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Journal of Pediatric Hematology/Oncology:
doi: 10.1097/MPH.0b013e3182121a45
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Optimizing Pain Care Delivery in Outpatient Facilities: Experience in NCI, Cairo, Egypt

Hameed, Khaled Abdel MD

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Author Information

Head of Pain Management Unit, NCI, Cairo University

Reprints: Khaled Abdel Hameed, MD, Professor & Head of Pain Management Unit, National Cancer Institute, Cairo University, Cairo, Egypt (e-mail: k24mostafa@hotmail.com).

Received January 11, 2011

Accepted January 24, 2011

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Abstract

As a result of increasing waiting lists of patients attending National Cancer Institute of Cairo, we are faced to provide high-quality pain care service through our outpatient pain clinic. The program description presented here shows the capacity of a 24 hours/7 days outpatient cancer pain management service to provide rapidly accessible, high-quality care to patients with complex pain and palliative care symptom burdens. In addition, this model avoids inpatient hospital admissions. Pain clinics of cancer are committed to helping patients and families identify and implement the treatments necessary to achieve optimum functional ability and the best possible quality of life. These clinics also help to communicate and work with the family physician, surgeon, and other physicians associated with patient treatment. Cancer pain is complex in its causes, and affects all parts of the body. It involves the tissues, body systems , and the mind. Being multidimensional, it is never adequately addressed with unidimensional treatment. Pain management must extend beyond physical approaches to include the psychological, social, and even spiritual aspects of the patient. Effective integrated treatment fosters self awareness and teaches appropriate and effective self care. With time, complex issues are managed, pain is reduced, and the patient moves toward peak physical and psychological functioning. These goals can be achieved by providing the highest quality pain management services. Patients attending the clinic get treated medically for their physical ailments. Their emotional and psychological problems also need to be attended with an atmosphere of love and care. The mission of the highest quality service is to obtain customer satisfaction with reduction of cost in a multidisciplinary (or better interdisciplinary) approach. This can be reached by proper identification of the customers either internal or external, assessing their needs, and implementing plans for their satisfaction. In addition, monitoring the improvement of such plans is an integral part of the quality process. Importantly, the facility provides comprehensive care with professionals available 24 hours/7 days. On-call teams assigned to manage pain and other treatment modalities comprises of staff supervised by the primary cancer clinicians; this arrangement facilitates reaching this goal. This study will illustrate our experience through 25 years, trying to provide the highest care of patients with cancer pain on an outpatient basis.

National Cancer Institute (NCI), Cairo University is one of the biggest academic and clinical centers dealing with cancer in Middle East. As it is the main reference in Egypt, it receives cases from other medical facilities all over the country. Therefore, the number of attending patients exceeds the maximum capacity of the hospital beds, and there are waiting lists always present.

Consequently, the high management council decided to depend on some outpatient clinics to supply high-quality service to the patients with minimal admission rates. Our pain clinic was one of them, and accordingly we had to manage optimally without an inpatient palliative care ward.

It seems intuitive that easily and promptly accessible outpatient cancer pain management may be associated with improved care quality and greater patient satisfaction. However, few studies have specifically assessed models for optimal delivery of cancer pain management. In most clinical settings, local emergency rooms function as de facto after-hours clinics for cancer pain emergencies. Often, emergency room visits for cancer pain problems lead to inpatient admissions and significant increases in health-care costs; however, this strategy does not necessarily result in a better quality of pain management or a higher level of patient satisfaction.1–3

At the beginning (more than 25 y ago), we tried many models to discover our customers and their needs, and did our best to satisfy them. Each model was applied for 3 months, which was then evaluated by the quality team to know the strong and weak points and it was remodeled accordingly till we reached the present model.

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THE PRESENT MODEL

We knew from our experience that to attain quality, we must believe and apply the universal philosophy of pain and then do brainstorming to identify customers, execute the mission, implement required features and how to achieve the same, and finally identify accurate indicators of measurement. Needless to say , this will lead to cost reduction.

Clinical philosophy of cancer pain management

1. Believe that Please verify that “believe” is to be retained.each patient's pain report is valid. Our approach to assisting the patient is driven by this basic assumption.

2. Treat each patient with dignity, acknowledging their perception of pain and accepting their cultural, spiritual, and psychological values as their reality.

3. Primary goal is to assist the patient by wisely and skillfully managing their pain experiences, based on the patient's stated desire for pain relief.

4. Given the nature of facility, working with patients with major heterogeneous rapidly changing pathologies subjected to different kinds of treatment. Therefore, work to complete comprehensive pain assessment with reassessment at regular intervals, taking into account the patient's progress, must be the policy. This can only be accomplished using a multidisciplinary team approach.

5. Pain will be a component of the patient's interdisciplinary treatment plan. Educate all clinicians to assure competence in dealing with the cancer patient whose treatment is complicated by coexisting pain issues.

6. The role is to advocate for the patient to assist in achieving his/her recovery goal while providing relief from pain.

7. Must have a committee for ongoing examination of the work in treating patients with acute and/or chronic cancer pain. Competent quality indicators must be implemented Please confirm whether the change made to the sentence retains the intended meaning.and reevaluated on a regular pattern.4

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THE MISSION

Supply integrated Pain Management Program aiming to achieve the following goals:

1. Safe and effective pain management service for patients with cancer 24 hours/7 days a week across the entire spectrum of care in a multidisciplinary approach.

2. Customer complaint is markedly decreased nearly to about 0% complaints.

3. Patient and family education about the proper use and safety precautions of modalities used in their pain treatment to achieve 100 Please clarify “achieve 100% misuse.”% misuse.

4. Paramedics and junior medical staff should undertake educational programs to reach approximately 100% of educational goals. Please confirm whether the change made to the sentence retains the intended meaning.

5. Guidelines of policy and procedures used that must be matched to 100% of evidence-based documented practices.

6. Cost reduction as a net result of the above.

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THE CUSTOMERS

(A) Internal

Physicians, pharmacists, nursing staff, administration and medical record staff, marketing, purchasing, and management council.

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(B) External

Patients, family and family caregivers, external physicians, community, media, third party payers, and suppliers.

Features of high-quality service in outpatient facilities

1. Accurate identification of patient and his illness in all settings of care.

2. Easy and accurate scheduling and follow-up systems.

3. Easy access to ancillary departments.

4. Adequate number of staff with a comfortable working environment.

5. Organize policy, procedures, and guidelines of standards.

6. Safety and effective opioid therapy.

7. Highly educated and trained providers available during work hours and on call.

8. Easy communication and collaboration between staff members and with other specialties.

9. Active involvement in palliative care literature reviews and scientific activities toward the goal of maintaining best practice protocols for clinical use.

10. Continuous and careful monitoring for periodic reevaluation of the service.

To assure optimal pain management, formal means should be developed and used within each institution for proper identification of the patient and his illness. This will minimize any errors and facilitate obtaining patient feedback to gauge the adequacy of control. The patient must be correctly recognized in all settings in which patients receive care using the available information technology.

The staff number should be adjusted to the number of patients attending the clinic. The staff members must include on-site full-time equivalent clinical social workers, dieticians, specialized nurses, administrative assistants, pharmacists, psychiatrists, and pain management physicians. The on-call team comprises of pain management, chemotherapy, and surgery specialists; trained nurses; and social workers, and they must be present around the clock, 7 days per week. A hotline service is applied for easy access to the on-call team. This can help solve many problems through phone and without home visits.

The availability of a 24 hours/7 days on-call coverage for after-hours problem-based patient visits saves countless trips to emergency rooms, avoids hospital admissions, and apparently results in high rates of patient satisfaction. On-site health information and the ability to access electronic data further integrate this service.5 Patients are referred for cancer pain management consultation/treatment at various stages of illness by their attending oncologists. Initial consultations are registered by appointment during regular weekday hours. The on-call physician covers the service's active roster and rarely counsels new consultations for emergent problems after hours.

Optimal pain management requires the interaction of all members of the health-care team including the patient. A formal process should be developed to evaluate the quality of pain management across all stages of the disease and across all practice settings.

Quality pain management begins with an affirmation by health-care professionals that patients should have access to the best level of pain relief that can safely be provided. In any setting, the quality of pain control is influenced by training, expertize, and experience of clinicians. Practice settings vary considerably in size, complexity, resources, and patient populations. In addition, the goals of pain management may differ depending on the cause of the pain and the stage of the disease. Different pain management programs are, therefore, suitable in different practice settings, but the responsibility for pain management should always be assigned to the most knowledgeable, experienced, interested, and available clinicians to respond to patients' needs quickly.

The safety use of strong opioids in treating patients with cancer pain is very challenging. This may be due to the unique nature of the patient, different drugs and forms used, and the level of education and training of health-care providers in proper use of this group of drugs. Policy and standard procedures, which define the acceptable level of patient monitoring and appropriate roles and limits practice for health-care providers, should govern the use of specialized analgesic technologies.6

A cancer patient has many problems, which must be taken into consideration before and during opioid therapy to ensure safety: First, there is marked heterogeneity between them with regard to the causative pathologies and the general condition before therapy. Second, there are anticipated and nonanticipated changes that may occur in pain origins and organ dysfunctions during the progress of cancer. Third, patients experience deleterious effects of anticancer therapies on their general condition and organ functions and also possible drug interactions with prescribed opioids. Finally, the misbeliefs about the story of addiction must be corrected to be sure of continuity of therapy. However, a minority of patients have the risk of developing addiction, such as those with a history of drug abuse.7 They must be suspected and traced well during therapy. Therefore, the follow-up intervals must not be fixed but tailored according to the case. In addition, it is of great value to implement home visits and hotline services for disabled patients and in emergency situations.

Although morphine in different forms is still the main opioid used in initiation and maintenance therapies, there are many other opioids available nowadays with different pharmacologic and pharmaceutical profiles. Most of the modified release preparations have special precautions and guidelines, which must be followed and conducted to the patient and family caregivers. Proper drug, proper dose, proper route, and proper withdrawal must be strictly followed. It is of great importance to follow patients closely specially at the beginning of therapy to stabilize the dose and to manage side effects.8 Presence of 3 or more opioids in immediate and modified release forms and opioid antagonists are mandatory in cancer pain treating facilities to ensure proper treatment of any opioid emergencies and for successful rotation. In NCI Cairo, 3 tables are available for each provider. One is the list of available opioids, the second is the equianalgesic doses and the methods of conversion of each drug, and the third is the modified doses in hepatic or renal dysfunctions.

Health-care providers including physicians, nurses, pharmacists, social workers, and family caregivers must be educated and trained to use different opioids effectively and safely. In fact, there must be different categories of programs for each provider. Approved guidelines must be present and continuously revised according to the updated evidence and/or the acquired experiences.9 Periodic seminars and morbidity and mortality committees are useful tools to ensure optimal level of providing service. Last but not the least is the proper and accurate documentation of the patient, illness, pain, drugs, and side effects. The most common personal factors that increase risks during opioid therapy may be the following:

1. Failure to evaluate the patient, such as not obtaining a personal history or conducting a physical examination of the patient.

2. Failure to make any diagnosis and possible drug interactions before starting treatment with a controlled substance.

3. Failure to obtain outside medical records of the patient, to talk with practitioners who previously treated the patient, or to obtain any verification at all of the patient's condition.

4. Failure to establish goals for treatment (eg, reduction in pain, improvement in function).

5. Failure to suspect patient misbehavior or substance abuse (eg, no screening for addictive potential, no monitoring through treatment).

6. Failure to discontinue opioids in a safe way.8

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EFFECTIVE COMMUNICATION AND COLLABORATION

Clarity among professionals about what they can and will contribute (eg, who will coordinate pain management—the primary nurse and attending physician or a specialized pain control team).

Decision making that reflects the input and preferences of the patient and family, such as providing a number of pain control choices that include pharmacologic and nonpharmacologic options.

Contingency planning, including orders to avert or treat possible side effects; a range of analgesic doses to deal with varying pain intensity; ongoing follow-up of cancer-related pain problems; and clear directions about whom the patient or caregiver should notify if changes in the plan are required.10

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QUALITY CONTROL PROCESS

The following steps must be performed periodically to ensure continuous improvement of the process:

Choose control indicators.

Establish measurement

Establish standards of performance

Measure actual performance.

Compare standards.

Take actions on the difference

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ESTABLISHED UNITS OF MEASUREMENTS (INDICATORS)

1. Communications between internal customers.

2. Complete records and filing systems.

3. Access to errors of medications.

4. Education and training programs.

5. Communication and access to patients.

6. Response to hotline calls.

7. Arrival of on-call team.

8. Rate of morbidities and mortalities.

9. Rate of patient trips to the emergency room.

10. Rate of admission of patients.

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CONCLUSIONS

Our experience in NCI Cairo University for about 25 years showed that urgent, high-intensity cancer pain management and palliative care services may be delivered with great efficiency in an outpatient setting that avoids use of the emergency room and inpatient ward. We have not attempted to assess explicit patient and family satisfaction about this particular issue in a scientifically validated manner. However, we receive a great deal of anecdotal feedback from patients and families; these comments often compare our model favorably with clinical settings that lack a 24 hours/7 days infusion area. In particular, feedback centers on our easy access of services and our responsive and expert staff. In addition, patients and their families stress that avoiding unnecessary hospital admissions minimizes the impact of urgent pain/symptom management on the activities of daily living.

This model also maintains a close working relationship with different hospital management programs. Other clinicians routinely participate in the weekly meeting of our unit. At that time, information on all new patient consultations and all clinically active patients is presented. Such close collaboration illustrates our direct, effective process of sharing responsibility for patient care. This type of collaboration also promotes relatively seamless transitions from “active” antitumor therapy to hospice, particularly in relation to pain and symptom management regimens.

Indeed, the 24-hour, outpatient model depends on 2 assumptions that may seem anathematic to most hospital administrators.

First, operating an infusion center 24 hours/7 days makes business sense. The direct revenues associated with operating 24 hours/7 days instead of 12 or 16 hours of every 24 hours might not stand alone as a compelling business reason for this model. Rather, the clinical rationales—patient and physician preference with the care setting, control treatment decision making, efficiencies associated with access to medical records, staffing by advanced practice cancer clinicians—are the most compelling arguments for this scheme. However, the avoidance of unnecessary hospital admissions may contribute to the overall fiscal well being of the outpatient cancer center as it keeps patients as outpatients. Thus, this approach supplies a type of revenue stream loss prevention.

Second, the psychosocial and symptom management services and their associated costs are subsidized by therobustness of the larger care delivery enterprise; thisrepresents an incredibly wise administrative stance. Infact, we believe that this stance is rewarded bothbytheexcellence of the clinical services provided and bythesuccessful effort to retain individuals who otherwise would be admitted to inpatient care in most settings.

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REFERENCES

1. Miaskowski C. The next step to improving cancer pain management Pain Manag Nurs.. 2005;6:1–2

2. Abernethy AP, Samsa GP, Matchar DB. A clinical decision and economic analysis model of cancer pain management Am J Manag Care.. 2003;9:651–664

3. Miaskowski C. New approaches for evaluating the quality of cancer pain management in the outpatient setting Pain Manag Nurs.. 2001;2:7–12

4. Main CJ, Spanswick CC Pain Management: An Interdisciplinary Approach. 2001 Elsevier:93 . ISBN 0-443-05683-8

5. Dahl JL, Bennett ME, Bromley MD, et al. Success of the state pain initiatives: moving pain management forward Cancer Pract.. 2002;10(suppl 1):S9–S13

6. Cancer Pain Relief and Palliative Care. Technical Report Series No 804. 1990 Geneva, Switzerland World Health Organization

7. Whitcomb LA, Kirsh KL, Passik SD. Substance abuse issues in cancer pain Curr Pain Headache Rep.. 2002;6:183–190

8. Hanks GW, de Conno F, Cherny N, et al. Morphine and alternative opioids in cancer pain: the EAPC recommendations Br J Cancer.. 2001;84:587–593

9. Anderson KO, Richman SP, Hurley J, et al. Cancer pain management among underserved minority outpatients: perceived needs and barriers to optimal control Cancer.. 2002;94:2295–2304

10. Gattellari M, Butow PN, Tattersall MH. Sharing decisions in cancer care Soc Sci Med.. 2001;52:1865–1878

Keywords:

pain care service; pain clinic; pain management

© 2011 Lippincott Williams & Wilkins, Inc.

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