The role of the psychologist in the inpatient pain service: development and initial outcomes.

AIM: This article describes the development and initial evaluation of introducing a psychologist role within an adult inpatient pain service (IPS) in a large North West of England National Health Service (NHS) trust. BACKGROUND: The role of a psychologist in the management of outpatient chronic pain has been well documented, but their role within the IPS is less well described and rarely evaluated. We describe the development of a psychologist role within the team and initial service evaluation outcomes. METHODS: Following an initial needs assessment, a band 8c psychologist joined the IPS one day per week offering brief one-to-one psychological interventions to people struggling with acute or chronic pain in hospital referred by inpatient pain team. The psychologist had an indirect role offering training, supervision and support to members of the inpatient pain team. Regarding direct patient work, following psychometric screening for pain-related disability and distress, a cognitive behavioural therapy (CBT) approach was applied including identifying unhelpful beliefs about pain, psychoeducation about acute and persistent pain, developing and sharing formulations, skills training including breathing and relaxation exercises and where appropriate, signposting onto an outpatient chronic pain services for further pain self-management advice (e.g. pain management programme. To explore the impact of this direct intervention, a prospective service evaluation with a controlled before and after design was conducted. This compared (a) number of admissions and (b) length-of-stay outcomes in the 12 months following psychometric screening for patients who received psychological input (n = 34, the treatment group) and a sample who did not receive input because of discharge before intervention or non-availability of the psychologist, for example, annual leave (n = 30, control group). Demographic information and summaries of psychometric questionnaires were also analysed. RESULTS: Of the sample of 64 patients, 50 were women, ages ranged from 18-80 years, 72% reported being currently unemployed or off sick from work and on screening and 39% and 48% met criteria for severe depression and pain-related anxiety, respectively. Hospital admissions in the intervention group reduced significantly (by 60%) in the 12 months following screening but increased (by 7%) for the control group (F(1,62) = 7.21, p = .009). Days of stay in hospital reduced significantly more (by 84%) in the intervention group than in the control group (by 41%) (F(1,62) = 8.90, p = .004). Illustrated case studies of brief psychological intervention with three people struggling with pain-related distress are presented. CONCLUSIONS: The psychologist became a valuable member of the multi-disciplinary IPS team, offering brief direct and indirect psychological interventions. While a relatively small sample, our prospective service evaluation data suggest brief psychological intervention may contribute to reduced length of stay and hospital admissions for people experiencing pain-related distress in hospital.

Effect of rectus sheath block vs. spinal anaesthesia on time-to-readiness for hospital discharge after trans-peritoneal hand-assisted laparoscopic live donor nephrectomy: A randomised trial.

BACKGROUND: The role of spinal anaesthesia in patients having a transperitoneal hand-assisted laparoscopic donor nephrectomy in an enhanced recovery setting has never been investigated. OBJECTIVE: We explored whether substituting a rectus sheath block (RSB) with spinal anaesthesia, as an adjunct to a general anaesthetic technique, influenced time-to-readiness for discharge in patients undergoing hand-assisted laparoscopic donor nephrectomy. DESIGN: Prospective randomised open blinded end-point (PROBE) study with two parallel groups. SETTING: Tertiary University Hospital. PATIENTS: Ninety-seven patients undergoing a trans-peritoneal hand-assisted laparoscopic donor nephrectomy. INTERVENTION: Patients (n=52) were randomly assigned to receive a general anaesthetic and a surgical RSB with 2 mg kg-1 of levobupivacaine at the time of surgical closure or a spinal anaesthetic with hyperbaric bupivacaine 12.5 mg and diamorphine 0.5 mg (n=45) before general anaesthesia. PRIMARY OUTCOME: The primary outcome was the time-to-readiness for discharge following surgery. RESULTS: Median [IQR] times-to-readiness for discharge were 75 [56 to 83] and 79 [67 to 101] h for RSB and spinal anaesthesia and there was no significant difference in times-to-readiness for discharge (median difference 4 (95% CI, 0 to 20h; P  = 0.07)). There were no significant differences in pain scores at rest (P  = 0.91) or on movement (P = 0.66). Median 24-h oxycodone consumptions were similar (P  = 0.80). Nausea and vomiting scores were similar (P = 0.57) and urinary retention occurred in one vs. four patients with RSB and spinal anaesthesia, respectively (P  = 0.077). CONCLUSION: Substitution of RSB with spinal anaesthesia using 12.5 mg hyperbaric bupivacaine and 0.5 mg diamorphine, together with a general anaesthetic failed to confer any benefit on time-to-discharge readiness following transperitoneal hand-assisted laparoscopic donor nephrectomy. RSB provided similar analgesia in the immediate postoperative period with a low frequency of side-effects in this cohort. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT02700217.