Nurse Led Pain Service at Mayo University Hospital

Written by Joanna Fahey Clinical Nurse Specialist CNS p, RGN, RM, RNP, MSc In Pain Management

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” Chronic pain is a major health issue for our patients, their families and us as healthcare professionals who care for them. Inadequately managed pain can lead to adverse physical and psychological patient’s outcomes for individual’s patients and families. Effective management of acute pain is key to prevent chronic pain.

According to a study (PRIME 2011) which looked at the prevalence, impact and cost of chronic pain, it is a significant health problem in Ireland with up 1 in 3 people experiencing chronic pain, at some point in their life. The cost of chronic pain per patient was ¤5,665 per year extrapolated to ¤5.34 billion or 2.86% of GDP per year. The current/ post COVID-19 pandemic also poses a challenge as an increase in demand for chronic pain services may occur with patients potentially developing post viral pain syndromes.

Acute Pain Service was developed in Mayo General Hospital (MGH) in 2007 to address the needs of patients with acute pain, including postoperative pain. Currently in Mayo University Hospital (MUH) a Clinical Nurse Specialist Ms Joanna Fahey, leads a Consultant anaesthetic supervised acute pain service. Nurse-led rounds have emerged as a promising strategy to foster patient engagement, improve communication among healthcare team members, and optimize patient care delivery. Nurse led pain rounds at Mayo university Hospital has given me significant experience working in the acute setting and recognises the patients always comes first. I am passionate about ensuring patients receive the best high quality care that meets their needs in a timely manner, I have the expertise and experience to deal with patients who are suffering in acute pain in the acute setting. I can assess, reassess and manage patient care to ensure the highest standard using evidence based practice, care planning approach.

I can plan, Implement and coordinate and evaluate care in collaboration with the patient, the family and the Multidisciplinary team. As a Clinical Nurse Specialist, I have a unique role in that I always get to have bedsides conversations with the patients and optimise their pain relief reducing their stay in hospital.

I began my nursing career in Beaumont hospital in 1999 in participation with RCSI and DCU, I moved to MUH in 2004 and has been at MUH for 20 years. I worked in theatre for over 10 years and this is where I found the labour of love for pain managements and completed my Masters in Pain Management in UCD under the late Professor Laserina O’ Connor. I was luckily enough to have had Laserina as my lecturer in UCD, she was an engaging and inspiring educator who was a bright light in advancement of pain nursing profession.

Laserina O’Connor was a registered advanced nurse practitioner (RANP) and registered nurse prescriber (RNP) in pain management. She led an MSc Advanced Pain Management / Prescriptive Authority Program, a Professional Certificate in Pain Management, a CPD ‘Developing Acute Pain Champions’ and a Diploma in Diabetes Nursing. She was also President of the Irish Pain Society, the first registered nurse appointed to this position. Laserina’s lasting influence on the pain nursing discipline has affected many of her students and colleagues alike.

Mayo University Hospital is a 362bed hospital, with 5 directorates, including the Peri-operative division and a maternity service and then orthopaedic dept. The Maternity ward within MUH has one of highest acuity level with on average 50 women undergoing a Lower Segment Caesar Section (LSCS) in a month. Irish caesarean section rates currently averaging 1 in 3 births (a combined rate for first and subsequent mothers of 36.6%), and much higher in some units, and climbing rapidly (AIMS Ireland 2024).

Surgical birth is major abdominal surgery which poses immediate short and long term health consequences for mother, infant and all future pregnancies. Caesarean section pain is associated with moderate to severe post-operative pain which can influence post-operative recovery and patient satisfaction as well as breast-feeding success and mother-child bonding.

Pain after caesarean section can be related to at least two components, somatic pain from the wound incision and visceral pain from uterine contractions. Relief of acute pain after LSCS represents a major therapeutic challenge as postoperative pain hinders early mobilization and rehabilitation with consequences on duration of hospital stay and overall recovery. Utilizing our proposed analgesia fast track regime for women have proved successful showing reduction in post-operative length of stay (LOS), shorter convalescence and rapid functional recovery with subsequent economic savings. Our data suggests the practice of a multimodal approach to post-operative analgesia and that the use of Diclofenac 100mg PR/ PO 50mg in conjunction with paracetamol (Oxynorm/ Tapentadol if required) provides effective postoperative analgesia.

A recent audit carried out on the use of rectal diclofenac for postop lower segment caesarean section pain: An audit examining compliance, complications and efficacy, 43 participants, with a mean age of 34.5, were recruited: with 32 participants prescribed as per FAST-TRACK. Non-adherence to prescribed post-op analgesia was reported in 11 participants. The anaesthesia team were responsible for 2 cases of nonadherence – 1 (0.43%) patient had an allergic reaction to paracetamol, 5 (2.15%) patients refused diclofenac per rectum and took oral diclofenac, 2 (0.86%) women had a post-partum haemorrhage (>1000mls) and did not receive diclofenac on the day of delivery but once bloods were checked the next day and bleeding had resolved received PR diclofenac. Side effects were reported by 2 (0.86%) women, 1 reported angio-oedema and a rash on day 2 (however this lady stay was extended due to ongoing rash secondary to an antibiotic allergy) and 1 (0.43%) reporting diarrhoea.

A median pain score of 1 (0-10) and median pain satisfaction of ‘very satisfied’ (satisfied – very satisfied) was reported. The audit was carried out by Professor Michelle Duggan consultant anaesthetist and Joanna Fahey. Mayo University Hospital has achieved significant standardization in post-operative pain management. Anesthetists have initiated evidenced based management strategies improving outcomes. These strategies are based on the PROSPECT guideline for elective caesarean section.

The occurrence of pain symptoms is one of the primary reasons to seek healthcare in the general population especially in the Orthopaedic department. Over 90 patients per month attend an injection clinic under the Orthopaedics service.

Currently the Orthopaedics service access and delivers most of the interventions for chronic back pain with some input from anaesthetics and radiology. The orthopaedic service offers epidural injections and Steroid Injection an adjuvant pain modality. The significant burden of chronic pain highlights the need for cost effective interventions to reduce long-term disability. The injection service had a high satisfaction rate among patients allowing them to return to functionality and return to work/ sport and reducing the socioeconomic burden.

However, the waiting lists are long and repeated injections are not often conducted in a timely manner, going against the HSE strategy of providing safe effective care in a timely manner. One of the main issues the Orthopaedics department within in Mayo University Hospital (MUH) was the lack of an integrated treatment space and/or adequate time slots for clinics. As part of the reconfiguration of services in the hospital, the development and integration of St Johns unit was used as a potential solution to this lack of room availability service in the MUH area allowing the orthopaedic access to twelve beds for injection service.

Utilization of St Johns on Saturdays have been phenomenally successful for the following reasons:

• All appointments are confirmed to validate appointments.
• Instructions from the orthopaedic office staff are friendly and helpful (the patients always know the name of the office staff)
• St Johns unit is easily accessible, especially for those with physical adversity
• Minimal wait times
• The waiting room is clean and comfortable
• Offering appointments on Saturday offers more flexibility for patients who require a lift, do not need to take data off work/college, and not an early appointment
• Consequently, this has yielded positive feedback being acknowledged by the office staff
• Finally, the utilisation at St Johns has reduced the waiting list.

I am immensely proud to have been part of such a successful project which has led to delivering safe and effective patient care.

The patient who is in pain is central to every decision I make or propose to make in relation to their care.

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