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REPORT

ESSENTIAL PAIN MANAGEMENT (EPM) WORKSHOPS

Kathmandu, Nepal

26-28 November 2012

Executive Summary

• Globally, pain (of all types) is often an unrecognized and inadequately treated problem.

• Fortunately, many effective pain management strategies are “low tech” and cheap and can offer significant improvements to an individual’s quality of life.

• The Essential Pain Management (EPM) workshop has been developed:

o To improve knowledge about pain. o To provide a simple framework for treating pain. o To address pain management barriers.

• We ran a series of EPM workshops in Kathmandu.

o EPM Workshop on 26 November o EPM Instructor Workshop on 27 November o Two concurrent EPM Workshops on 28 November (taught by local

instructors)

• The objective of the visit was to introduce EPM to Nepal. We trained eight EPM instructors and these new instructors now have the knowledge and skills to teach regular EPM courses in Nepal.

Recommendations Summary 1. Run 2-3 more EPM workshops in Nepal during the next three months. 2. Form an EPM steering committee. 3. Start regular EPM training for nursing and medical staff 4. Address specific local pain management barriers (e.g. inadequate

education, absence of basic drugs, absence of protocols) 5. Liaise with Dr Rajan regarding monitoring and future instructor courses. Background Nepal has a population of approximately 27 million. The capital, Kathmandu, has a population of approximately 1.7 million.

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The Society of Anaesthesiologists of Nepal (SAN) represents about 160 physician anaesthetists. There are eight postgraduate anaesthesiology training programmes in Nepal – the largest programmes are based at the Tribhuvan University Teaching Hospital (TUTH), National Academy of Medical Sciences (NAMS) based at Bir Hospital, and B.P. Koirala Institute of Health Sciences (BKIHS) in Dharan. The EPM Workshop was developed by Wayne Morriss and Roger Goucke with the assistance of ANZCA to improve pain knowledge, to provide a simple framework for managing pain and to address pain management barriers. Pilot courses were held in Papua New Guinea in April 2010 and workshops have since been held in a number of countries in the Pacific, Asia, Central America and Africa. The management framework we use is RAT, standing for Recognize, Assess and Treat. This has been used very successfully to discuss common and also difficult pain management scenarios. Local Coordination Dr Renu Gurung, Lecturer, TUTH invited us to assist with running the workshops. Professor Moda Nath Marhatta, President of SAN and HOD at TUTH provided invaluable support. Dr Gurung and her colleagues at TUTH did a huge amount of preparatory work, including printing the teaching materials, organising excellent venues, and selecting course participants. External Instructors

1. Dr Wayne Morriss

Anaesthetist, Christchurch, New Zealand 2. Dr Quentin Fisher

Anaesthesiologist, Washington D.C., United States

3. Dr Jonny Rajan Anaesthetic Registrar, Manchester, United Kingdom

Dr Wayne Morriss, Dr Quentin Fisher, Prof Roshana Amatya, Dr Bishnu Paudel, Dr Jonny Rajan,

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Course Participants See Appendix 1. 21 doctors and nurses attended the first one-day EPM Workshop on 26 November. Most work at TUTH and other hospitals in the Kathmandu Valley; one doctor (Dr Asish Subedi) works at BKIHS, Dharan, East Nepal. Eight doctors then attended an Instructor Workshop on 27 November. On the third day, there were 43 local participants – 32 nurses, 3 anaesthesia assistants and eight doctors. These were split into two groups and the newly trained instructors ran two concurrent courses.

EPM Workshop 1 participants

Instructor Workshop participants

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Course Programmes The workshop programmes are shown in Appendix 2 and 3. EPM Workshop 1 An opening ceremony was held on the first morning and Professor Marhatta and Professor Amatya gave an overview of pain management in Nepal. The rest of the morning consisted of a series of short interactive lectures and group discussions. Most of the afternoon was spent doing a series of small group case discussions where RAT was used to consider the management of a variety of pain problems. EPM Instructor Workshop This workshop was conducted over five hours. It began with a series of short interactive lectures. This was followed by a session where participants practised giving a lecture and running a case discussion. Finally, the group planned the two one-day EPM workshops to be held the following day. EPM Workshops 2 and 3 The same one-day programme was used, but was taught by the newly trained instructors.

Case discussions during EPM Workshops 2 and 3 Venue and Catering The workshops were held in the Seminar Room and Inservice Training Room at TUTH. The Seminar Room was a large room suitable for small group discussions. Morning tea, lunch and afternoon tea were provided. The quality of the food was excellent. Teaching Materials All teaching materials (slides, manuals, answer and feedback sheets) were printed locally.

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Assessment Course participants completed a 25-question test at the beginning and end of the workshop to assess learning during the day. The baseline scores were high but showed an improvement at the end of the day. The graph only shows data from participants who completed both the pre- and post-tests. Subjectively, there was an excellent improvement in application of knowledge during the day. By the end of the workshop, participants were able to effectively work together to come up with management plans using the RAT framework.

Feedback See Appendix 4. Participants completed a feedback form at the end of each course. Overall, feedback was very positive. “RAT” was popular and the vast majority of participants stated that EPM would change the way they assess and treat pain. A large number of participants stated that EPM should be run frequently. Financial The workshops were very generously supported by the Australian Society of Anaesthetists (ASA) and the Anaesthesiology Department at Tribhuvan University Teaching Hospital. The Association of Anaesthetists of Great Britain and Ireland also contributed to Dr Rajan’s costs. We are very grateful for this support.

0  

5  

10  

15  

20  

25  

EPM  1  (n=18)   EPMs  2  and  3  (n=36)  

Score  (out  of  25)  

Mean  Pre-­  and  Post-­Test  Scores  

Pre-­‐Test  

Post-­‐Test  

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Publicity and Liaison An opening ceremony was held at the start of the first EPM Workshop. This was attended by a number of VIPs, including Professor Prakash Sayami (Dean), Professor Jeeban Shrestha (Campus Chief) and Professor Bhagawan Koirala (Director). This ceremony was a great way to start EPM in Nepal. A television reporter and cameraman attended part of the third day and a short item was shown on the News-24 channel that evening. The item included interviews with Dr Marhatta and Dr Gurung and gave a good summary of the aims of EPM. Success and Relevance of the Visit In my view, this was a very successful series of EPM workshops. This was the first time that EPM has been run in Nepal and we can be optimistic that a group of local instructors will now run regular courses. The series of workshops were exceptionally well organised by Dr Gurung and her colleagues at TUTH. We were very grateful for the support of Prof M.N. Marhatta, President of SAN and HOD, and Prof Roshana Amatya, past-HOD of TUTH. Most participants were anaesthesiologists and nurses from TUTH but there were a number of key people from other institutions, including Bir Hospital, private Kathmandu hospitals and BPKIHS in Dharan. We were able to train an enthusiastic and talented group of instructors on the second day. These new instructors went on to deliver two excellent concurrent courses on the third day. At the end of this day, we had a useful debrief session and discussed future plans for EPM in Nepal, including the recommendations below. Feedback from the participants was very positive and there was a good improvement in test scores. The courses were also an opportunity to introduce EPM to Dr Quentin Fisher (USA) and Dr Jonny Rajan (UK). Recommendations 1. Run 2-3 more EPM workshops in Kathmandu during the next three months.

There is now a knowledgeable and enthusiastic group of instructors in Nepal with access to all the EPM teaching materials. The workshop is cheap and relatively easy to run. It will be important to run more workshops soon to reinforce knowledge and teaching skills. It will be desirable to run an EPM course at the BPKIHS at an early stage, but this will depend on funding for local instructors to assist Dr Asish Subedi.

2. Form an EPM Steering Committee.

This committee will coordinate the planning of courses and explore funding options.

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EPM is very cheap to run but funding is required for printing and catering. The group discussed the possibility of the host institution covering these costs. It will be important to get some “runs on the board” and then it may be possible to seek some funding from the Ministry of Health.

The committee may develop into a larger pain management committee, involving other non-anaesthetic specialties.

3. Start regular EPM training for nursing and medical staff.

The group discussed the possibility of introducing EPM into the undergraduate medical and nursing curricula. Another option is to start regular EPM courses (similar to CPR training) for resident medical staff.

4. Address specific local pain management barriers

A number of barriers were discussed in the workshops. Running more EPM workshops will address some of the issues related to inadequate knowledge. It is very important to address other local barriers, for example, absence of pain management protocols, and issues with drug supply in some hospitals.

5. Liaise with Dr Rajan regarding monitoring and future instructor courses. Dr Rajan has agreed to act as a “resource person” regarding monitoring of EPM. He may be able to return to Nepal in the second half of 2013 to help run another instructor course, if required.

Acknowledgements Special thanks to Dr Renu Gurung and her colleagues at TUTH for all their hard work. Many thanks to Professor Marhatta and the Society of Anesthesiologists of Nepal. Thanks also to Dr Binita Acharya for being our chauffeur! Thanks to all the participants for their enthusiasm and good humour. Special thanks to the new instructors for a job very well done – Dr Renu Gurung, Prof Roshana Amatya, Dr Binita Acharya, Dr Bigen Shakya, Dr Ninadini Shrestha, Dr Pradeep Vaidya, Dr Asish Subedi and Dr Sachin Shakya. Many thanks to the organisations who provided financial support – TUTH Department of Anaesthesiology, the Australian Society of Anaesthetists, the Australian and NZ College of Anaesthetists and the AAGBI. Dr Wayne Morriss 9 December 2012

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Appendix 1: Course Participants EPM 1 (26 November) S. No Name Position Hospital / Institution

1 Asha Paudel S/N Recovery, TUTH

2 Shashi Kala Ghimire S/N FSW, TUTH

3 Bimala Shrestha Nursing Supervisor ICU, TUTH

4 Durga Thapaliya Dhungan Sister ICU, MCTVT

5 Ganga Devi Upreti Nursing Supervisor TUTH

6 Jaldevi Rai Sister Medicare National Hospital

7 Pabitra Neupane Sister FSW, TUTH

8 Ramita Lama Staff nurse Medicare National Hospital

9 Ramita Maharjan Staff nurse Alka Hospital

10 Sarah Gurung Staff nurse TUTH

11 Tara Karki N supervisor ENT, TUTH

12 Kabita Kunwar N supervisor OT , TUTH

13 Dr Sachin Shakya Medical Oncologist Sarvanga Hospital

14 Dr Roshana Amatya Professor TUTH

15 Dr Binita Acharya Anaesthesiologist TUTH

16 Dr Bigen M Shakya Anaesthesiologist TUTH

17 Dr Ninadiani Shrestha Anaesthesiologist TUTH

18 Dr Asish Subedi Anaesthesiologist BPKIHS

19 Dr Pradeep R Vaidya Anaesthesiologist NAMS

20 Dr Bishnu Paudel Pall Care Physician Manmohan Memorial Community Hospital

21 Dr Renu Gurung Lecturer TUTH

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EPM Instructor Workshop (27 November) S. No. Name Position Hospital / Institution

1 Prof Roshana Amatya Anaesthesiologist TUTH, IOM, Kathmandu

2 Dr Renu Gurung Anaesthesiologist TUTH, IOM, Kathmandu

3 Dr Binita Acharya Anaesthesiologist TUTH, IOM, Kathmandu

4 Dr Bigen M Shakya Anaesthesiologist TUTH, IOM, Kathmandu

5 Dr Ninadini Shrestha Anaesthesiologist TUTH, IOM, Kathmandu

6 Dr Pradeep Raj Vaidya Anaesthesiologist Bir Hospital, Kathmandu

7 Dr Asish Subedi Anaesthesiologist BPKIHS, Dharan

8 Dr Sachin Shakya Medical Oncologist Sarvanga Nursing Home

EPM 2 (28 November) S. No Name Position Hospital / Institution

1 Sushila Shrestha Staff nurse TUTH

2 Bina Shrestha Staff nurse Bir Hospital

3 Bina Bantawa Staff nurse Kist Medical Hospital

4 Dhurba K.C Staff nurse Medicare National Hospital

5 Himal Dewan Staff nurse OT, TUTH

6 Kiran Sah Anaesthesia Assistant OT, TUTH

7 Krishnashworee Shrestha Staff nurse Bir Hospital

8 Lasana Prajapati Staff nurse Bhaktapur Cancer Hospital

9 Laxmi Yogi Staff nurse Postop , TUTH

10 MIra Khanal Staff nurse Bir Hospital

11 Nabina Sharma Staff nurse POW,TUTH

12 PrIti Pun Staff nurse MCTVTC

13 Ranju Khanal Staff nurse TUTH

14 Rasmila Acharya Staff nurse Alka Hospital

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15 Sajana Prajapati Staff nurse TUTH

16 Sangita Maharjan Staff nurse Sarvanga Hospital

17 Saraswati Pathak Staff nurse TUTH

18 Dr Anubhav Sharma Resident TUTH

19 Dr Rolina Karki Staff nurse Nepal Orthopedic Hospital

20 Dr Kishor Khanal Resident TUTH

21 Dr Krishna Psd. Acharya Resident TUTH

22 Rajiv Subedi Anaesthesia Assistant

TUTH

EPM 3 (28 November) S. No Name Position Hospital / Institution

1 Aagya Karki Staff Nurse Medicare National Hospital

2 Anita Suwal Staff Nurse Bhaktapur Cancer Hospital

3 Anamika Pudasaini Staff Nurse MCVTC

4 Chandrakala Khanal Staff Nurse Bir Hospital

5 Deepa Budathoki Anaesthesia assistant TUTH

6 Muna Poudel Staff Nurse Om Hospital

7 Laxmi Pahadi Staff Nurse TUTH

8 Madhavi Upreti Sister TUTH

9 Narbada Thapa Sister TUTH

10 Naina Lama Sister TUTH

11 Neeru Khadka Staff Nurse Sarvanga Hospital

12 Nirmika Rai Staff Nurse Bir Hospital

13 Sabina Khadka Staff Nurse Kist Medical College

14 Sarmista Shakya Staff Nurse TUTH

15 Sushila Prajapati Staff Nurse Om Hospital

16 Ujeli Pacchai Staff Nurse OT, Bir Hospital

17 Dr Ayushma Shrestha House Officer OHRC

18 Dr Alina Shrestha Medical Officer Bhaktapur Cancer Hospita

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19 Dr Pankaj Joshi Resident TUTH

20 Dr Pradeep Tiwari Resident TUTH

21 Dr Prakash Karki Resident TUTH

EPM Workshops 2 and 3 participants and instructors

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Appendix 2: EPM Workshop Programme

Time Duration

(mins)

Lecture / Discussion Instructor/s

0830-0915 45 Welcome

Local perspective

Pre-test

0915-0930 15 Introduction

0930-0945 15 What is pain?

0945-1000 15 Why should we treat pain?

1000-1015 15 Classification of pain

1015-1045 30 Morning tea

1045-1115 30 Physiology and pathology

1115-1135 20 Pain treatment overview

1135-1155 20 Pain drugs

1155-1230 35 Barriers to pain management

1230-1330 60 Lunch

1330-1400 30 Basic approach to pain management

1400-1500 60 Case discussions

1500-1530 30 Afternoon tea

1530-1630 60 Overcoming barriers

1630-1700 30 Post-test

Feedback

Certificates

Photo

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Appendix 3: EPM Instructor Workshop Programme Time Duration

(mins)

Lecture / Discussion Instructor/s

Session 1: Introduction and Teaching Basics

15 Welcome

Introduction

0845-0900 15 Adut learning

0900-0915 15 Teaching overview

0915-0930 15 Giving a lecture

0930-0945 15 Running a discussion group

0945-1000 15 Morning tea

Session 2: Teaching Rotations

Divide into 2 groups:

• Giving a lecture

• Running a discussion group

1000-1045 45 Teaching rotation 1

1045-1130 45 Teaching rotation 2

Session 3: How to Run an EPM Workshop

1130-1145 15 EPM planning

1145-1215 30 Workshop preparation – venue, lecturers,

catering etc

1215-1245 30 Feedback

Certificates

Photo

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Appendix 4: Analysis of Participant Feedback EPM 1 (20 responses) 1

Strongly disagree

2 Disagree

3 Not sure

4 Agree

5 Strongly

agree EPM will be useful in my daily work.

2 8 10

EPM has improved my understanding of pain.

1 6 13

I will now be able to assess pain better.

1 7 12

I will now be more willing to prescribe or give opioids.

1 12 7

The training today was effective.

2 18

Comments • Will EPM change how you work?

o I will use the various approaches to make my patients pain free. o Start with strong opioids for strong pain. o I will assess severity (2) o Involvement of nursing staff

• How can the EPM Workshop be improved? o Slightly more focus on treatment part. o Involve surgeons (3) o Time management o Make longer (2)

• Any other comments? o Should be mandatory (2) o Please continue! o Do regularly (3) o It is perfect (2)

EPM Instructor Workshop (8 responses) 1

Strongly disagree

2 Disagree

3 Not sure

4 Agree

5 Strongly

agree The training today was effective.

6 2

I will be a better teacher as a result of this workshop.

5 3

The workshop today improved my knowledge of EPM.

5 3

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Comments • Most important things learned?

o How to face a difficult question o Case discussions o Communication, keeping people interested o Making lectures effective o How to simplify content (2) o Importance of preparation

• Will you be able to use your EPM Instructor training? o Use for training postop ward and residents o Training students using RAT o Yes, in BPKIHS – general practitioners, surgeons, nurses o Yes, to doctors and nurses

• How can the EPM Instructor Workshop be improved? o More practice giving lectures o Include role play o Use pre- and post -tests

• Any other comments? o We will need monitoring o Well organised

EPMs 2 and 3 (41 responses) 1

Strongly disagree

2 Disagree

3 Not sure

4 Agree

5 Strongly

agree EPM will be useful in my daily work.

10 30

EPM has improved my understanding of pain.

14 26

I will now be able to assess pain better.

15 25

I will now be more willing to prescribe or give opioids.

1 8 14 16

The training today was effective.

7 32

Comments • Most important things learned?

o Classification (7) o Drugs o RAT approach (30) o Difference between neuropathic and nociceptive pain o Physiology and pathology (7) o Barriers (8) o Drug and non-drug treatments (8) o Contributing factors (2) o “Do not fear when prescribing morphine”

• Will you be able to use your EPM Instructor training? o Use both non-drug and drug treatments (3)

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• How can the EPM Instructor Workshop be improved? o Better noise control o Use play and drama (2) o More group discussions (4) o More specific aspects. More advanced course.

• Any other comments? o Need frequent workshops (17) o Good 2-way communication / interaction o Use follow-up (2) o “It is absolutely effective and romantic” o Need longer course (9) o Need to change attitude (2) o Need protocols (2)