COVID-19 impact and response by Canadian pain clinics: A national survey of adult pain clinics

Figures & data

Figure 1. The survey questions

Table 1. Responses to question “Are you still trying to see all patients or are you triaging? What criteria are you using for triage?”

Still seeing all patients	9 clinics
Triaging	8 clinics
Triage responses	Clinic was totally closed for 4 weeks … no phone no nothing. We are starting back with patients who do not need ‘only’ an infiltration, and we will also call those patients if visits in person cannot start back
	Deferred patient list contacted and asked if they can wait
	Not determined yet
	Urgent cases; that is, life or limb. If patient will come to harm without treatment within 6 weeks (e.g., intrathecal pump fills, infections, malfunctioning neurostimulators, or acute CRPS less than 3 months)
	Patients offered the opportunity to discuss pain management treatment with clinicians. Emphasis placed on medication and self-management strategies
	Absence of COVID-19 symptoms. Need for urgent evaluation (e.g., the patient will come to the emergency if his condition is not addressed). Need to prescribe opioid
	Patients with cancer are prioritized for assessment and treatment; patients who are essential workers are also prioritized for treatments (such as injection therapies)
	We prioritize cancer patients, acute radicular pain, acute CRPS, and patients in severe pain. We see patients that will otherwise go to ER. We postpone treatments on elderly with multiple comorbid conditions

CRPS = chronic regional pain syndrome; ER = emergency room.

Table 2. Answers to question “Are any procedures continuing? If yes, what procedures and what criteria are you using for urgent procedures?”

No procedures	6 clinics
Yes procedures	11 clinics
Criteria for urgent procedures	Cancer for both inpatients and outpatients
	Procedures for hospitalized patients (e.g., ketamine infusion, lidocaine infusion, some spinal injections)
	Urgent only; for example, patients who would otherwise be at risk of accessing acute care services to manage pain flares
	Intrathecal drug delivery systems only
	Intrathecal pump fills, malfunctioning stimulators, and blocks for acute CRPS
	Intrathecal pump refills. All other treatments at this point are deferred
	Very few procedures for specific indications (severe pain despite optimized medical treatment). No corticosteroids
	Cancer-related interventional procedures are being performed, as are injection therapies for patients with headache, as well as trigger point injections for essential workers
	Nonsteroid injecting procedures including neurotomy, pulsed radiofrequency, local anesthetic injections
	Only patients in severe pain: acute radicular pain (epidurals or nerve root blocks) or neuropathic pain (post herpetic neuralgia), acute facet joint pain for medial branch blocks and rhizotomies
	College of Physicians and Surgeons Alberta guidelines

CRPS = chronic regional pain syndrome.

Table 3. Answers to question “What have the biggest obstacles to providing virtual care been? How do you see these obstacles being resolved?”

Biggest obstacles	How resolved
(1) Insufficient equipment in the hospital; (2) unclear billing policies; (3) elder, poorer, and lower educated patients with harder access to virtual means; (4) administrative coordination is challenging; (5) insufficient practice-based guidelines/recommendations	Except for (3), all are being resolved slowly
Getting the “OK” from our chief to start back (confusing information for hospital authorities). Getting lists of patients while at home. Getting access to the electronic files of the patients (took 2 weeks!)	Finally got the OK (!) Found a way by password protected pdf to exchange information, but it takes a lot longer to do simple tasks
None
New patients	Not resolved
Hospital support	Time
Mainly provider comfort with the technology. To be honest, most patients are more comfortable with it than we are	Experience/practice
None
Slow process for technology selection, program development, and ensuring availability of staff (some have been redeployed to COVID-related activities. Management attention is focused on COVID related responsibilities, clinic is low priority.)	We have identified available staff now and tech platform(s). Program development underway, 6 weeks into the process
New patients cannot be examined physically	I opened up the clinic to see new patients who want to come in last 2 weeks
None really, we have good technology. Some patients aren’t that facile with smartphones, or don’t have them, so we use landline telephone calls for that
Physical assessment, patient access, and ability to use IT	Offer telephone visit. Will see patient in person at later date for physical assessment
New platform. Some patients do not have access to Internet	The more we practice this, I expect the easier it will become
Adequate access to the authorized platforms	Time
Actually, the provision of virtual care has been facilitated in a number of ways: (1) The provincial government has created billing codes for such services; (2) patients have been receptive to being contacted by phone or Zoom and have found this to be more practical than coming in to the hospital, finding parking, etc.; (3) the clinic admin staff have facilitated setting up Zoom accounts for the physicians
Approving secure formats to conduct virtual visits	Administration working on these issues to ensure secure formats
No real obstacle
Cannot examine or do other procedures, no rehab, social isolation	Focus on other strategies; more frequent contact

Table 4. Answer to question “What federal, provincial, or territorial support would be helpful to facilitate providing virtual care?”

Virtual platforms	3 clinics
Billing support	8 clinics
Other forms of support	Allowing secure access to patient records from personal devices, as happens in other provinces. Providing limited access only through health authority–owned computers is very restrictive
	Helping patients with higher needs accessing virtual care
	To be able to bill for phone visits or consultations. To have access to “anonymous” e-mails for the clinic to send information that is not from our perennial mail
	Allowing me to resume my operations in full. Medical consults is a small part only of what we do
	We have just been approved for new and follow-up tariffs, which are the same as for in-patient clinic visits

Table 5. Answers to question “What practices will your clinic continue once the COVID-19 crisis is over? Do you have any other comments or lessons learned while providing care during the COVID-19 pandemic?”

After COVID-19	Lessons learned
Telemedicine, no doubt
Phone follow-up if possible to bill (was not possible before; we have a basic amount and phone follow-ups are supposed to be included, but it takes as long as a regular visit in person!)	Patients appreciate support on the phone. We should continue using this modality
More virtual visits for follow-ups
Phone follow-up
Virtual clinic for patients who are far away
Likely all of our new virtual options will continue for patients	Many patients prefer the virtual encounters and are not interested in going back to driving/parking
Not clear yet	No
It will partly depend upon billing practice changes at the provincial level
We are preparing some additional online services for the future	Yes, it has made us more creative to add online services while we retain all that we do in the premises
The appetite for virtual follow-ups is huge among patients. Provided the billing codes remain on par, I can see that becoming the default method for simple follow-ups
Some video follow ups if supported by government
Virtual follow-up of patients with stable conditions, who live far from the hospital. Control visits after a procedure, if billing permits
It is likely that follow-up visits will continue; it is possible that our clinic’s group medical visits may be delivered by virtually	We have seen that patients have demonstrated tremendous understanding about the challenging situation of not being able to see them in clinic, perform scheduled interventional procedures, etc. They have appreciated being contacted by telephone. Other patients have not been coping well and we have seen some patients contacting our nurses and physicians for increased psychological support
If billing tariffs remain we will continue to provide telephone follow-up and possibly initial new patient assessment by telephone	Patients have been very kind and supportive to clinic staff. Patients are very keen to continue with telephone follow-ups. Staff have been very supportive to each other. Great to see people come together and work together to the benefit of all
Initial consults for rural patients. Group counseling for our health region, which is the size of Texas with only one pain center
Continue Zoom; continue online	Using it as an opportunity to promote other self-management strategies