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ZISOP The concept of the Centre for interdisciplinary pain therapy, oncology and palliative medicine. Univ.Prof. Dr. Rudolf Likar Pain Clinic, General Hospital Klagenfurt Klagenfurt, Austria. IINTERDISCIPLINARYPAIN CLINIC KLAGENFURT GENERAL HOSPITAL. - PowerPoint PPT Presentation
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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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
IINTERDISCIPLINARYPAIN CLINIC
KLAGENFURT GENERAL HOSPITAL
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
IINTERDISCIPLINARYPAIN CLINIC
KLAGENFURT GENERAL HOSPITAL
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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”
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
Pain MeasurementPain Measurement
Pain on rest/on movement
VAS/NRS/VRS/KUSS and SMILEY
Twice daily
Documented on a chart
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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)
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
Pain TherapyPain TherapySymptomatic Treatment OptionsSymptomatic Treatment Options
Pharmacological Pharmacological pain pain
treatmenttreatment
Physical Physical therapytherapy
TENSTENSAcupunctureAcupuncturePsychologicalPsychological
therapytherapy
PhysiotherapyPhysiotherapy
InvasiveInvasiveproceduresprocedures
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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).
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
CT-guided blockadeCT-guided blockade
epidurale blockadeepidurale blockade
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
CT-guidedCT-guidednerve-blockadenerve-blockade
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
CT-gezielte Blockadebehandlung
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
IINTERDISCIPLINARYPAIN CLINIC
KLAGENFURT GENERAL HOSPITAL
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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.
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
Average hospital stay in daysAverage hospital stay in days
0
2
4
6
8
10
12
14
16
2005 2006 2007
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
Institutions of Palliative Medicine in Institutions of Palliative Medicine in CarinthiaCarinthia
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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.
ZISOP - Zentrum für interdisziplinäre Schmerztherapie, Onkologie und Palliativmedizin, Center of excellence
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:
tamara.kreuter@kabeg.attamara.kreuter@kabeg.at
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