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 Background Critically ill adults often cannot self-report pain. Objective To determine the effect of the Critical-Care Pain Observation Tool on frequency of documentation of pain assessment and administration of analgesics and sedatives in critically ill patients unable to self-report pain. Methods Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after implementation of the tool. Patients were prospectively screened for eligibility; data were extracted retrospectively. Results Data were recorded for a maximum of 72 hours before and after implementation of the tool in the cardiovascular intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% (P < .001) in the cardiovascular unit and from 22% to 80% (P < .001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit (P = .02) and increased from 27 mg to 75 mg (P = .002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg (P < .001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. Conclusion Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units. (American Journal of Critical Care. 2013;22:246-255)
Notice to CNE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following 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. To read this article and take the CNE test online, visit www.ajcconline.org and click “CNE Articles in This Issue.” No CNE test fee for AACN members. ©2013 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2013200
AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3
tudies1-5 on recall of moderate to severe pain challenge the effectiveness of pain management during an intensive care unit (ICU) stay. Patients’ inability to selfreport pain is a marked barrier to effective assessment and management of pain. Because impaired communication is common among critically ill patients as a result of sedation, altered level of consciousness, and endotracheal intubation,6 clinicians cannot use self-report tools and must rely on alternative methods to determine if a patient has pain.
Several behavioral pain assessment tools7-11 are now available that facilitate detection of pain experienced by critically ill patients unable to communicate. Systematic pain assessment, with either patient self-reporting or use of behavioral pain assessment tools as appropriate, can improve patients’ outcomes. In a large multicenter observational study,12 pain assessment was associated with reductions in the duration of mechanical ventilation and ICU stay. In a small study13 involving patients in a neurotrauma ICU, introduction of the Nonverbal Pain Scale9 increased documentation of pain assessments and...