Background and objectives In pain management clinics, refractory chronic pain often needs to be managed by potentially iatrogenic treatments that have not been fully validated in terms of evidence-based medicine, such as intravenous lidocaine treatment for neuropathic pain (NP). Our primary objective was to evaluate professional practices in the pain day care unit of Nice university hospital. Secondary objectives were to study the efficacy and safety of intravenous lidocaine treatment of NP and to assess the heath economics impact of our quality improvement programme. Programme Our quality improvement programme was part of a wider initiative to harmonise clinical practices in pain clinics in France. It took place between November 2007 and September 2009 and was implemented by three physicians. It followed the Plan-Do-Check-Act procedure. ‘Plan’: The first step was (i) a systematic literature review on the use of intravenous lidocaine to treat NP, (ii) consultation of the HAS practice appraisal process and of the 2010 version of the HAS accreditation manual for healthcare organisations, and (iii) consultation of the rules and regulations on day hospitals. After an analysis of quality improvement methods used in day hospitals, we selected the clinical pathway method. ‘Do’. A multidisciplinary team meeting (MTM) on pain was held every week in order to validate the indications for intravenous lidocaine and monitor progress. The following documents were drawn up: a care protocol, procedures to be followed in the case of adverse events, a patient information and consent form, a prescription and evaluation form, a standard letter requesting an evaluation by a cardiologist, MTM and hospital reports for the GP, a phone follow-up form. A vital signs monitor was purchased and emergency trolley equipment was brought up to standard. ‘Check and act’. Three audit rounds were carried out using a 10-item questionnaire. Data on efficacy (pain intensity on a visual analogue scale (VAS), patient satisfaction), safety (‘active’ recording of side effects), and health economics were collected. Results The quality improvement programme was integrated by the pain team into their daily practice. Between the first and last round of the audit, compliance with quality criteria increased markedly from 45%–95% to 80%–100%, according to item. Overall, 53% (63/119) of patients experienced a 30% reduction in pain intensity (VAS) and 29.4% (35/119) reported that they were satisfied or very satisfied with the treatment. Adverse events occurred in 46% of patients (55/119). There were four early treatment interruptions but no serious adverse events. After an initial 36% reduction in 2008, the recruitment level at the end of the programme was identical to that before programme implementation. A clear increase in activity-based funding was observed at the end of the programme (+66%). Discussion Our programme led to an improvement in practice. This justified the resources allocated within the day hospital to intravenous lidocaine use for neuropathic pain. Treatment efficacy was similar to that recorded in the literature. However, we encountered no serious adverse events. Our good safety profile was probably due to systematic assessment by a cardiologist before initiating therapy and to active monitoring in the day hospital. Financial savings resulted from activity-based costing after the creation of a ‘disease-related group’ for refractory chronic pain but also from compensation of the initial fall in activity by a better occupancy rate in the day hospital. In conclusion, the clinical pathway is a simple and effective method of optimising clinical practices in pain clinics and limiting iatrogenic risks associated with the treatment of refractory chronic pain. Contexte Dans les structures tertiaires de prise en charge de la douleur, les douleurs chroniques irreductibles necessitent souvent le recours a des traitements potentiellement iatrogenes dont le niveau de validation n9est pas optimal, comme le traitement des douleurs neuropathiques (DN) par la lidocaine intraveineuse (Liv). Objectifs L9objectif principal etait de realiser une demarche qualite (DQ) sur les pratiques de l9hopital de jour (HDJ) du DETD-MP validante au titre de l’evaluation des pratiques professionnelles (EPP). Les objectifs secondaires etaient d9evaluer l9efficacite et la securite d9emploi du traitement des DN par Liv et d9evaluer l9impact medico-economique de la DQ. Programme ‘Plan’- Il s9agissait une revue bibliographique portant sur: i) la Liv a visee antalgique pour les DN, ii) la methodologie de la DQ de la HAS avec le manuel de certification v2010, iii) la circulaire frontiere encadrant les activites en HDJ, associee a une analyse des procedures en cours en HDJ par une reflexion d9equipe qui a permis le choix du chemin clinique comme outil d9amelioration. ‘Do’ - La DQ a ete realisee entre novembre 2007 et septembre 2009 et pilotee par 3 medecins. Elle a conduit a mettre en place une reunion de concertation pluridisciplinaire hebdomadaire permettant de valider les indications de Liv et d9en assurer le bilan. Elle s9est accompagnee de la creation de documents tel le protocole d9administration. Elle a necessite l9achat d9un saturometre et une mise en conformite du chariot d9urgence. Elle a justifie la creation d9une grille d9audit de 10 criteres pertinents pour evaluer la qualite des pratiques. ‘Check et act’ - Au cours de cette demarche trois audits qualite successifs ont ete realises. Ont ete egalement evalues des criteres d9efficacite: evaluation visuelle analogique de la douleur (EVA) et satisfaction patient (PGIC). Une procedure de recueil actif des effets indesirables (EI) a ete etablie et des donnees medico-economiques ont ete recuperees par le PMSI. Resultats La DQ a ete bien integree dans la pratique quotidienne. Les criteres qualite sont passes selon l9item de 40%-95% a 80-100% de conformite entre l9audit 1 et 3. 55% (63/119) des patients ont eu une reduction de 30% de l9EVA et 29,4% des patients (35/119) se disaient bien a tres bien soulages. 46% (55/119) ont eu des EI dont 4 ont necessite l9arret de la perfusion mais sans aucun EI severe. Apres une diminution initiale de la file active de patients (-36%), les effectifs de l9annee de reference 2007 ont ete retrouves en 2009. Une nette augmentation de la valorisation en T2A a ete observee pour la meme periode (+66%). Discussion La DQ a produit une amelioration qualitative des pratiques. L9efficacite de la Liv sur les DN est comparable aux donnees de la litterature. A contrario nous n9avons pas observe d9EI severe grâce a une selection prealable des patients lors de la consultation cardiologique systematique. La baisse initiale d9activite est liee au respect de criteres plus stricts d9acces au traitement conformement a la circulaire frontiere. Le gain financier s9explique par la revalorisation des seances d9HDJ, la creation d9un GHM specifique “douleur chronique irreductible” mais egalement par une compensation de la baisse initiale d9activite du fait d9un meilleur taux d9occupation de l9HDJ. Ce protocole a ete valide dans le cadre de l9harmonisation des pratiques des structures douleur de la region PACA. Cette DQ a permis la validation de l9EPP des medecins du DETD-MP. Elle informe le critere12a E2 chapitre 4 du manuel de certification v 2010. Conclusion La DQ par le CC permet d9optimiser un traitement potentiellement iatrogene en HDJ dans une structure tertiaire de prise en charge de la douleur. Conduite par un groupe pilote de soignants, elle permet de federer une equipe autour d9un objectif d9excellence.