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EHAVIORAL
PAIN
ASSESSMENT TOOL
FOR CRITICALLY ILL
ADULTS UNABLE TO
SELF-REPORT PAIN
By Louise Rose, RN, BN, MN, PhD, ICU Cert, Lynn Haslam, RN, BScN(Hons), MN,
NP(Hons), Craig Dale, RN, BScN(Hons), MN, CNCC(C), Leasa Knechtel, RN,
BScN(Hons), MN, CNCC(C), and Michael McGillion, RN, BScN, PhD
CNE
1.0 Hour
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AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3
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Methods
Systematic pain
assessment
improves patients
outcomes, reducing mechanical
ventilation time
and length of stay.
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247
Two intensive
care units were
used, a 20-bed
mixed unit and a
14-bed cardiovascular unit.
Data Collection
Research staff prospectively screened the eligibility of all consecutive patients admitted to the 2
ICUs. In order to minimize the impact of data collection on critical care nurses practices of documenting pain assessment, the relevant data were extracted
from each study patients record retrospectively after
the patient had been discharged from the ICU.
Demographic data included age,
sex, admission type, primary reason
for ICU admission, and number of
invasive catheters or tubes. Additional information collected included
frequency and type of documentation (either pain score or narrative
description) of pain assessment
from the time of inclusion in the
study until the patient regained the
ability to communicate (indicated
by a motor score of 6 on the Glasgow Coma Scale or nursing documentation) or a
maximum of 72 hours; type, delivery method, and
dose of analgesic and sedative medications administered; and daily scores on the Sequential Organ
Failure Assessment (SOFA), duration of mechanical
For extraction of
pain assessment
descriptors, potential behavioral
descriptors were
compiled from
published tools.
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Table 1
Patients demographics
No. (%) of patients
CVICU
CRCU
Before
(n = 130)
After
(n = 132)
70 (61-76)
91 (70)
Admission category
Surgical
Trauma
Medical
Reason for ICU admission
Cardiovascular
Respiratory
Gastrointestinal
Neurologic
Trauma
Metabolic
Genitourinary
Hematologic
Sepsis
Before
(n = 59)
After
(n = 52)
67 (60-75)
57 (38-75)
54 (43-63)
93 (70)
42 (71)
40 (77)
123 (95)
0 (0)
7 (5)
124 (94)
2 (2)
6 (4)
13 (22)
28 (48)
18 (30)
6 (12)
23 (44)
23 (44)
123 (95)
3 (2)
0 (0)
2 (2)
0 (0)
2 (2)
0 (0)
0 (0)
0 (0)
125 (95)
3 (2)
1 (1)
0 (0)
2 (2)
0 (0)
0 (0)
3 (2)
1 (1)
1 (2)
14 (24)
2 (3)
9 (15)
28 (48)
1 (2)
2 (3)
0 (0)
2 (3)
2 (4)
5 (10)
7 (14)
6 (12)
23 (44)
0 (0)
0 (0)
3 (6)
6 (12)
9 (8-9)
9 (8-10)
8 (7-9)
6 (6-7)a
6 (3-8)
4 (3-6)a
8 (5-11)
8 (6-11)
Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit; ICU, intensive care unit; IQR, interquartile range.
a
b
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Results
A total of 189 patients were recruited before
implementation of the CPOT and 184 patients after
implementation. Demographic characteristics for
both study phases according to ICU are shown in
Table 1. Patient characteristics in the 2 study phases
were similar except for median maximum SOFA
scores in the CVICU and number of catheters in
the CRCU cohort. In both units, the number of
PAIs did not differ significantly during the study
phases. In the CVICU, the proportion of PAIs with
pain assessment documented increased from 15%
to 64% (P < .001) and from 22% to 80% (P < .001)
in the CRCU. The median number of PAIs for each
patient with documented pain assessment increased
after CPOT implementation in both ICUs (Table 2).
Because an increase in documentation of a
behavioral pain score after implementation of the
CPOT was anticipated, the frequency of documentation of narrative assessments of behavioral and physiological indicators of pain was determined. The
number of narrative assessments increased in the
CVICU and were unchanged in the CRCU (Table 2).
For the CVICU patients, the median maximum
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Table 2
Documentation of pain assessment
No. of patients, median (IQR)
CVICU
CRCU
Documentation
Before
(n = 130)
After
(n = 132)
Eligible hoursa
1321, 3 (2-6)
893, 3 (2-6)
.20
2390, 37 (14-72)
2627, 68 (26-72)
.09
633, 3 (2-6)
519, 3 (2-5)
.18
580, 9 (3-18)
646, 17 (7-18)
.08
180, 1 (0-2)
341, 2 (1-3)
<.001
213, 2 (1-5)
516, 11 (5-16)
<.001
96, 0 (0-1)
333, 2 (1-3)
<.001
127, 1 (1-4)
515, 11 (5-16)
<.001
254, 1 (0-2)
172, 1 (1-2)
.001
336, 3 (2-8)
310, 2 (2-8)
.56
130, 0 (0-1)
147, 1 (1-2)
<.001
262, 2 (1-7)
218, 3 (1-6)
.93
PAIs
PAIs with pain assessment (all)
PAIs with pain assessment
(eligible)b
Before
(n = 59)
After
(n = 52)
Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit; IQR, interquartile range; PAIs, pain assessment intervals.
a
b
Refers to the number of hours of data collection during which patients remained eligible for the study.
Excludes PAIs coded as 2 (ambiguous as to whether documented assessment referred to pain, agitation, or delirium because interventions for management of agitation and delirium coincided with documentation) and 4 (documentation of analgesia given, though no assessment data recorded).
250
Discussion
Our findings indicate successful implementation of the CPOT in terms of improved compliance
with regular documentation of pain assessment in
2 ICUs with no previous formal use of this, or any
other, behavioral pain assessment tool. Although
we showed improved compliance with the policyrecommended frequency of documented pain
assessment, we did not achieve compliance rates
higher than 80%. Although 100% is obviously
preferable, 80% compliance may be acceptable in
ICUs with large numbers of nurses, staff turnover,
and acutely ill patients. The rate was also a marked
improvement from compliance at baseline. A similar compliance rate for documented pain assessment
was reported by Topolovec-Vranic et al,13 whereas
Glinas et al14 reported a median of 12 documented
assessments (every 2 hours) per 24 hours of ICU
stay 12 months after CPOT implementation,
although compliance cannot be calculated because
institutional recommendations for frequency of
documentation were not described.
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Table 3
Drug dosesa
CVICU
Drug
Fentanyl, total, g
No.
21
94
107
104
2
(2-2)
5
(3-9)
112
1.6
(1.6-1.6)
24
(24-24)
0.6
(0.4-1.0)
1.4
(0.8-3.0)
11
0.0
(0.0-0.0)
800
(100-2650)
0.2
(0.1-0.3)
No.
47
(15-82)
Before
(n = 130)
CRCU
16
100
(100-225)
14
(9-18)
After
(n = 132)
100
(50-670)
.17
14
(4-50)
.09
0.6
(0.4-0.8)
.26
0.2
(0.1-0.3)
.84
4
(3-7)
.02
1.2
(0.6-2.0)
.04
1.0
(1.0-1.0)
31
(31-31)
100
(100-200)
.85
17
(11-21)
.50
No.
38
Before
(n = 59)
300
(100-725)
No.
44
After
(n = 52)
775
(313-2712)
.003
20
(8-83)
.006
2.2
(1.9 -2.4)
.85
0.1
(0.0-0.2)
>.99
16
(11-20)
.79
0.2
(0.2-0.3)
.79
75
(30-258)
.002
2
(0.6-8.0)
.008
10
(4-21)
5
1.6
(0.7-3.0)
0.1
(0.0-0.3)
3
15
(2-17)
0.2
(0.0-0.3)
42
27
(11-73)
45
1.0
(0.4-2.3)
350
(200-500)
0
(0-0)
0.2
(0.1-0.8)
13
(8-18)
Acetaminophen, total, g
36
1
(1-3)
16
1
(1-4)
.95
32
3
(1-6)
33
5
(2-9)
.17
Benzodiazepine, total
99
12
(4-60)
63
2
(2-5)
<.001
21
2
(1-3)
25
2
(2-2)
.34
1
(0.3-2)
<.001
0.0
(0.0-0.2)
.93
418
(118-1513)
.46
14
(3-30)
.28
8
(5-13)
>.99
3
(1-19)
11
20
15
(10-50)
150
(90-400)
5
(5-5)
0.1
(0.1-0.1)
103
(30-225)
.33
15
(9-27)
.43
5
(3-7)
>.99
0.5
(0.2-0.7)
.44
0.1
(0.0-0.2)
20
603
(378-1375)
28
23
(11-34)
2
10
(2-80)
0.3
(0.0-1.4)
0.1
(0.1-0.2)
.68
Data are median (interquartile range) for hourly dose. All doses are in milligrams unless otherwise indicated. Dashes indicate no data.
Numerous observational studies24-26 have indicated poor compliance with various evidence-based
practice recommendations, indicating that implementation of the recommendations remains a
challenge in the ICU. Assessment of the need for
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Table 4
Multivariable analysis of patients characteristics
associated with documented pain assessment
CVICU
Before CPOT
CRCU
After CPOT
PAIs
1.15 (1.11-1.19)
<.001
1.16 (1.13-1.19)
Age
Before CPOT
P
<.001
After CPOT
1.19 (1.14-1.25)
<.001
1.12 (1.10-1.14)
<.001
0.99 (0.98-1.00)
.15
1.01 (1.00-1.02)
.003
0.99 (0.98-1.00)
.14
1.00 (0.99-1.00
.16
.53
1.03 (1.00-1.07
.09
0.99 (0.93-1.06)
.76
0.98 (0.96-1.00)
.04
Sex
0.86 (0.52-1.44)
.58
1.17 (0.96-1.41
.11
1.13 (0.73-1.76)
.59
0.94 (0.78-1.13)
.50
Admission category
Surgical
Trauma
Medical
1
1.28 (0.66-2.50)
1.0 (1.00-1.00)
.46
>.99
1
2.48 (1.27-4.81)
1.26 (0.95-1.68)
.007
.10
1
0.89 (0.48 -1.64)
1.41 (0.79-2.51)
.71
.25
1
0.95 (0.75-1.20)
0.91 (0.73-1.14)
.66
.43
Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit; IRR, incidence rate ratio; PAIs, pain assessment intervals;
SOFA, Sequential Organ Failure Assessment.
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Limitations
Because of the limitations of the study design,
our results may have been influenced by unaccounted confounders such as other ongoing quality initiatives; in particular, a sedation score and
algorithm targeting low levels of sedation were
introduced at the same time as the CPOT. Other
potential confounders include turnover of physicians
and nurses and differences in patient characteristics,
although the cohort groups were equivalent in
terms of measured baseline characteristics except
for a lower maximum SOFA scores in the CVICU
patients and fewer invasive catheters in the CRCU
patients after implementation of the CPOT. Our
results may also be subject to performance bias despite
our attempts to avoid influencing pain assessment
practices by collecting most data from the medical
record after patients were discharged from the ICU.
Ascertainment bias may have occurred despite random audits of the accuracy of data extraction because
the persons who extracted information from nurses
narratives were not blinded to the study period or
the study purpose. Because the data collection was
retrospective, we were unable to accurately determine assessment of response to analgesics. The exact
time of assessment was not well documented, and
the documentation did not directly describe response
to treatment; narrative notation is often documented
by nurses in retrospect rather than real time. We were
5 PAIs short of our target sample size in the CVICU
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Conclusion
Implementation of the CPOT increased the frequency of pain assessment and most likely influenced administration of opioid analgesics in the 2
ICUs. Few episodes of pain were detected by using
the CPOT, although approximately 40% of pain
episodes were not addressed with administration of
analgesia, suggesting the need to link pain management to assessment findings. The effectiveness of
the CPOT for optimizing appropriate administration of an analgesic in critically ill patients unable
to self-report needs to be evaluated in randomized
controlled trials.
ACKNOWLEDGMENTS
We thank Alex Kiss for his advice and assistance with
statistical analyses.
FINANCIAL DISCLOSURES
This study was supported by a grant from the Sunnybrook
Health Sciences Centre Practice Based Research Fund.
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SEE ALSO
For more about pain management, visit the Critical
Care Nurse Web site, www.ccnonline.org, and read the
article by Arbour and Glinas, Setting Goals for Pain
Management When Using a Behavioral Scale: Example With the Critical-Care Pain Observation Tool.
(December 2011).
REFERENCES
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2. Puntillo KA. Pain experiences of intensive care unit patients.
Heart Lung. 1990;19:526-533.
3. Whipple J, Lewis K, Quebbeman E, et al. Analysis of pain
management in critically ill patients. Pharmacotherapy.
1995;15:592-599.
4. Arroyo-Novoa C, Figueroa-Ramos M, Puntillo K, et al. Pain
related to tracheal suctioning in awake acutely and critically
ill adults: a descriptive study. Intensive Crit Care Nurs.
2008;24:20-27.
5. Ethier C, Burry L, Martinez-Motta C, et al; Canadian Critical
Care Trials Group. Recall of intensive care unit stay in
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3
253
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
254
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3
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CNE Test
Test ID A132232: Behavioral Pain Assessment Tool for Critically Ill Adults Unable To Self-Report Pain
Learning objectives: 1. Describe key elements of the behavioral assessment Critical-Care Pain Observation Tool (CPOT). 2. Evaluate effects of CPOT with change
in practice for documentation and administration of analgesics and sedatives. 3. Compare results among studies regarding compliance with pain assessment
documentation and practice recommendations.
1. Which of the following has been identif ied as the most signif icant barrier
to effective assessment and management of pain in the intensive care unit?
a. Patient inability to self report
b. Nurses perception of pain management
c. Family interventions
d. Documentation
7. Which of the following admissions categories provided the most patients for
the study?
a. Surgical
b. Trauma
c. Medical
d. Respiratory
1. a
b
c
d
2. a
b
c
d
3. a
b
c
d
4. a
b
c
d
5. a
b
c
d
6. a
b
c
d
7. a
b
c
d
8. a
b
c
9. a
b
c
d
10. a
b
c
d
Test ID: A132232 Contact hours: 1.0; pharma 0.0 Form expires: May 1, 2016. Test Answers: Mark only one box for your answer to each question.
11. a
b
c
d
12. a
b
c
d
Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP A Test writer: Jean Shinners, PhD, RN-BC
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