Survey: Re-opening of Chronic Pain Services during COVID-19

Limitations

Though there are significant limitations on thematic analysis of the data provided there were a number of emerging themes which are summarised. One limitation relates to the weight that should be given to an individual theme made strongly once or twice or when a number of respondents highlight a similar theme and also the management of conflicting views where a narrative analysis is provided.  It is clear that there is significant heterogeneity in activities and responses. The themes will be covered under the individual questions.  

Out-patient and related chronic pain services

Some respondents reported a decline in new patient referrals thought partly to be due to a reduction of patients being seen by other specialities.  Some respondents highlighted reduced numbers of injection procedures, reduced numbers of clinics as well as capacity within clinics such as for face to face appointments. Some centres stopped face to face appointments all together.  

“We are running at reduced capacity, due to loss of out-patient department rooms (reconfiguration to expand A&E assessment areas due to Covid), longer appts due to new technology and reduced list capacity due to social distancing measures, on top of dealing with a backlog in referrals.”

“My clinic room was taken away...during Covid and they are yet to allocate me a new room.”

In some units, whether appointments were undertaken face to face was determined by patient preference while some units used a screening or triage process.  Unsurprisingly, there was a switch towards telephone and other forms of remote consultation including video.  
A number of units highlighted a system where the initial assessment was being undertaken by video or telephone.  Much pain management programme activity was generally being reported to be undertaken virtually. It was reported that staff, although shielding or working from home, made positive and effective contribution to the service which helped to maintain restricted services.

In the section on changes to service, there was a strong theme related to pain management programmes not being undertaken face to face with respondents indicating pain management programme had either stopped or other systems were being used.   

“Wish to have remote PMP but don't have the software”

Urgent injections, such as those used in cancer pain work, continued albeit with significant problems with theatre availability.   The key themes relating to theatre lists were ones of reduction, avoidance of steroid and the issue of how pain procedures were prioritised for theatre time with other specialties.

“2 treatments lists per month for all 5 consultants who do interventions”

 A number of services had not resumed interventional procedures at the time of the survey.  Significant impact on spinal cord stimulator services was also reported.   A common theme was a reduced capacity for patients on procedure lists, due to longer turnover time with COVID infection control measures. Similarly, within clinics the impact of COVID measures and the need for social distancing adversely affected productivity. One unit reported significant numbers of pain consultants still seconded to anaesthetics.

“no F2F clinics, no steroid injections, no PMP, grossly reduced list sizes when we are intervening. Common sense seems to be a COVID victim”

In-patient services

Themes included reduced staff availability, but also mention of reduced workload (including reduced elective surgery) so high quality services could be maintained.   Changes in workforce involved themes such as the absence of consultant cover, or nurse ‘skeleton staff’ due to staff redeployment. There were interruptions in normal in-patient services. One theme was that there was reduced staff but also reduced workload so high quality services could be maintained.  There was a reduced demand for elective services.  Changes in workforce involved themes like ‘no consultant cover’ or nurse skeleton staff, with pain nurses still re-deployed as well as consultants to cover COVID-19.   There were interruptions in normal in-patient services. 

New activities and in-patient services

There was a consistent theme about using more remote methods for providing in-patient pain advice, including by telephone or by email. There was report of restricted epidural and nerve catheter services, with reports of more regional blocks being undertaken to avoid aerosol generating procedures in theatre. There was relocation of staff relating to COVID work, and various strategies to implement COVID screening.  One interesting innovation was the introduction of post-operative analgesic protocols for surgical trainees.  Several units still reported no in-patient services and this may link to the reporting of reallocation of staff. The need for education of new staff due to changes in wards arrangements was noted.  There was some utilisation of non-pain team members for in-patient services.  

New activities and out-patient services

Some of the themes here mirror responses already described in earlier sections.
Themes involved increased advice to GP’s and various forms of revaluation and reprioritisation of waiting list with triage.  With COVID, clearly strict infection control measures were required including themes of social distancing, reports of assistance where patients would wait in the car park until called and strict infection control in clinic.   There are reports of some clinics being run from home and a consistent theme of fewer face to face clinics.  One respondent reported shifting some review appointments to nursing staff or physiotherapists.  There was a consistent theme of increased remote consultations which was unsurprising with video and telephone consultations being one of the strongest themes.  Multi-disciplinary team meetings were reported to be done remotely. 
 

 “I think all at some point have missed F2F contact.”

“Video MDTS are useful and I would expect them to be ongoing but not as the sole method of the team getting together and face to face definitely missed.”

Some units had attempted to undertake remote pain management programmes. 

Effectiveness of video consultations

A negative impact of experience of video consultations included doctors stress and concerns of missed pathology. There appears to be genuine concerns regarding quality of patient service, with lack of examination, reduction in rapport, communication issues and fear regarding standard of care and ‘cutting corners’.

“There is a sense among us all that, at some point, we will miss serious pathology.”

 “There is no substitute for seeing patients and so video conference will never be as good”.   

“Video and telephone consults - these are the future….”

On the positive side, it was reported that some patients might feel less stressed being able to undertake consultation in the home environment.   Advantages of remote consultations for patients included that they would not have to travel to hospital, park and perhaps take time off work.   One respondent stated, “avoids half a day”.  The inability to assess body language and difficulty explaining complex concepts were negatives.  Another reported restriction was that relatives cannot join in if they are not living with the patient if shielding.   There were reported issues with translator services.

There was a theme that remote consultations were better for follow up consultations. There were difficulties in examination and sharing materials though some basics were reported to be possible and some diagnoses could be made.  Video consultations are good if all parties had decent computer equipment, access and level of knowledge to use it.  Significant technology issues reported included inadequate equipment or limitation of software and internet connection. 

Barriers to remote consultations

Barriers included patient willingness or refusal with some patients expressing preference for face to face.  One report indicated a majority of patients, when given the option, choose face to face.  The remote consultations were not viewed suitable for cognitive impaired patients and some elderly patients as well as some with mental health issues.   Some reports highlighted that examination is a key part of the assessment process and that the inability to examine was considered to be a problem for procedures.  There were practical barriers including inaccurate telephone numbers, incorrect patient details, patients not answering numbers and concerns about privacy.  The limitations of examination was repeatedly mentioned as well as themes of communication barriers for disabled or impaired for patients. A range of technological limitations and capabilities were recurrent themes.   There was a very strong theme of issues with technology raised by multiple fellows.  Problems with technology and internet are one of the strongest themes coming out from this survey.  

Provision of pain management programmes

There are limited number of responses in this area but one unit implied that there was no software to do the pain management programmes while another reported they were on hold.  Several reported that they were being done remotely.  Four units reported using online resources. 

Team safety

One respondent highlighted that the COVID risk was very specific to the theatre work in hospital setting and individual risk stratification.  The safety of travel and being at home were also mentioned.  Re-deployment was reported by some to be stressful and a challenge.  Some felt safe with PPE and COVID safety procedures while others did not.  Some respondents reported a lack of PPE early on. There were some specific bad experiences:

 “I caught COVID, was off work for three weeks…” 

“worry about possible lack of PPE took a toll on our mental health at the time when we were dealing with COVID patients…” 

“once surgery picks up and numbers of patients requiring input increases the team will be under significant stress”

Comparison between first and second survey

Some of the key changes between the first and second survey are highlighted in the key findings for reference.