METHODS

CONCLUSIONS

RESULTSNeuropathic pain (NP) is common and debilitating problem in acute care. To address this problem, the Vancouver Acute Neuropathic Pain Treatment Guideline (VANPTG) was developed. It is a clinical protocol composed of screening all patients for NP using a modified DN4 (mDN4), prescribe initial treatment according to a treatment algorithm and initiate a consult to a pain expert. The mDN4 used in the study is shown below:

The objectives of this study were:1)To evaluate the effectiveness of the VANPTG (implemented actively –

knowledge translation strategies used to facilitate clinician behaviour change) for screening patients with NP compared to ‘Green Sticker’ (implemented passively – no knowledge translation strategies were used) and ‘Historical Cohort’;

2)To determine the incidence of NP in patients with acute traumatic spinal cord injury (SCI);

3)To evaluate the effect of the VANPTG on NP management.

Study Design: Pre- and post-test study design with retrospective data collection.Setting: SCI-specialized acute care unit (ASU) in a provincial tertiary care center.Sample: Randomly selected patients from Rick Hansen Spinal Cord Injury Registry (RHSCIR). Three cohorts were created based on the exposure to a NP-screening protocol: cohort 1 (no protocol), cohort 2 (“green sticker” protocol), and cohort 3 (VANPTG protocol). Protocol: 1) Nurses screen all patients with SCI every 12 hours using the mDN4.2) Upon obtaining a positive screen, treatment is initiated according to the

treatment algorithm. 3) At the same time as the initial treatment prescription, the patient is

referred to a pain expert (fellowship trained anaesthesiologist, a psychiatrist with a specialty in pain management, the Peri-Operative Pain Service anaesthesiologists and physiatrists) to confirm the diagnosis of NP.

Data Collection: demographic/injury data (e.g. age at injury, gender, mechanism of injury) from RHSCIR supplemented with detailed pain data (e.g. medication prescribed, date of initial NP diagnosis) abstracted from patient charts.Analysis: Adherence to the clinical protocol (e.g. NP screening every 12 hours, referral to a pain expert upon positive screen), incidence of NP and time to NP care milestones (e.g. first NP screening, positive diagnosis) were compared among three cohorts

Evaluation of a clinical protocol to screen, diagnose and manage neuropathic pain in patients with traumatic spinal cord injury in an acute care setting 1Lise M. Bélanger, RN MSN; 2Michael Negraeff, M.D.; 2Hamed S Umedaly, M.D.; 3Marcel F. Dvorak, M.D.; 4Andrea F. Townson, M.D.; 1Jenni Prince, RN MSc; 5Tian Shen, MSc; 3,5So Eyun Park, BMLSc; 3,5Vanessa K. Noonan, Ph.D. PT 1Vancouver General Hospital, Vancouver, Canada; 2Department of Anesthesia, University of British Columbia, Vancouver, Canada; 3 Division of Spine, Department of Orthopedics, University of British Columbia, Vancouver, Canada; 4Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada, 5Rick Hansen Institute, Vancouver, Canada.

The date range and number of participants included in each cohort is shown below:

Incidence of NP in acute traumatic SCI population was high regardless of the screening tool or reporting source used. Implementation of the VANPTG ensured routine and timely screening for patients with acute traumatic SCI. Lessons from this study highlight the importance of integrating outcome measures into clinical workflow along with a systematic implementation strategy to standardize practice.

SUPPORT: This project was funded by Western Economic Diversification Fund and Rick Hansen Institute.

INTRODUCTION

Ø

Historical(No protocol)

Passive Implementation(green sticker protocol)

VANPTG

Active Implementation(VANPTG protocol)

Neuropathic Pain Symptoms Score 1 Point for each Symptom

Burning/painful cold/electric shocksTingling/pins & needles/numbness/Itching

TotalHypersensitivity to Touch (allodynia) (Y/N)

Score of 3 AND/OR sig allodynia (NRS ≥ 4/10) = Positive Screen

Effectiveness of the VANPTG NP screening:Documentation of screening for NP was superior in cohort 3 (mDN4; 99%) compared to cohort 2 (green sticker; 0%); no formal screening was in place in cohort 1. Incidence of NP:The incidence of NP in cohort 1, 2 and 3 based on expert diagnosis (the gold standard) did not differ significantly (79% vs 82% vs 75%; p=0.68).

Effect of the VANPTG NP screening on pain management:The mean number of days from hospital admission to initial screening decreased in cohort 3 compared to the other two cohorts (5.10±5.69 vs 4.65±10.83 vs 3.71±5.68; p=0.001). However, the mean number of days from a positive diagnosis of NP to initial treatment was not significantly different (-0.19±5.77 vs -0.13±3.16 vs -0.10±1.39; p=0.24).

Cohort 1 Cohort 2 Cohort 30

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

66%70% 71%

53% 55%61%

72%

81%76%

0.4429

Incident of NP by Reporting Source

mDN4 Diagnosis

Non-Expert Diagnosis

Expert Diagnosis

% who Received NP Treatment

CONTACT: For questions or information, please contact Lise Bélanger at Lise.Belanger@vch.ca.