Recognizing that this Standard contains new expectations that may require time for physicians to adjust how they practice, CPSO has implemented a formal transition period to allow physicians to align with the new expectations. This transition period will end on Sunday, September 3, 2023.

What does quality care look like when treating chronic pain?

As set out in Health Quality Ontario’s Chronic Pain Quality Standard, quality care for the management of chronic pain involves a holistic, multi-modal approach, with interventional pain management representing one tool to assist patients suffering from chronic pain. Other tools include physical activity, physically based interventions such as manual therapy and breathing activities, therapeutic exercise, pharmacotherapy, psychologically based interventions such as cognitive behavioural therapy and mindfulness-based interventions, and psychosocial supports.

To provide quality care you will need to ensure a comprehensive patient assessment has been undertaken. Where you are utilizing interventional techniques (such as nerve blocks) these need to be monitored closely for effectiveness in improving pain and function and consider discontinuing such interventional techniques if the patient does not experience clinically meaningful improvements.

Physicians need to exercise due care to ensure that they are providing any interventional treatments in a manner and at a frequency that is appropriate and clinically indicated for that patient and their chronic pain.

In accordance with CPSO’s Medical Records Documentation policy physicians’ documentation must be complete and comprehensive including documentation that supports the rationale for the treatment or procedure. Any treatment or therapy provided, and the patient’s response and outcomes must be documented.

Why have you developed this Standard for OHPs?

CPSO is directly responsible for the regulation and oversight of Out-of-Hospital Premises (OHPs) and as such, sets standards for appropriate practice in these settings.

Why is CPSO requiring the use of image guidance for certain nerve blocks?

There are a number of potential risks associated with different kinds of nerve blocks including: bleeding, infection, vascular puncture, pneumothorax, hematoma, inadvertent epidural or intrathecal injection, pain at injection site, bradycardia, hypotension, and local anesthetic toxicity.¹

As nerve blocks have become increasingly utilised over the years, the advancement and use of image guidance technologies have dramatically improved the accuracy and safety of these interventions.²

Through CPSO’s regulatory work we know that significant harm can and does happen when nerve blocks are administered incorrectly. Use of appropriate image guidance can decrease the likelihood of significant adverse events, poor outcomes, and harm to patients, and enhance the efficacy of the nerve block being administered.

Does CPSO require image guidance for all interventional pain management procedures done in Out-of-Hospital-Premises (OHPs)?

No. CPSO does not require image guidance for low risk interventional pain management procedures that are not captured by the OHP program or that are not considered nerve blocks (e.g., trigger point injections, joint injections, and bursa injections).

Which nerve blocks require image guidance?

The Standard requires that physicians use image guidance for all neuraxial, paravertebral and plexus nerve blocks. For all other nerve blocks, the Standard requires that physicians use image guidance where indicated in the circumstances and lists a number of factors for consideration when making this determination. Nerve blocks that are deep, and/or in close proximity to the neuroaxis or to other vital structures (e.g., major blood vessels and internal organs) are more likely to need image guidance. In contrast, superficial peripheral nerve blocks³ are less likely to need image guidance, unless there are specific considerations related to the patient. Where nerve blocks are being administered to patients with abnormal or challenging anatomy, as well as to those who have had previous injuries or surgeries in the area where the nerve block is to be administered that may affect the anatomy or the spread of medications, image guidance is more likely to be needed. Even where image guidance is not required by the Standard, it can still be beneficial as visualizing the nerve can help to improve the efficacy of the block. 

Physicians are always expected to use their clinical judgement and provide care that is in the best interest of the patient.

As technology evolves the standard of care will also evolve and physicians are expected to remain familiar with current standards, clinical practice guidelines, and best practices that are relevant to their practice.

What practice standards, quality standards, and clinical practice guidelines are relevant in this space?

The Spine Intervention Society (SIS) sets out Safety Practices for Interventional Pain Procedures. Generally, SIS recommends the use of fluoroscopy for the following procedures:

• Epidural steroid injections
• Medial branch blocks
• Medial branch radiofrequency neurotomy
• Lateral atlantoaxial joint injections
• Sacroiliac joint injections
• Sacral lateral branch blocks.

For additional information and guidance, please see the Spine Intervention Society’s website.

Consensus practice guidelines need to be considered where they exist, such as the consensus guidelines on interventions for cervical spine (facet) joint pain that are set out in the American Academy of Pain Medicine practice guidelines⁴.

Are epidurals administered for chronic pain considered to be nerve blocks under this Standard?

Yes. Epidural injections for chronic pain are considered to be nerve blocks and physicians must comply with the expectations in this Standard when administering them in OHPs.

What if ultrasound is not part of my practice?

In general, the adoption of point of care ultrasound for the purposes of supporting the administration of a nerve block is not a change of scope. However, a physician will need to have or obtain the knowledge, skill and judgement to use ultrasound effectively in order to incorporate its use into their practice. This can be obtained through appropriate training to ensure a physician can use the device safely while performing a block, read and interpret the image being produced and capture an image.

What if CT and/or fluoroscopy is not part of my current practice?

If you are administering nerve blocks for adult chronic pain, there are likely to be instances where use of CT and/or fluoroscopy will be necessary. If you do not have the qualifications to use CT and/or fluoroscopy as part of your practice and there is no other physician qualified to perform these procedures using CT or fluoroscopy within your premises, you will need to refer patients to another qualified health care professional who can provide them.

What if practice standards, quality standards, and clinical practice guidelines indicate that fluoroscopy is appropriate for a specific block, but I don’t think it is indicated for a specific patient?

You are required to practise in a manner that is consistent with this Standard, other relevant practice standards, quality standards, and clinical practice guidelines. Any departure from these standards will require strong and appropriate justification.

 Endnote

^1. George Deng, Michael Gofeld, Jennifer N Reid, Blayne Welk, Anne MR Agur & Eldon Loh (2021) A Retrospective Cohort Study of Healthcare Utilization Associated with Paravertebral Blocks for Chronic Pain Management in Ontario, Canadian Journal of Pain, 5:1, 130-138.

^2. Wang, D. (2018) Image Guidance Technologies for Interventional Pain Procedures: Ultrasound, Fluoroscopy, and CT. Curr Pain Headache Rep 22, 6.

^3. Examples of superficial peripheral nerve blocks include greater and lesser occipital nerve blocks, supraorbital blocks, infraorbital blocks, supratrochlear blocks, greater auricular, auriculotemporal, and mental branch of mandibular nerve blocks.

^4. Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group, Pain Medicine, Volume 22, Issue 11, November 2021, Pages 2443–2524, https://doi.org/10.1093/pm/pnab281.