbar region, head, chest. Neuropathies, CNS infections, muscleskeletal and rheumatological abnormalities were causes related to pain. Anxiety and dullness were present in more than 50% of the cases. 29.33% used analgesics, 36% of them referred relied of more than 50% of pain intensity. Quality of life improvement after medications was referred by 31%. 19% of the patients knew the existence of pain specialists.

Conclusions: The incidence of pain is high in HIV/AIDS patients. The consumption of analgesics is relatively low by the patients, and its use seems to be incorrect by the low rate of relief achieved. Popularization of existence of professionals specialized in pain treatment should be sought.

EVALUATION OF THE DIRECTION OF HIV/AIDS PATIENTS WITH PAIN TO THE PAIN SERVICE IN SPECIALIZED UNIT

ML Nobrega, HA Ashmawi, MJ Teixeira, MHO Leite, DE Uip. Pain Clinic, Hospital das Clinicas FMUSP, Sao Paulo, SP, Brazil

Aim of Investigation: HIV/AIDS patients with pain need treatment, provided by infectologists or pain services. The interaction among infectologists and pain services needs to be studied. This study tried to find the frequency of directing patients to the pain service, how infectologists treat pain in AIDS, when they send them to pain service.

Methods: All patients sent to pain service in three months penod were classified. 300 Aids patients were interviewed on pain presence in the two previous weeks. 18 infectologists were interviewed on treatments of pain, causes of patients' direction to pain service.

Results: 1.04% from 1447 patients were sent to pain service. Pain was referred by 44.33% of 300 patients interviewed. Improvement of pain occurred in 36% of the patients that used medications. All infectologists prescribed NSAID, 61.1% opioids, 55.5% antide-pressants, 38.9% benzodiazepines. They sent patients to pain service because of inadequate analgesia (94.4%), associated diseases (33.3%), reluctance to prescription (27.8%).

Conclusions: There was great difference between the patients' frequency of patients sent to pain service and the index of patients with pain. NSAIDS and opioids were mainly used. There was low rate of improvement of pain with the therapeutics used by infectologists. Educational programs headed to infectologists should be accomplished for better treatment results, and more interaction with the pain service.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.474

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