Can the critical-care pain observation tool (CPOT) be used to assess pain in delirious ICU patients?

Knowledge and Attitudes of Critical Care Nurses Regarding Pain Management in Saudi Arabia

Background

Approximately five million patients on yearly basis are being admitted to the critical care unit around the world. Around (77%) of these patients suffer from pain during their stay in critical care units. Undertreated pain aggravates anxiety, sleep deprivation, agitation, delirium, and depression that often lead to a chronic condition. There are various barriers toward recognition and proper management of pain such as sedation, the presence of endotracheal tube, healthcare providers lack of knowledge etc. Therefore, it becomes essential for the nurses to have the required knowledge related to pain, valid pain assessment tools, and proper management.

Objective

The present study aimed at investigating the critical care nurses' knowledge and attitude towards pain management at a university hospital in Saudi Arabia.

Methods

A descriptive cross-sectional design of 112 nurses working at intensive care units and emergency department. The data collected using a knowledge and attitude regarding pain (KASRP) survey.

Results

Majority of nurses had inadequate knowledge regarding pain management. Among 112 nurses, only 8 nurses (7.1%) were with good level of knowledge compared by 54 nurses (48.2%) with poor level of knowledge. Results showed significant association between knowledge and attitude and the current position in the ICU (p=0.043).

Conclusion

It is mandatory to monitor nurses' pain management knowledge continuously. As well as to emphasis significance of an educational programs that serve nursing practice.

Pain Assessment with the BPS and CCPOT Behavioral Pain Scales in Mechanically Ventilated Patients Requiring Analgesia and Sedation

BACKGROUND

Intensive Care Unit (ICU) patients often experience pain, especially during diagnostic, nursing, and therapeutic interventions. Pain assessment using the Behavioral Pain Scale (BPS) and Critical Care Pain Observation Tool (CCPOT) are recommended, but they are difficult to do in patients undergoing deep sedation. This study analyzed the usefulness of the BPS and CCPOT scales in assessing pain among patients with varying degrees of sedation.

METHODS

In 81 mechanically ventilated and sedated ICU patients, 1005 measurements were performed using the BPS and CCPOT scales. The study was conducted by 3 trained observers 3 times a day (each measurement at rest, during painful nursing interventions, and after the intervention). The Richmond Agitation-Sedation Scale (RASS), the Simplified Acute Physiology Score (SAPS II), and the Acute Physiology and Chronic Health Evaluation (APACHE II) were also analyzed from medical records as well as information on the length of hospitalization and treatment.

RESULTS

It was shown that signs of pain increased significantly (p < 0.001) during interventions in patients on both scales (BPS and CCPOT), and then returned to values close to the resting period. RASS results correlated significantly (p < 0.05) and positively with the results of the BPS and CCPOT. A strong correlation was found between the results of both scales at each stage of the study (R = 0.622-0.907).

CONCLUSIONS

Nursing procedures are a source of pain in analgosedated patients. The BPS and CCPOT scales are useful tools for assessing the occurrence of pain in mechanically ventilated patients, including those in deep sedation.

A prospective comparison between multidisciplinary healthcare providers' clinical examination and a validated pain scale

Introduction

Unrecognized pain in the Intensive Care Unit (ICU), due to inadequate assessment and therapeutic management, is associated with increased morbidity and mortality. Despite the availability of validated pain monitoring tools, such as the Critical-Care Pain Observational Tool (CPOT), these scales are not commonly used in clinical practice, with healthcare professionals often relying on their clinical impression. Our study aims to determine the agreement between the pain examination performed by ICU professionals and the CPOT.

Methods

Prospective cohort study that included critically ill patients and physicians, nurses and physiotherapists from an ICU in Bahia, Brazil. During bedside clinical rounds, the CPOT score was applied to assess the pain of hospitalized patients, and health professionals were interviewed to ascertain their perception of the patient's pain for a maximum of five consecutive days. Correlations were assessed using the Spearman rank tests. Hierarchical cluster analysis was employed to show the results of CPOT score and pain assessment by healthcare professionals at each study time. And the Kappa statistic was calculated to assess the agreement between the CPOT score vs. the pain assessment by healthcare providers.

Results

One hundred one patients were included in the study with median age of 74 years (IQR 61.5–83.5), a predominance of women (55.4%) and a median SAPS 3 score of 45 (IQR 39.5–53.0). The correlation between the professional's pain assessment and the CPOT were mostly statistically significant, ranged from negligible to weak, being the highest index obtained in the evaluation of nurses on day 5 (Kappa index = 0.43, p = 0.005). Physician assessments were significant only in day 1. On the presence of pain, the professionals' assessments and CPOT revealed mild to a moderate agreement.

Conclusion

Healthcare professional's pain assessment displayed a weak positive correlation with a validated pain scale and poor agreement amongst members of the ICU team, particularly when the pain was felt to be absent. Thus, this study highlights the importance of routine tools for pain assessment in the ICU for all members of multidisciplinary teams.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

Pain and delirium: mechanisms, assessment, and management

PURPOSE

Pain and delirium are common problems for older people. Both conditions are prevalent in acute hospital settings. In people living in the community, delirium often precipitates presentation to the emergency department. Pain and delirium are known to interact in a complex and multidirectional way. This can make it challenging for staff to recognize and treat pain in people with delirium.

METHODS

This paper aims to explore the complex relationship between pain and delirium and on pain assessment in delirium, drawing together evidence from a range of settings including acute medical, cardiac and orthopaedic post-operative cohorts, as well as from aged care.

RESULTS

A limited number of studies suggest there is an association between pain and delirium; however, this is a complex, particularly where analgesics which may-themselves cause delirium are prescribed. Factors acting on the pathway between pain and delirium may include depression, sleep deprivation and disturbance of the cholinergic system. Delirium affects the ability to self-report pain. The fluctuating nature of delirium as well as reduced awareness and attention may challenge practitioners in recognizing, assessing and treating pain. Evidence concerning the reliability and validity of current observational and self-assessment tools in people with delirium is unclear but some show promise in this population.

CONCLUSION

The current evidence base regarding assessing pain in people with delirium is lacking. Tentative recommendations, drawing on current guidelines require robust testing. Guidelines for people with pain and dementia require adaptations regarding the unique characteristics of delirium. The complex interplay between dementia, pain and delirium warrants further investigation across a range of settings.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BACKGROUND

Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes.

OBJECTIVES

To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.

METHODS

Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.

RESULTS

A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).

CONCLUSION

Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

The German version of the Critical-Care Pain Observation Tool for critically ill adults : A prospective validation study

BACKGROUND

The implementation of the Critical-Care Pain Observation tool (CPOT) in intensive care units (ICU) has been associated with more frequent pain assessments, a reduced number of complications, and improved administration of analgesics and sedatives. So far no German translation exists. Translating this tool into foreign languages requires further validation testing.

OBJECTIVE

The aim of this prospective observational validation study was to translate the original version of the CPOT according to scientific principles for translation and to establish the validity and reliability of the German translation of CPOT for critically ill adult patients.

MATERIAL AND METHODS

A total of 292 cardiac surgery patients from 2 ICUs of 2 German university teaching hospitals were included (114 patients at center 1 and 178 patients at center 2). Of the included patients 22.6% were female and 76.4% were male with a mean age of 68.5 years ±9.3 SD. Pain was evaluated with the CPOT, the Bhavioral Pain Scale (BPS) and with the Numeric Rating scale (NRS) at three time points (1. intubated + sedated, 2. intubated + awake, 3. extubated + awake) at rest and during nociceptive stimulus (positioning). Assessments were made separately by trained physicians and nursing staff.

RESULTS

Good results for interrater reliability and internal consistency could be demonstrated (weighted Cohen's kappa of 0.73, Cronbach's coefficient alpha of 0.8). Spearman correlation between CPOT and NRS was moderate but significant. The receiver operating characteristic (ROC) analysis to obtain optimal thresholds of CPOT to detect pain revealed different results during rest and stimulus and in intubated and extubated patients.

CONCLUSION

The validated German CPOT translation is a reliable tool for pain assessment in cardiac ICU patients in the absence of patients' ability for self-reporting. The use of this German version of CPOT now allows a better international comparability of corresponding data in future studies.

Strategies for Pain Assessment in Adult Patients With Delirium: A Scoping Review

CONTEXT

Pain and delirium are highly prevalent in the same patient groups. Disturbances in attention, awareness, and cognition are characteristics for delirium and can compromise pain assessment.

OBJECTIVES

The aim of this review was to examine and map models and understandings of pain and delirium as well as pain assessment instruments and strategies for adult patients with delirium.

METHODS

A scoping review of all publications that reported on pain assessment in adult patients with delirium was conducted with no time and language constraints, searching Medline, CINAHL, Scopus, Embase, and PsycINFO and systematically assessing for inclusion. Standardized data extraction and a narrative synthesis followed.

RESULTS

A total of 90 publications were included in the final analysis. Despite being recommended for practice, no evidence for the use of self-report or behavioral pain assessment instruments in patients with delirium was identified, with the exception of limited evidence for the validity of the Critical Care Pain Observation Tool and Behavioral Pain Scale in delirious intensive care patients. Proxy ratings of pain and comprehensive pain assessment hierarchies were also recommended, but not supported by evidence. Current models and/or understandings of pain and delirium were not applied in most publications.

CONCLUSION

The current literature is insufficient to guide clinical practice in pain assessment in patients with delirium. Future research will be needed to address the validity of existing pain assessment instruments, apply theoretical and conceptual understandings of pain and delirium, and build on prior studies to close evidence gaps.

Pain Screening in the Older Adult With Delirium

BACKGROUND

In patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking.

AIM

To examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings.

DESIGN

A descriptive repeated measures design.

SETTING

Medical-surgical units in an urban tertiary care hospital.

PARTICIPANTS

Sixty-eight older adults with delirium.

METHODS

Patients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention.

RESULTS

Patients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, η_p² = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, η_p² = 0.11.

CONCLUSIONS

The PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings.

CLINICAL IMPLICATIONS

Pain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.

Validating a pain assessment tool in heterogeneous ICU patients: Is it possible?

BACKGROUND

Non-communicative adult ICU patients are vulnerable to inadequate pain management with potentially severe consequences. In German-speaking countries, there is limited availability of a validated pain assessment tool for this population.

AIM

The aim of this observational study was to test the German version of the Critical-Care Pain Observation Tool (CPOT) in a heterogeneous adult ICU population.

METHODS

The CPOT's feasibility for clinical use was evaluated via a questionnaire. For validity and reliability testing, the CPOT was compared with the Behavioural Pain Scale (BPS) and patient's self-report in 60 patients during 480 observations simultaneously performed by two raters.

RESULTS

The feasibility evaluation demonstrated high satisfaction with clinical usability (85% of responses 4 or 5 on a 5-point Likert scale). The CPOT revealed excellent criterion validity [agreement between CPOT and BPS 94.0%, correlation of CPOT and BPS sum scores r = 0.91 (P < .05), agreement of CPOT with patient self-report 81.4%], good discriminant validity [mean difference of CPOT scores between at rest and non-painful stimulus 0.33 (P < .029), mean difference of CPOT scores between at rest, and painful stimulus 2.19 (P < .001)], for a CPOT cut-off score of >2 a high sensitivity and specificity (93% and 84%), high positive predictive value (85%), and a high negative predictive value (93%). The CPOT showed acceptable internal consistency (Cronbach's α 0.79) and high inter-rater reliability [90% agreement, no differences in CPOT sum scores in 64.2% of observations, and correlation for CPOT sum scores r = 0.72 (P < .05)]. Self-report obtained in patients with delirium did not correlate with the CPOT rating in 62% of patients.

CONCLUSION

This is the first validation study of the CPOT evaluating all of the described validity dimensions, including feasibility, at once. The results are congruent with previous validations of the CPOT with homogeneous samples and show that it is possible to validate a tool with a heterogeneous sample. Further research should be done to improve pain assessment and treatment in ICU patients with delirium.

RELEVANCE TO CLINICAL PRACTICE

The German CPOT version can be recommended for ICUs in German-speaking countries.

Pain measurement techniques: spotlight on mechanically ventilated patients

Background

Procedural pain is a frequent problem in intensive care units (ICUs). For that, pain assessment has been increasingly introduced to the ICU professional’s routine, and studies have been developed to show the relevance of measuring pain in critically ill patients.

Objective

This review aimed to describe pain measurement techniques for mechanically ventilated adult patients based on evidence and already published.

Method

Systematic literature search was performed on PubMed and Google Scholar. Keywords “pain”, “pain measurement”, “intensive care units” and “respiration, artificial” were combined to the Boolean operator AND. No language or publication year was limited in this search. The purpose and method of all papers were analyzed and only studies which described pain assessment in mechanically ventilated patients were included in this review.

Results

Objective methods were found in the literature to assess pain in mechanically ventilated adults. Behavioral scales were the most used method for pain measurement in noncommunicative patients. Vital signs were used, but the reliability of this method was questioned. Pupillometry, bispectral index and skin conductance were found and described as pain assessment methods.

Conclusion

This review showed that objective measures, as behavioral scales, are the gold standard tools to measure pain intensity in noncommunicative subjects. These data contribute to professionals’ knowledge about ICU pain measurement and emphasize its importance and consequences for adequate pain management.

Implementation of the Critical Care Pain Observation Tool increases the frequency of pain assessment for noncommunicative ICU patients

BACKGROUND

Pain is a common stressor for ICU patients, necessitating routine assessment. For patients who are unable to communicate, self-report tools are unsuitable, and the use of an observational tool is required to assess pain appropriately. The Critical Care Pain Observation Tool (CPOT) is the most reliable tool currently available to assess pain in these patients. We investigated whether the implementation of the CPOT in one Australian ICU could increase frequency of appropriate pain assessments, and if this would affect the administration of analgesia and sedation.

METHODS

In this before and after study, we first performed a retrospective chart audit on 441 adult ICU patient charts, over 49 days. Data collected included frequency and type of pain assessments, sedation and analgesia administered, communication and CAM-ICU status, and bedside nurse-perceived pain. During the implementation phase, new policy and guideline documents were released, and ICU charts were redesigned to incorporate the CPOT. All nursing staff attended an education session on pain assessment and correct use of the CPOT. The chart audit was repeated, capturing 344 charts over 43 days.

RESULTS

Mean total assessments in 24 hours increased from 7.2 to 7.9 for communicative, 3.0 to 8.9 for non-communicative, and 5.1 to 9.1 for transitioning patients. For non-communicative patients there was a significant increase in observational assessments including the CPOT (1.7 to 8.3), and a decrease in inappropriate use of self-report tools (1.3 to 0.2). We also observed significant increases in administration of paracetamol, opiates, propofol, patient-controlled analgesia, modified-release opiates, and neuropathic pain agents.

CONCLUSIONS

Implementation of the CPOT using standardised education and resources led to increased frequency of pain assessment, particularly for non-communicative patients. Appropriate observational assessments were also more frequently used for these patients. Analgesic administration generally increased, as did the use of propofol.

The Critical care Pain Observation Tool is reliable in non-agitated but not in agitated intubated patients

OBJECTIVE

The Critical-Care Pain.

OBSERVATION

Tool is one of the instruments developed to assess pain in patients who are unable to communicate verbally. The study aimed to survey the psychometric properties of Critical-Care Pain.

OBSERVATION

Tool in four groups of non-verbal patients according to their Richmond Agitation Sedation Score (RASS).

STUDY DESIGN AND METHODOLOGY

65 critically ill patients (medical, surgical, trauma) were assessed using the critical care pain observation tool on six occasions (before, during and after nociceptive and non-nociceptive procedures). Patients were divided into four groups according to their RASS score: 1. All patients (RASS -3 to +2), 2. Sedated patients (RASS -3 to -1), 3. Restless patients (RASS +1), 4. Agitated patients (RASS +2).

RESULTS

Discriminant and criterion validity, confirmatory factor analysis and internal reliability showed good validity and reliability in the critical care pain observation tool in all groups except agitated patients. The results showed that, in general, the CPOT has good version of the critical care pain observation tool has good psychometric properties to evaluate pain in non-verbal patients admitted to intensive care units who have a RASS score ranging from -3 to +1, but it is not a good tool to evaluate pain in patients who are agitated according to RASS.