Pain Assessment and Management in Intensive Care Unit: Nurses' Practices, Perceived Influencing Factors, and Educational Needs

Impact of implementing the critical-care pain observation tool in the adult intensive care unit: A nonrandomised stepped-wedge trial

BACKGROUND

Approximately 70% of patients in intensive care units (ICUs) experience untreated pain, often due to severe patient conditions and communication barriers.

AIM

The aim of this study was to implement the Critical-Care Pain Observation Tool (CPOT) to improve pain assessment in patients unable to self-report pain in the ICU.

METHOD

A stepped-wedge trial was conducted in six adult ICUs in Saudi Arabia between February and June 2022. The sequential transition of ICU clusters occurred in February 2022, from control to intervention, until all ICUs were exposed to the intervention. The primary outcome was the number of pain assessments, whereas the secondary outcomes were reassessments. Other outcomes were length of stay, mechanical ventilation duration, and administered doses of sedatives and analgesic agents. Statistical analyses were performed using the Statistical Analysis Software v9.4.

RESULTS

A total of 725 patients unable to self-report pain were included; 65% (n = 469) were male with an average age of 55 years. Implementing CPOT showed a significant increase in the number of pain assessments (rate ratio: 1.77, 95% confidence interval: 1.45, 2.16, p < 0.001) and reassessments (rate ratio: 13.99, 95% confidence interval: 8.14, 24.02, p < 0.001) between intervention and control conditions. There was no significant effect on the ICU length of stay, mechanical ventilation duration, and the amount of sedation (midazolam, propofol, and ketamine) and analgesia (fentanyl) administered.

CONCLUSION

The study indicates that the implementation of the CPOT increased the frequency of pain assessment and reassessment. However, the impact on patient outcomes remains inconclusive. Further investigations focussing on CPOT as the primary pain scale are necessary to determine its holistic impact on patient outcomes over the long term.

TRIAL REGISTRATION

NCT05488834.

CLINICAL TRIAL REGISTRATION NUMBER

This study was registered with the U.S. National Library of Medicine (ClinicalTrial.gov, NCT05488834).

The comparison of pupillometry to standard clinical practice for pain and preemptive analgesia before endotracheal suctioning: A randomized controlled trial

BACKGROUND

Pain during endotracheal aspiration (ETA) is frequent in critically ill patients. Managing pre-emptive analgesia before procedures remains a crucial aspect of care. We compared pupillometry to standard clinical practice for assessing preemptive-analgesia administration and pain before ETA according to Behavioural Pain Scale (BPS), the Behavioural Pain Indicator Scale (ESCID), and the Pupillary Dilation Reflex (PDR).

TRIAL DESIGN

A multicentre parallel-group, controlled trial with balanced (1:1) randomization.

METHODS

Sedated, mechanically ventilated patients aged ≥ 18 with baseline BPS = 3, ESCID = 1, and RASS scores between -1 and -4 were included.

CONTROL GROUP

preemptive-analgesia was administered according to nurse criteria. In the experimental group, preemptive analgesia was administered in patients with PDR ≥ 11.5 % after a 20 mA stimulus measured using AlgiScan®. The preemptive analgesia was fentanyl one µg/kg iv bolus. We used the Chi-square statistic to compare post-intervention pain according to BPS, ESCID, and PDR pain values. A multivariate logistic regression study adjusting for sex, BIS, RASS, APACHE II, remifentanil, and preemptive analgesia was conducted.

RESULTS

Ninety-two patients were studied, 51 in control groups and 41 in intervention groups. Pain incidence was lower in the experimental group. Significantly, 43.9 % of patients in the experimental group were prescribed preemptive analgesia before ETA compared to 19.6 % in the control group (p = 0.03). Multivariate analysis showed significant reductions in pain in the group that received preemptive-analgesia before ETA guided by pupillometry across BPS [OR = 0.34 (95 % CI: 0.12-0.99), p = 0.048], ESCID [OR = 0.29 (95 % CI: 0.09-0.88), p = 0.030] and PDR [OR = 0.27 (95 % IC: 0.08-0.86), p = 0.027] compared to standard clinical practice.

CONCLUSIONS

Preemptive analgesia monitored with pupillometry group had a lower percentage of patients with pain than those who received analgesia based on standard clinical practice. This effect was independent of the sex, patient severity, BIS score, remifentanil use, or preemptive- analgesia.

IMPLICATIONS FOR CLINICAL PRACTICE

The requirement for preemptive analgesia before aspiration, evaluated through routine clinical practice, was lower than detected by pupillometric monitoring of patients. The use of pupillometry to monitor preemptive analgesia reduced pain after secretion aspiration. Pupillometry would be an effective tool to individualize the need for preemptive analgesia before potentially painful interventions, applicable to all patients regardless of sex, severity, or sedation level.

Pain management of adult sedated and ventilated patients in the intensive care units: A survey with free text responses

BACKGROUND

Pain management of sedated and ventilated patients in intensive care units lacks consistency.

OBJECTIVES

To investigate nurses' training, governance, practices, knowledge and attitudes relating to pain management in consideration of published guidelines and explore nurses' perspectives.

METHODS

A survey design, using an online questionnaire with free text responses, was employed. Quantitative and qualitative data from nurses working across different hospitals were collated and saved on Qualtrics platform. Quantitative data were analysed non-parametrically and narrative responses thematically. CROSS and SRQR reporting guidelines were adhered to.

OUTCOME MEASURES

Demographics, training, governance, clinical practice, knowledge, and attitudes.

RESULTS/FINDINGS

108 nurses participated with ninety-two completed surveys analysed. Analgesia was used to complete nursing tasks regardless of comfort needs (n = 49, 53.3 %). Changes in vital signs prompted opioid administration (n = 48, 52.1 %). Choice of analgesia depended on doctor's preference (n = 63, 68.5 %). Non-opioid therapy was administered before opioids (n = 42, 45.7 %). Sedatives were used to alleviate agitation(n = 50,54.3 %). No statistically significant difference in nurses' knowledge existed between hospitals. Weak positive relationship: r = [0.081], p = [0.441] between "knowledge scores" and "years of ICU experience" and weak negative relationship r = [-0.119], p = [0.260] between "knowledge scores" and "hours of clinical practice" was detected. Lack of training, resources, policies, high patient acuity and casual employment were acknowledged barriers to pain management. Two overarching themes emerged from narrative responses: "Pain assessment, where is it?" And "Priorities of critical illness."

CONCLUSION

The study uncovered pain management situation and examined nurses' demographics, training, governance, practices, knowledge and attitudes. Narrative responses highlighted barriers to pain management.

IMPLICATIONS FOR CLINICAL PRACTICE

Health organisations should provide education, institute governance and develop policies to inform pain management. Nurses' role encompasses updating knowledge, adhering to interventions and overcoming biases. This subsequently manifests as improvement in patient outcomes.

Evaluation of Pain During Endotracheal Aspiration in Intensive Care Patients Diagnosed with COVID-19

BACKGROUND

Endotracheal aspiration, a procedure that is particularly painful for intensive care patients, has received little attention in terms of pain evaluation specifically among intubated patients with COVID-19 in intensive care.

AIM

The study aims to assess the level of pain experienced by intubated intensive care patients diagnosed with COVID-19 during an endotracheal aspiration procedure.

METHOD

The study population was composed of patients admitted to the COVID-19 intensive care unit of the specified hospital between February and March 2021. Of the 56 patients admitted during that period, 47 were contacted and participated in the study. These 47 intubated and sedated patients were evaluated for 94 different expressions of pain during endotracheal aspiration twice a day before and during the procedure. Data were collected using the patient descriptive information form, the Non-Verbal Pain Scale for adults and data observation record form.

RESULTS

In the study, pain behavior was observed in 54.2% (n = 51) of the 94 observations. The patients were found to experience mild pain with an average score of 3.6 ± 1.07 on the Non-Verbal Pain Scale. The mean pain score before the procedure was found to be significantly different from the mean pain score during the procedure (p < .05), with an increase in pain during the procedure. During the procedure, 33.3% (n = 17) of the patients had a 10% decreased SpO2, and 29.4% (n = 15) had an increase in systolic blood pressure (>20), pulse (>20), and respiration (>10). Additionally, 21.5% (n = 11) of the patients experienced severe incompatibility with the ventilator, and 15.68% had muscle tension.

CONCLUSIONS

The study findings showed that nonverbal pain scores of sedated and intubated intensive care patients diagnosed with COVID-19 increased during endotracheal aspiration, accompanied by physiologic pain indicators. Effective pain management should be a priority for nurses. It is important to remember that patients with COVID-19 in the intensive care unit may experience pain while sedated and intubated. A holistic approach should be adopted for the evaluation and relief of pain in these patients. Intensive care nurses should consider physiologic and nonverbal behavioral pain indicators when evaluating pain in patients diagnosed with COVID-19.

Nurses' Attitudes, Practices, and Barriers to Assessing Symptoms of Discomfort in Mechanically Ventilated Patients: A Cross-Sectional Study

Introduction

Critically ill patients experience various stressful symptoms of discomfort, including dyspnea, pain, and sleep disruption. Notably, ventilated patients have difficulty self-reporting discomfort symptoms. Nurses need to assess discomfort symptoms to alleviate them, but limited research exists on discomfort symptom assessment and management in critically ill patients.

Objective

To identify the practices, attitudes, and barriers among nurses related to the assessment of discomfort symptoms in mechanically ventilated patients.

Methods

Using a cross-sectional, descriptive study design, a web-based survey was conducted between May and June 2022 with critical care nurses sampled through Japanese academic societies and social networking services. The survey contained questions relative to the above-stated objective. Descriptive statistical analysis was performed without sample size calculation because of the descriptive and exploratory nature of this study.

Results

There were 267 respondents to the questionnaire. The discomfort symptoms that nurses perceived as important to assess were pain (median 100 [interquartile range, IQR 90-100]), insomnia (99 [80-100]), and dyspnea (96.5 [75-100]). Most participants (89.8%) routinely assessed pain in mechanically ventilated patients using a scale; however, other discomfort symptoms were assessed by less than 40% (dyspnea [28.4%], fatigue [8.1%], thirst [13.1%], insomnia [37.3%], and anxiety [13.6%]). Two major barriers to assessing discomfort symptoms were lack of assessment culture within the intensive care unit and lack of knowledge of the relevant evaluation scales.

Conclusions

Nurses were aware of the importance of using scales to assess the discomfort symptoms experienced by mechanically ventilated patients. However, except for pain, most nurses did not routinely use scales to assess discomfort symptoms. Barriers to routine discomfort symptom assessment included the lack of an assessment culture and the lack of knowledge of the assessment scales. Clinicians should be educated regarding the existence of validated rating scales and develop additional rating scales utilizable for minor discomforts in mechanically ventilated patients.

Pain assessment practice and associated factors among nurses working at adult care units in public hospitals in Wolaita Zone, Southern Ethiopia, 2021

BACKGROUND

Using standard pain assessment techniques is a cornerstone for effective pain management. Pain is not assessed in a standardized manner in numerous practice settings. The problem of applying pain assessment principles was found to be higher in low-income countries. Very limited evidence indicates the standard of pain assessment practice among nurses in Ethiopia. Therefore, the purpose of this study was to identify pain assessment practice and associated factors among nurses working at adult care units in public hospitals in the Wolaita Zone, Southern Ethiopia.

METHODS

A cross-sectional study was conducted among 290 nurses working at adult care units in public hospitals in Wolaita zone. Data were collected from February to March 2021. A structured self-administered questionnaire was used for data collection. Epi Data 4.6 was used to enter the data, and SPSS version 26 was used to analyze the data. A logistic regression model was used, and statistical significance was declared at P ≤ 0.05. An adjusted odds ratio with 95%CI was used to measure the degree of association.

RESULTS

A total of 267 nurses participated in the study, giving a response rate of 97.8%. Almost three-fourths (73.8%) of the study nurses reported that they assessed pain for their patients. Only 23.6% of the study nurses discussed pain assessment scores during a nurse-to-nurse report. Below, half (47.2%) of the study participants documented pain assessment scores. The proportion of nurses with good pain assessment practice was found to be 38.2%. The odds of having good pain assessment practice among nurses who received training on pain management was two times higher than its counterpart. The nurses who perceived organizational support were twice more likely to have good pain assessment practice than their counterparts.

CONCLUSION

Nurses' pain assessment practice was found to be low. Moreover, a substantial proportion of the study nurses did not discuss pain assessment scores during a nurse-to-nurse report with low documentation practice. Continuous professional development through in-service training and education is crucial to the improvement of nurses' pain assessment practice. Furthermore, ameliorating organizational support by means of a supportive working environment is suggested to the betterment of nurses' assessment practice.

Nurses' Knowledge and Attitudes Regarding Pain Assessment and Management in Saudi Arabia

Inadequate pain management affects the patient outcome. Pain assessment and management are fundamental in nursing care, and nurses must be equipped with adequate knowledge and a positive attitude toward pain assessment and management. This study aims to evaluate nurses’ knowledge and attitudes regarding pain assessment and management at King Fahad Hospital, Al-Madinah, Kingdom of Saudi Arabia. A quantitative, cross-sectional survey, using a self-administered questionnaire, was conducted from January to February 2020 with 660 registered nurses working in the Emergency Department, critical care units, inpatient and outpatient departments at King Fahad Hospital in Al-Medinah, Kingdom of Saudi Arabia. The data were analyzed with descriptive and inferential statistics. Of the 660 nurses, 291 responded, resulting in a response rate of 44.09%. The participants’ scores ranged from 17.7% to 100%, with a mean score 45.29%. The majority of the participants (70.1%) had a poor level of knowledge and attitudes (score < 50%). Nurses working in the outpatient department scored significantly higher than the group working in the Emergency Department and inpatient wards. Deficient knowledge and negative attitudes were found and nurses continue to underassess and undertreat pain. Nursing school curricula and in-service continuous education must equip nurses with the required knowledge and attitudes to enable them to manage pain effectively.