Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients

OBJECTIVE

To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients.

DESIGN

A multicentre, prospective observational study was designed to validate a scale measuring instrument.

SETTING

Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System.

PARTICIPANTS

A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients.

PROCEDURE

Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure.

MAIN VARIABLES

ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS.

RESULTS

A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88).

CONCLUSION

ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Content Validation of the Behavioural Indicators of Pain Scale in Critically Ill Patients With Acquired Brain Injury: A Delphi Study

BACKGROUND

Pain assessment in critically ill patients with acquired brain damage and disorders of consciousness is challenging.

AIM

To evaluate the content validity of an adapted version of the Behavioural Indicators of Pain Scale (Spanish: Escala de Conductas Indicadoras de Dolor [ESCID]) in patients with acquired brain damage, disorders of consciousness and an artificial airway.

STUDY DESIGN

Modified e-Delphi study. Five rounds of e-Delphi study to assess the content validity of the ESCID were conducted. Ten experienced clinical experts specialized in the area of interest were recruited. The starting point for the e-Delphi study was a questionnaire containing 30 behavioural indicators of pain. The expert panel evaluated the content validity of the 30 items based on four criteria: relevance, pertinence, clarity and usefulness. Each criterion was scored on a Likert-type scale ranging from 1 'strongly disagree' to 5 'strongly agree'. Upon completion of all five e-Delphi rounds, a face validity test was performed.

RESULTS

Of the initial 30 behavioural indicators, 10 remained after the final round. These items were defined and categorized and included in the final version of the instrument. The degree of consensus among the experts was high with regard to the content validity of these 10 indicators. In terms of face validity, 70% of the experts considered that the writing and comprehensibility of nine of the 10 items was 'good'.

CONCLUSIONS

A strong consensus was reached by the expert panel through the e-Delphi technique. The 10 items represent the content of the behavioural response to pain in this population.

RELEVANCE TO CLINICAL PRACTICE

This study is the first step to adapt Behavioural Indicators of Pain Scale for use in this patient population. This adapted scale will provide clinicians with a specific tool to improve pain detection and management.

TRIAL REGISTRATION

The protocol is registered with ClinicalTrials.gov: NCT04898491, available at: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04898491.

Identification of hospitalized patients with nutritional risk at admission assessed with the Nutrition Risk Screening

AIM

To determine the prevalence of nutritional risk in hospital admission of adult patients and to analyse its association with patients' sociodemographic and clinical factors.

METHOD

Cross-sectional, analytical and prospective study carried out on patients at the Hospital de la Santa Creu i Sant Pau in Barcelona between November and December 2018, during the first 48 hours of hospital admission. Nutrition Risk Screening (NRS-2002) was used to detect malnutrition. Sociodemographic (age, sex), clinical (admission diagnosis, unit and comorbidities) and anthropometric (weight, height and BMI) data were collected. The association between the NRS and the study factors was estimated using a logistic regression model.

RESULT

285 patients with a mean age of 69.6 years (SD 15) were included, of which 56.5% (161) were ≥70 years. The prevalence of risk of malnutrition at hospital admission was 35.1% (95% CI: 29.8% - 41.1%), this being 15.9 times higher in patients with a previous stay in intensive care (OR 15 .90, 1.82 - 139.11: p 0.012); 10.35 times higher in patients with severe pneumonia (OR 10.35; 2.48 - 41.91: p 0.004) and 5.6 times higher in patients with stroke (OR 5.63; 1.71 - 18.53: p 0.004).

CONCLUSIONS

The prevalence of nutritional risk at admission was high and factors such as severe pneumonia, stroke and previous ICU admissions were associated with a higher risk of malnutrition. However, the findings of this study should be interpreted with caution due to the limitations of the Nutrition Risk Screening. severity criteria.

Electrophisiological monitoring of pain in non-communicative critically ill patients

Electrophysiological monitoring of pain provides objective measures that allow for pain control and adjustment of analgesia in non-communicative patients. Among the available electrophysiological devices, automated infrared pupillometry, Analgesia Nociception Index (ANI), and Nociception Level Index (NOL®) stand out. These non-invasive measurement systems analyze the sympathetic or parasympathetic nervous system response to painful stimuli by observing pupillary dilatation and reactivity (pupillometry), heart rate during respiration (ANI), or a combination of multiple parameters from the nociceptive-autonomic medullary circuit (NOL®). These methods have mainly been used in the monitoring of nociception related to procedures in critically ill patients. Furthermore, they have allowed for the prediction, adjustment, and customization of analgesia administration prior to painful procedures. To obtain accurate measurements and properly interpret the values provided by these devices, it is important to consider certain limitations in their use, such as the administration of specific medications or the presence of certain pathologies, due to their influence on the autonomic nervous system response. It is also important to note that the reported level of evidence is limited, as randomized clinical trials in the context of intensive care unit regarding these devices are currently lacking.

Validity and Reliability of the Behavioural Indicators of Pain Scale Adapted to Patients With Acquired Brain Injury: ESCID-DC Study Protocol

AIM

To adapt and validate the Behavioural Indicators of Pain Scale (ESCID) for use in critically ill patients with acquired brain injury and artificial airway who are unable to self-report (ESCID-DC).

DESIGN

Multicentre, prospective, observational validation study of the Behavioural Indicators of Pain Scale-Brain Injury (ESCID-DC).

METHODS

The study will be carried out in three phases, as follows: (1) Content development and evaluation of content validity by a group of experts (Delphi technique). Face validity will be assessed through a pilot study; (2) multicentre validation study of the new scale (ESCID-DC) in a large sample of patients (≥ 300) at 17 hospitals in Spain. Two blinded observers at each centre will assess painful behaviours using the ESCID-DC and a reference scale, the NCS-R-I (Nociception Coma Scale-Revised-adapted for Intubated patients). Pain will be assessed at three time points: 5 min before, during and 15 min after the performance of painful and non-painful procedures; (3) the psychometric evaluation of the scale will consist of a reliability analysis, a validity analysis (construct, convergent and discriminant), and a sensitivity to change analysis.

DISCUSSION

The ESCID-DC scale will provide specific, adapted behavioural indicators to detect the presence of pain in this patient population.

IMPACT

Given the high prevalence of pain in critically ill patients, the availability of a new instrument to detect and monitor pain behaviours associated with routine ICU procedures will allow clinicians to reliably assess pain and implement preventive strategies in a highly vulnerable patient population.

REPORTING METHOD

The report of this study protocol followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines and Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines and standards.

PATIENT OR PUBLIC CONTRIBUTION

This study did not receive any patient or public contributions.

TRIAL REGISTRATION

The protocol is registered with ClinicalTrials.gov: NCT04898491, available at: https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04898491.

Development and psychometric validation of the Behavioral Indicators of Pain Scale-Brain Injury (ESCID-DC) for pain assessment in critically ill patients with acquired brain injury, unable to self-report and with artificial airway

INTRODUCTION

The aim of this study was to develop and validate the adaptation of the behavioural indicators of pain scale (ESCID) for patients with acquired brain injury (ESCID-DC), unable to self-report and with artificial airway.

METHODS

Multicenter study conducted in 2 phases: scale development and evaluation of psychometric properties. Two blinded observers simultaneously assessed pain behaviours with two scales: ESCID-DC and Nociception Coma Scale-Revised version-adapted for Intubated patients (NCS-R-I). Assessments were performed at 3 time points: 5 min before, during and 15 min after the application of the painfull procedures (tracheal suction and application of pressure to the right and left nail bed) and a non-painful procedure (rubbing with gauze). On the day of measurement, the Glasgow Coma Score (GCS) and the Richmond Agitation Sedation Scale (RASS) were evaluated. A descriptive and psychometric analysis was performed.

RESULTS

A total of 4152 pain evaluations were performed in 346 patients, 70% men with a mean age of 56 years (SD = 16.4). The most frequent etiologies of brain damage were vascular 155 (44.8%) and traumatic 144 (41.6%). The median GCS and RASS on the day of evaluation were 8.50 (IQR = 7 to 9) and -2 (RIQ = -3 to -2) respectively. In ESCID-DC the median score was 6 (IQR = 4 to 7) during suction, 3 (RIQ = 1 to 4) for right pressure and 3 (RIQ = 1 to 5) for left pressure. During the non-painful procedure it was 0. The ESCID-DC showed a high discrimination capacity between painful and non-painful procedures (AUC > 0.83) and is sensitive to change depending on the time of application of the scale. High interobserver agreement (Kappa > 0.87), good internal consistency during procedures (α-Cronbach≥0.80) and a high correlation between the ESCID-DC and the NCS-R-I (r ≥ 0.75) were obtained.

CONCLUSIONS

The results of this study demonstrate that the ESCID-DC is a valid and reliable tool for assessing pain in patients with acquired brain injury, unable to self-report and with artificial airway.

10 key issues for prevention, monitoring and non-pharmacological treatment of delirium in critically ill patients

In intensive care units, due to critical illness nature and environment special characteristics, it is relatively common for admitted patients to develop acute confusional syndrome (ACS) or delirium. The nurse's duties are to carry out interventions that reduce the presentation of this process, which is still an important complication as it is related to longer periods of mechanical ventilation, longer ICU and hospital stays, higher mortality; both in-hospital and after discharge and grater long term cognitive dysfunction. Therefore, nurses participation is essential to prevent and treat delirium, and more specifically in the autonomous part with non-pharmacological measures such as pain control, avoid under or oversedation, promoting restful sleep and facilitating family support among other measures. The objective is to carry out an update that describes 10 key points focused on the tools for detecting/monitoring delirium and non-pharmacological measures for its prevention and treatment. Based on the review of the literature, the 10 most common interventions are described to serve as an action plan to be included in the care plans of patients affected with delirium, providing quality care to prevent and/or treat delirium in critical patients.