ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence ZISOP The concept of the Centre for interdisciplinary

ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence

ZISOP ZISOP The concept of theThe concept of the

Centre for interdisciplinary pain Centre for interdisciplinary pain therapy, therapy,

oncology and palliative medicineoncology and palliative medicineUniv.Prof. Dr. Rudolf LikarUniv.Prof. Dr. Rudolf Likar

Pain Clinic, General Hospital KlagenfurtPain Clinic, General Hospital KlagenfurtKlagenfurt, AustriaKlagenfurt, Austria

IINTERDISCIPLINARYPAIN CLINIC

KLAGENFURT GENERAL HOSPITAL


Development and implementationDevelopment and implementation 1992 Establishment of interdisciplinary Outpatient Pain

Department (anaesthesiology, neurosurgery, neurology, orthopaedics, radiology) at Klagenfurt General Hospital

1992 Introduction of postoperative pain service and regional anaesthesiological procedures

1993 – 2005 Organisation (planning, concept, implementation) of the international pain congresses in Carinthia

1999, 2002, 2003 Co-Organisation of the Austrian Pain Congress

1996 Introduction of and cooperation in establishing the Outpatient Pain Department at Graz University Clinic for Anaesthesiology and Intensive Medicine




Interdisciplinary Outpatient Pain Interdisciplinary Outpatient Pain DepartmentDepartment

PurposePurpose

interdisciplinary cooperation for optimal management of inpatients and

outpatientsat Klagenfurt General Hospital

Pain:Pain:

Symptom of many different diseases,interdisciplinary approach essential




Fields of activity: Fields of activity:

chronic pain therapy and palliative medical management of outpatients and inpatients

postoperative pain therapy

preoperative regional anaesthesia techniques

postoperative pain therapy in recovery room (evaluation – patient survey 2000 in Austria)

concept “painless hospital”


Pain MeasurementPain Measurement

Pain on rest/on movement

VAS/NRS/VRS/KUSS and SMILEY

Twice daily

Documented on a chart


Treatment of the following Treatment of the following diseases/symptomsdiseases/symptoms

Postoperative pain Cancer pain Chronic forms of headache and facial pain (migraine,

tension headache, cluster headache etc.) Neuropathic pain (trigeminal neuralgia, post-zoster

neuralgia, phantom pain, central pain syndromes etc.)

ischemic pain (DST [Dynamic Sequential Thermography] III bis IV)

CRPS (Complex Regional Pain Syndrome = sympathetic reflex dystrophy and causalgia)

Chronic spinal pain syndromes Spasticity associated pain Pain due to central nervous disorders Psychogenic pain


Use of the following forms of Use of the following forms of therapytherapy

Oral and transdermal pharmacological treatments with analgesics and other agents used for chronic pain syndromes (anticonvulsants, psychotropics etc.)

Nerve blocks:a) reversible blocks (CT-guided, under

fluoroscopic control)b) neurolytic blocks (chemical and

thermal)

Radiofrequency cryotherapy (in cooperation with neurosurgery department): gasserian ganglion, peripheral nerves, facet joint denervation

Subcutaneous and intravenous administration of opioids with pain pumps


Spinal opioid analgesia (in cooperation with neurosurgery department)

a) Trial use with bolus injections, catheter with a portb) Implantation of medication pumps (volume flow controlled

gas-pressure pumps, electronically programmable pumps)

Spinal cord stimulation (in cooperation with Neurosurgery Department)

a) Implantation of epidural test electrodes in the screening phaseb) Implantation of pulse generators

Implantation of medication pumps for intrathecal baclofen administration in spasticity (in cooperation with neurosurgery department)

TENS

Acupuncture

Provision of psychotherapeutic support (pain-coping training, behavioural therapy) and learning of relaxation methods (biofeedback, Jacobson)


Pain TherapyPain TherapySymptomatic Treatment OptionsSymptomatic Treatment Options

Pharmacological Pharmacological pain pain

treatmenttreatment

Physical Physical therapytherapy

TENSTENSAcupunctureAcupuncturePsychologicalPsychological

therapytherapy

PhysiotherapyPhysiotherapy

InvasiveInvasiveproceduresprocedures


YearYear

1998 2001 2004 2007

Outpatients 587 804 1.750 2.150

Follow-up examination of an outpatient

2.386 4.047 5.9276.630

Consultation activities for inpatients:

5.529 6.490 7.019 9.190

2001: total 19.074 services2002: total 21.895 services2004: total 21.562 services2007: total 22.323 services


CT-guided blocks: 424 / 2001964 / 2004982 / 2007

Invasive procedures: 1,284 / 2001

1,950 / 20042.037 / 2007

(One-day surgical interventions).

25 to 30 SCS* (114.000 performance-oriented hospital financing points).

* Spinal cord stimulations

10 to 15 pain pumps (220,000 performance-oriented hospital financing points).

(hospital admission – Neurosurgery, Neurology, Orthopaedics and other wards).


CT-guided blockadeCT-guided blockade

epidurale blockadeepidurale blockade


CT-guidedCT-guidednerve-blockadenerve-blockade


CT-gezielte Blockadebehandlung


Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and

Pain Medicine 2006; Pain Medicine 2006; Vol. 31 No. 5 September – October 2006Vol. 31 No. 5 September – October 2006

Ultrasonographic cross-axis view with the needle at the groove of the transverse process adjacent to the superior articular process. SP, spinous process; TP,trans-verse process; AP, articular process; Lat,lateral; Med, medial


Ultrasonographic longitudinal paravertebral view with the needle at the cephalad margin of the transverse process. TP, transverse process.

Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Shim JK, Moon JC, Yoon KB, Kim WO,Yoon DM. Ultrasound-Guided Lumbar Medial-Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and Branch Block: A Clinical Study With Fluoroscopy Control . Regional Anesthesia and

Pain Medicine 2006; Pain Medicine 2006; Vol. 31 No. 5 September – October 2006Vol. 31 No. 5 September – October 2006


HLST_Code Type of Activity 2007 2008

IBL_7832 CONSULTATION WITH AN IN-PATIENT 10.174 11.417

IBL_7803 CLINICAL FOLLOW-UP EXAMINATION OF AN OUT-PATIENT 9.426 11.500

RZI_4774 Pain-pump check postop. 2.569 4.335

IBL_7425 AUTOMATIC MEDICATION APPLICATION 4.069 2.638

IBL_4550 PDA PER DAY postop. 3.117 2.801

IBL_3496 STANDARD MONITORING/epidural blocks,sympathetic blocks 2.308 3.046

IBL_8612 Acupunture 1.372 1.978

IBL_7782 First consultation with an out patient 1.400 1.069

IBL_8617 Lumbar nerve blockade CT guided 716 811

IBL_7825 Consultation with an out-patient 917 599

UNF_205 INFILTRATION 474 1.032

IBL_3490 PLEXUS ANASTHESIA 806 233

IBL_8614 INTRADERMAL 434 554

IBL_8613 TENS per day 309 470

IBL_8615 Cervical nerve blockade CT guided 134 203

RZI_5304 Facet blockade US guided 79 242

total 40.465 43.918


Interdisciplinary OUTPATIENT PAIN Interdisciplinary OUTPATIENT PAIN DEPARTMENTDEPARTMENT

CONSULTING ACTIVITIESChronic - 80 % cancer pain patientspain - 20 % chronic non-cancer pain syndromes

OUTPATIENT- 30 % cancer pain patients- 70 % chronic non-cancer pain syndromes

Acutepain postoperative pain therapy 2 rounds daily

Outpatients

• Referred by GP• Referred from other general hospital outpatient department• former inpatients


Interdisciplinary OUTPATIENT PAIN Interdisciplinary OUTPATIENT PAIN DEPARTMENTDEPARTMENT

INTERDISCIPLINARY OUTPATIENT PAIN DEPARTMENT

PATIENT GENERAL PRACTITIONERHOME CARE

PAIN CONFERENCES(intramural and district advanced training for physicians

and nursing personnel)

TRAINING OF NURSING PERSONNEL AND PHYSICIANS

International and national CONGRESSES


Interdisciplinary centre for pain therapy and Interdisciplinary centre for pain therapy and palliative medicine (ZISOP) Centre of palliative medicine (ZISOP) Centre of

Excellence Excellence (Austrian Pain Society) Klagenfurt General (Austrian Pain Society) Klagenfurt General

HospitalHospital• Anesthesia and intensive medicine• Neurosurgery• Neurology• Orthopaedics• Radiology• Physical medicine, clinical psychology, oncology,

surgery, radiotherapy, nuclear medicine

Outpatient department times: MO – FR 7 a.m. – 2 p.m. Tel. ++43 463 538 23720 Fax. ++43 463 538 23722




Palliative ward „local competence Team“

(14 Beds)

Out-patients

Out-patients

Out-patients

Out-patients

Family physician

Hospice Service

Out-patient home - care

Daytime hospice

Palliative Team


PALLIATIVE CARE DEFINITIONSPALLIATIVE CARE DEFINITIONS

Palliative care is the active, holistic care of Palliative care is the active, holistic care of patients with advanced, progressive illness. patients with advanced, progressive illness. Management of pain and other symptoms Management of pain and other symptoms and provision of psychological, social and and provision of psychological, social and

spiritual support is paramount. The goal of spiritual support is paramount. The goal of palliative care is achievement of the best palliative care is achievement of the best

quality of life for patients and their families. quality of life for patients and their families. Many aspects of palliative care are also Many aspects of palliative care are also

applicable earlier in the course of the illness applicable earlier in the course of the illness in conjunction with other treatments.in conjunction with other treatments.


Change of paradigm in palliative Change of paradigm in palliative carecare

Palliative Care cannot only be defined

by the stage of disease

but

by the actual needs of the

patient and his family


Number of Patients – palliative care Number of Patients – palliative care unitunit

0

25

50

75

100

125

150

175

200

225

2005 2006 2007

male

female

295 322 410


Diagnosis (in %)Diagnosis (in %)

0 10 20 30 40 50 60 70 80 90

malignant tumors

neurological illness

respiratory illness

chron. pain syndrome

other

2007

2006

2005


Reason for admittance (in %)Reason for admittance (in %)

0 5 10 15 20 25 30 35 40 45 50

Pain

gastroint. Sympt.

Fatigue

Social

Mobilization

respir. Sympt.

neurol. Sympt.

Radiation

wors. of general cond.

other

2007

2006

2005


Average hospital stay in daysAverage hospital stay in days

0

2

4

6

8

10

12

14

16

2005 2006 2007


Type of discharge (in %)Type of discharge (in %)

0

10

20

30

40

50

60

70

2005 2006 2007

to home care

to nursing home

to other dept. atgeneral hosp.

to other hospital

deceased


3 mobile palliative care teams3 mobile palliative care teams

– Interprofessional (physician, nurse, psychologist)

– Support of general practicioners and nurses, when palliative patients are at home or in nursing-home

– „bridge“ between palliative care unit and home care

– Project of Carinthian government, free of charge


Institutions of Palliative Medicine in Institutions of Palliative Medicine in CarinthiaCarinthia


The terminal patient may stay at home

in the last weeks of lifePalliative care

is available around the clockHe may die without pain

in the family circle



Course:Course:

• Decompressive laminectomy Th 7 and Decompressive laminectomy Th 7 and placing of fixateur interne placing of fixateur interne

• complete transection at Th 7complete transection at Th 7• weakness of the upper extremities following weakness of the upper extremities following

possibly old injurypossibly old injury

Patient, male, 62 years oldPatient, male, 62 years old


Intensive care 10.09.04 – 10.03.05Intensive care 10.09.04 – 10.03.05

Reason for hospitalization:Reason for hospitalization:

The patient felt tingling in both legs for The patient felt tingling in both legs for several hours and increasing pain in the mid several hours and increasing pain in the mid thoracic vertebral region. thoracic vertebral region.

Diagnoses:Diagnoses:• compression fracture Th6 and Th7 with severe compression fracture Th6 and Th7 with severe

compression on vertebra Th7 and compression of compression on vertebra Th7 and compression of the myelon, slightly less compression on Th6the myelon, slightly less compression on Th6

• marked COPDmarked COPD• osteoporosis associated with long-term cortisone osteoporosis associated with long-term cortisone

therapytherapy

Patient, male, 62 years oldPatient, male, 62 years old


Admittance with acute respiratory insufficiency Admittance with acute respiratory insufficiency Local infection at the operative siteLocal infection at the operative site- removal and reimplantation of material- removal and reimplantation of material

Difficulties in mobilizationDifficulties in mobilization- Decubitus sacralis (attempt at plastic - Decubitus sacralis (attempt at plastic

coveringcovering only moderately successful)only moderately successful)

Difficulties in establishing feedingDifficulties in establishing feeding- PEG tube implantation- PEG tube implantation

Delay in withdrawal of artificial ventilation, Delay in withdrawal of artificial ventilation, repeated episodes of pneumonia and repeated episodes of pneumonia and atelectasis atelectasis

- tracheostomy, weaning up to adjustment to - tracheostomy, weaning up to adjustment to home respiratorhome respirator


Admittance to palliative ward 10.3. – 25-03. Admittance to palliative ward 10.3. – 25-03. 20052005

• stabilization of general conditionstabilization of general condition• induction of future careinduction of future care• organization of home help for the organization of home help for the

patient and organization of patient and organization of antidecubitus mattress antidecubitus mattress

• organization of home respirator and organization of home respirator and oxygen supply serviceoxygen supply service

• introduction of the management by introduction of the management by mobile palliative teammobile palliative team



10 inpatient beds: partially implemented10 inpatient beds: partially implemented

for two patients with back pain,two patients with headache,two patients with neuropathic pain,two patients with articular or myofacial pain,two patients with lower abdominal pain (networking with obstetrics and gynecology)

5 part-time inpatient treatment places (interdisciplinary pain day-clinic)

14 beds for palliative ward (networking with interdisciplinary pain centre /

oncology)

Night duty up to 10 p.m. Area of responsibility: chronic pain therapy, palliative,

acute postoperative pain therapy


Mission statement – ZISOPMission statement – ZISOP We are a multiprofessional interdisciplinary team located in

Klagenfurt General Hospital – specialists under one roof.

We offer our patients individualised holistic care with curative and palliative intention with the aim of maintaining / improving quality of life.

We care for people with acute /chronic pain, malignant diseases and neurological illnesses.

Our research and teaching focus on improving people’s quality of life.

We are a team characterised by medical and human competence, openness, reliability, flexibility, tolerance and willingness to continuously learn and develop.

We aim at achieving high efficiency combined with the careful use of available resources.


THANK YOU FOR YOUR THANK YOU FOR YOUR ATTENTION!ATTENTION!

If you have any questions to this If you have any questions to this presentation please contact me per e-presentation please contact me per e-

mail:mail:

[email protected]@kabeg.at

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ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence ZISOP The concept of the Centre for interdisciplinary