You are on page 1of 11

Behavioral Pain Assessment Tool for Critically Ill Adults Unable to

Self-Report Pain
Louise Rose, Lynn Haslam, Craig Dale, Leasa Knechtel and Michael McGillion
Am J Crit Care 2013;22:246-255 doi: 10.4037/ajcc2013200
2013 American Association of Critical-Care Nurses
Published online

Personal use only. For copyright permission information:

Subscription Information

Information for authors

Submit a manuscript

Email alerts

AJCC, the American Journal of Critical Care, is the official peer-reviewed research
journal of the American Association of Critical-Care Nurses (AACN), published
bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049.
Copyright 2013 by AACN. All rights reserved.

Downloaded from at Mobile User on May 20, 2013

Critical Care Evaluation

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

CNE 1.0 Hour 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 inten-
Notice to CNE enrollees:
sive care unit (130 patients before and 132 after) and in the
A closed-book, multiple-choice examination
following this article tests your understanding of medical/surgical/trauma unit (59 patients before and 52 after).
the following objectives: Proportion of pain assessment intervals with pain assessment
documented increased from 15% to 64% (P < .001) in the car-
1. Describe key elements of the behavioral assess- diovascular unit and from 22% to 80% (P < .001) in the other
ment Critical-Care Pain Observation Tool unit. Median total dose of opioid analgesics decreased from 5
(CPOT). mg to 4 mg in the cardiovascular unit (P = .02) and increased
2. Evaluate effects of CPOT with change in prac- from 27 mg to 75 mg (P = .002) in the other unit. Median total
tice for documentation and administration of
dose of benzodiazepines decreased from 12 mg to 2 mg (P <
analgesics and sedatives.
.001) in the cardiovascular unit and remained unchanged in
3. Compare results among studies regarding com-
the other unit. Increased documentation of pain assessment
pliance with pain assessment documentation
and practice recommendations. was associated with increased age in the cardiovascular unit
and with decreased maximum scores on the Sequential Organ
To read this article and take the CNE test online, Failure Assessment in the other unit.
visit and click CNE Articles Conclusion Implementation of the tool increased frequency
in This Issue. No CNE test fee for AACN members. of pain assessment and appeared to influence administration

2013 American Association of Critical-Care Nurses

of analgesics in both units. (American Journal of Critical Care.



Downloaded from at Mobile User on May 20, 2013

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 self-
report 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 of patients, including trauma and cardiothoracic
now available that facilitate detection of pain expe- surgery patients. We hypothesized that implementa-
rienced by critically ill patients unable to communi- tion of the CPOT would increase documentation of
cate. Systematic pain assessment, with either patient pain assessment and influence administration of
self-reporting or use of behavioral pain assessment analgesics and sedatives. Our primary objective was
tools as appropriate, can improve patients outcomes. to determine the effects on the frequency of docu-
In a large multicenter observational study,12 pain mentation of pain assessment (pain scores and nar-
assessment was associated with reductions in the dura- rative) and on the administration of analgesics and
tion of mechanical ventilation and ICU stay. In a sedatives in patients unable to self-report pain. Our
small study13 involving patients in a neurotrauma secondary objectives were to determine patient fac-
ICU, introduction of the Nonverbal Pain Scale9 tors associated with documented pain assessment
increased documentation of pain assessments and and opioid administration and to
decreased recalled severity of the pain patients examine the impact of CPOT imple-
experienced. More recently, Glinas et al14 reported mentation on ICU length of stay and
Systematic pain
increased pain documentation and decreased admin- the duration of mechanical ventilation. assessment
istration of analgesic and sedative agents after intro-
duction of the Critical-Care Pain Observation Tool Methods improves patients
(CPOT) in a small mixed ICU population (30 patients Study Design, Participants, and outcomes, reduc-
before, 30 at 3 months, and 30 at 12 months after Setting
implementation). However, few studies have evalu- A before-and-after design was ing mechanical
ated the effect of these tools on pain assessment and used to examine the effect of CPOT ventilation time
management practices; most published studies7,8,14 implementation in 2 ICUs at Sunny-
have been conducted by investigators involved in brook Health Sciences Centre, a 600- and length of stay.
the development and or validation of the tools. bed university-affiliated hospital in
Our goal was to determine the effect of imple- Toronto, Ontario. The ICUs were a 20-bed mixed
menting the CPOT7 in 2 ICUs of a university-affiliated medical/surgical/trauma ICU (CRCU) that admits
hospital that provide services to a mixed population more than 1100 patients annually and a 14-bed car-
diovascular ICU (CVICU) that admits 1150 patients
each year. Both ICUs functioned as closed intensivist-
About the Authors led units. Each week, the 20-bed CRCU was overseen
Louise Rose is a Lawrence S. Bloomberg limited-term
professor in critical care, Lawrence S. Bloomberg Faculty
by 2 intensivists; the 14-bed CVICU was supervised
of Nursing, University of Toronto, Toronto, Ontario, by 1 intensivist. A team of medical trainees, includ-
Lynn Haslam is an advanced practice nurse, Department ing fellows and residents, supported each intensivist
of Anaesthesia, and Leasa Knechtel is the director of
nursing education, Sunnybrook Health Sciences Centre,
to provide 24-hour care. These ICUs employed more
Toronto, Ontario, Craig Dale is an advanced practice than 100 (CRCU) and 65 registered nurses (CVICU)
nurse, Department of Trauma, Emergency and Critical in full- and part-time positions.
Care, Sunnybrook Health Sciences Centre, and a PhD
candidate, Lawrence S. Bloomberg Faculty of Nursing,
The CPOT consists of 4 domains: facial
and Michael McGillion is an assistant professor, Lawrence expression, body movement, muscle tension, and
S. Bloomberg Faculty of Nursing, and a member of the compliance with the ventilator (or vocalization for
board of directors of the Canadian Pain Society.
nonintubated patients). Each domain is scored from
Corresponding author: Louise Rose, Lawrence S. Bloomberg 0 to 2, with a maximum score of 8. The tool has
Faculty of Nursing, University of Toronto, 155 College
St, Toronto, Ontario, Canada, M5T IP8 (e-mail: louise.rose content validity, moderate to high interrater relia- bility, discriminate validity, and moderate criterion AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 247

Downloaded from at Mobile User on May 20, 2013

validity.7,16,17 Before implementation of the CPOT, ventilation, and length of ICU stay. In order to
the pain management policies of the ICUs did not guide extraction of narrative descriptions of pain
include use of a behavioral pain assessment tool, assessment, a reference compendium of potential
although individual nurses self-reported that they behavioral descriptors was compiled from published
used various tools, including the CPOT.18 The rec- behavioral pain assessment tools.7-9,11,19,20 Data abstrac-
ommended frequency of pain assessment, or pain tors were instructed to record verbatim all docu-
assessment intervals (PAIs), for surgical patients was mentation potentially related to pain assessment
hourly for 6 hours postoperatively and then a mini- and management, including ambiguous documen-
mum of every 4 hours. Nonsurgical tation. The abstractors excluded any reference to
Two intensive patients were expected to have pain pain behaviors elicited during routine neurological
assessment documented a minimum assessment. Random audits of data extraction were
care units were of every 4 hours. done to ensure consistency of nurses narratives of
used, a 20-bed For the baseline phase of the
study, patients were recruited from
pain documentation recorded by research staff.

mixed unit and a September 2008 to January 2009. Tool Implementation

After a 4-month implementation Before use of the CPOT was implemented, all
14-bed cardio- phase, patients were recruited from nurses attended educational sessions that included
vascular unit. June to October 2009. Patients were video demonstration of pain behaviors and instruc-
eligible if they were unable to com- tion on application of CPOT. Videos were provided
municate verbally or via other means, as determined by Dr Glinas, who developed the CPOT and who
by documented failure to follow verbal commands used the videos in the study of CPOT implementa-
or a motor score of 5 or less on the Glasgow Coma tion.14 Existing unit protocols and ICU flow sheets
Scale. Each patients inability to communicate was were modified to incorporate the CPOT. Point-of-
confirmed with the patients bedside nurse. Patients care CPOT scoring guides were available at every
were excluded if they were receiving neuromuscular bedside, posters were displayed in prominent loca-
blockers at the time of screening, were readmitted tions, and educational materials were posted on the
to the ICU and had previously been enrolled in the ICUs Web portal and published in newsletters. The
study, or were in the ICU during both study phases. senior nursing team provided focused 1-on-1 bed-
side education during implementation and moni-
Data Collection tored compliance via monthly random chart audits.
Research staff prospectively screened the eligi- Results of monthly audits were e-mailed to staff,
bility of all consecutive patients admitted to the 2 posted on notice boards, and discussed at staff
ICUs. In order to minimize the impact of data col- meetings. Auditing for compliance with the pain
lection on critical care nurses practices of document- assessment policy was incorporated into individual
ing pain assessment, the relevant data were extracted performance reviews. Senior nurses and physicians
from each study patients record retrospectively after were involved in tool selection and championed
the patient had been discharged from the ICU. implementation through existing quality and edu-
Demographic data included age, cation forums.
For extraction of sex, admission type, primary reason
for ICU admission, and number of Statistical Methods
pain assessment invasive catheters or tubes. Addi- Assessment of the primary outcome, the fre-
descriptors, poten- tional information collected included quency of documentation of pain assessment,
frequency and type of documenta- required a sample size of 524 PAIs (524 before and
tial behavioral tion (either pain score or narrative 524 after) in each participating ICU to detect a 10%
descriptors were description) of pain assessment difference in the frequency of the documentation
from the time of inclusion in the with 90% power and a = .05.
compiled from study until the patient regained the Descriptive statistics were used to summarize
ability to communicate (indicated demographic characteristics and doses of medications.
published tools. by a motor score of 6 on the Glas- Continuous variables were described by using meas-
gow Coma Scale or nursing documentation) or a ures of central tendency and spread (means and
maximum of 72 hours; type, delivery method, and standard deviations or medians and interquartile
dose of analgesic and sedative medications admin- ranges, depending on data distribution). Frequencies,
istered; and daily scores on the Sequential Organ proportions, and 95% confidence intervals were
Failure Assessment (SOFA), duration of mechanical used to describe categorical variables. The overall


Downloaded from at Mobile User on May 20, 2013

Table 1
Patients demographics

No. (%) of patients


Before After Before After

(n = 130) (n = 132) (n = 59) (n = 52)

Age, median (IQR), y 70 (61-76) 67 (60-75) 57 (38-75) 54 (43-63)

Male sex 91 (70) 93 (70) 42 (71) 40 (77)
Admission category
Surgical 123 (95) 124 (94) 13 (22) 6 (12)
Trauma 0 (0) 2 (2) 28 (48) 23 (44)
Medical 7 (5) 6 (4) 18 (30) 23 (44)
Reason for ICU admission
Cardiovascular 123 (95) 125 (95) 1 (2) 2 (4)
Respiratory 3 (2) 3 (2) 14 (24) 5 (10)
Gastrointestinal 0 (0) 1 (1) 2 (3) 7 (14)
Neurologic 2 (2) 0 (0) 9 (15) 6 (12)
Trauma 0 (0) 2 (2) 28 (48) 23 (44)
Metabolic 2 (2) 0 (0) 1 (2) 0 (0)
Genitourinary 0 (0) 0 (0) 2 (3) 0 (0)
Hematologic 0 (0) 3 (2) 0 (0) 3 (6)
Sepsis 0 (0) 1 (1) 2 (3) 6 (12)
Number of invasive catheters/tubes, median (IQR) 9 (8-9) 9 (8-10) 8 (7-9) 6 (6-7)a
Maximum SOFA score,b median (IQR) 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 P < .05 before and after study phases.
b The maximum Sequential Organ Failure Assessment (SOFA) score22 was calculated by summing the worst (greatest) scores for all 6 components of the
SOFA score recorded daily during inclusion in the study. The 6 components of the SOFA score are respiratory (ratio of PaO2 to fraction of inspired oxygen),
coagulation (platelets), liver (bilirubin), cardiovascular (hypotension), central nervous system (score on Glasgow Coma Scale), and renal (creatinine). Each
is scored from 0 (no organ failure) to 4, with a maximum score of 24.

proportion of PAIs in which pain assessment was Results

documented before and after CPOT implementa- A total of 189 patients were recruited before
tion was determined for each ICU and the results implementation of the CPOT and 184 patients after
were compared by using c2 tests. Median pain implementation. Demographic characteristics for
assessments per patient and medication doses both study phases according to ICU are shown in
before and after CPOT implementation were Table 1. Patient characteristics in the 2 study phases
compared by using Wilcoxon rank sum tests. were similar except for median maximum SOFA
Duration of mechanical ventilation and ICU stay scores in the CVICU and number of catheters in
were determined by using time-to-event methods, the CRCU cohort. In both units, the number of
which account for censoring due to death, and PAIs did not differ significantly during the study
were compared by using log-rank tests. Multiple phases. In the CVICU, the proportion of PAIs with
Poisson regression was used to examine prospec- pain assessment documented increased from 15%
tively chosen patient factors associated with pain to 64% (P < .001) and from 22% to 80% (P < .001)
assessment in each ICU. In order to examine in the CRCU. The median number of PAIs for each
patient characteristics associated with median patient with documented pain assessment increased
opioid equivalent total dose, multivariable mod- after CPOT implementation in both ICUs (Table 2).
els were constructed according to ICU and study Because an increase in documentation of a
phase. Models were assessed for collinearity and behavioral pain score after implementation of the
goodness of fit. All tests were 2-tailed, and P = .05 CPOT was anticipated, the frequency of documenta-
was considered significant. Analyses were per- tion of narrative assessments of behavioral and phys-
formed by an independent statistician who used iological indicators of pain was determined. The
SAS 9.1 software (SAS Institute). Analysis of the number of narrative assessments increased in the
narrative descriptions of pain has been described CVICU and were unchanged in the CRCU (Table 2).
in detail elsewhere.21 For the CVICU patients, the median maximum AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 249

Downloaded from at Mobile User on May 20, 2013

Table 2
Documentation of pain assessment

No. of patients, median (IQR)


Before After Before After

Documentation (n = 130) (n = 132) P (n = 59) (n = 52) P

Eligible hoursa 1321, 3 (2-6) 893, 3 (2-6) .20 2390, 37 (14-72) 2627, 68 (26-72) .09
PAIs 633, 3 (2-6) 519, 3 (2-5) .18 580, 9 (3-18) 646, 17 (7-18) .08
PAIs with pain assessment (all) 180, 1 (0-2) 341, 2 (1-3) <.001 213, 2 (1-5) 516, 11 (5-16) <.001
PAIs with pain assessment (eligible)b 96, 0 (0-1) 333, 2 (1-3) <.001 127, 1 (1-4) 515, 11 (5-16) <.001
Narrative episodes (all) 254, 1 (0-2) 172, 1 (1-2) .001 336, 3 (2-8) 310, 2 (2-8) .56
Narrative episodes (eligible) 130, 0 (0-1) 147, 1 (1-2) <.001 262, 2 (1-7) 218, 3 (1-6) .93

Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit; IQR, interquartile range; PAIs, pain assessment intervals.
a Refers to the number of hours of data collection during which patients remained eligible for the study.
b Excludes PAIs coded as 2 (ambiguous as to whether documented assessment referred to pain, agitation, or delirium because interventions for manage-
ment of agitation and delirium coincided with documentation) and 4 (documentation of analgesia given, though no assessment data recorded).

CPOT score was 0 (interquartile range [IQR], 0-2), determined by using the Kaplan-Meier method,
and 28 of the 274 documented scores (10%) were 3 decreased from 2.0 (IQR, 1.0-5.0) days to 1.8 (IQR,
or greater, indicating the presence of pain.23 For 11 of 1.0-3.0) days (P = .007); no difference was found in
the 28 scores (39%), patients medical records had the CRCU (median, 5.9; IQR, 2.9-13.6 days before
no documentation of administration of an analgesic. and median, 7.0; IQR, 5.0-14.7 days after). No dif-
For CRCU patients, the median score was 4 (IQR, ference was found in the duration of mechanical
1-5), and 104 of the 693 scores (15%) were 3 or ventilation before and after CPOT implementation
greater; for 43 scores (41%), medical records had no in either ICU. The CVICU median was 0.6 (IQR,
documentation of administration of an analgesic. 0.3-0.8) days before CPOT and 0.5 (IQR, 0.3-0.8)
Table 3 presents median total and hourly doses days after implementation. The CRCU median was
of analgesic and sedative agents administered before 3.9 (IQR, 1.4-10.7) days before implementation and
and after CPOT implementation. Median total opi- 5.9 (IQR, 3.0-9.1) days after use of the CPOT began.
oid equivalent doses decreased by 1 mg in the
CVICU (P < .001) and increased by 48 mg in the Discussion
CRCU (P < .001). The total dose of benzodiazepines Our findings indicate successful implementa-
decreased in the CVICU by 10 mg (P < .001), but tion of the CPOT in terms of improved compliance
remained unchanged in the CRCU. In the CVICU, with regular documentation of pain assessment in
both before and after CPOT implementation, 2 ICUs with no previous formal use of this, or any
higher total opioid doses were received by sicker other, behavioral pain assessment tool. Although
patients (higher maximum SOFA scores) and by we showed improved compliance with the policy-
patients admitted for medical indications. In the recommended frequency of documented pain
CRCU, after CPOT implementation, patients admit- assessment, we did not achieve compliance rates
ted for medical indications received less total opioid higher than 80%. Although 100% is obviously
compared with patients admitted after surgery or preferable, 80% compliance may be acceptable in
trauma (P = .001), when adjustments were made for ICUs with large numbers of nurses, staff turnover,
age, sex, number of invasive devices, maximum SOFA and acutely ill patients. The rate was also a marked
score, and duration of ICU stay; no differences were improvement from compliance at baseline. A simi-
noted before CPOT implementation. lar compliance rate for documented pain assessment
Accounting for the number of PAIs, admission was reported by Topolovec-Vranic et al,13 whereas
category, sex, and maximum SOFA score, increased Glinas et al14 reported a median of 12 documented
age was associated with increased documentation assessments (every 2 hours) per 24 hours of ICU
of pain assessment in the CVICU. In the CRCU, stay 12 months after CPOT implementation,
decreased maximum SOFA scores were associated although compliance cannot be calculated because
with increased documentation (Table 4). In the institutional recommendations for frequency of
CVICU, the estimated median duration of ICU stay, documentation were not described.


Downloaded from at Mobile User on May 20, 2013

Table 3
Drug dosesa


Before After Before After

Drug No. (n = 130) No. (n = 132) P No. (n = 59) No. (n = 52) P

Fentanyl, total, g 21 800 11 100 .17 38 300 44 775 .003

(100-2650) (50-670) (100-725) (313-2712)
Fentanyl, per hour, g 47 14 .09 10 20 .006
(15-82) (4-50) (4-21) (8-83)
Hydromorphone, total 94 0.6 104 0.6 .26 5 1.6 2 2.2 .85
(0.4-1.0) (0.4-0.8) (0.7-3.0) (1.9 -2.4)
Hydromorphone, per hour 0.2 0.2 .84 0.1 0.1 >.99
(0.1-0.3) (0.1-0.3) (0.0-0.3) (0.0-0.2)
Morphine, total 1 2 3 15 2 16 .79
(2-2) (2-17) (11-20)
Morphine, per hour 0.0 0.2 0.2 .79
(0.0-0.0) (0.0-0.3) (0.2-0.3)
Opioid equivalents, total 107 5 112 4 .02 42 27 45 75 .002
(3-9) (3-7) (11-73) (30-258)
Opioid equivalents, per hour 1.4 1.2 .04 1.0 2 .008
(0.8-3.0) (0.6-2.0) (0.4-2.3) (0.6-8.0)
Ketamine, total, g 1 1.6 1 1.0 3 0
(1.6-1.6) (1.0-1.0) (0-0)
Ketamine, per hour 24 31 0.2
(24-24) (31-31) (0.1-0.8)
Gabapentin, total 16 100 8 100 .85 2 350
(100-225) (100-200) (200-500)
Gabapentin, per hour 14 17 .50 13
(9-18) (11-21) (8-18)
Acetaminophen, total, g 36 1 16 1 .95 32 3 33 5 .17
(1-3) (1-4) (1-6) (2-9)
Benzodiazepine, total 99 12 63 2 <.001 21 2 25 2 .34
(4-60) (2-5) (1-3) (2-2)
Benzodiazepine, per hour 3 1 <.001 0.1 0.0 .93
(1-19) (0.3-2) (0.0-0.2) (0.0-0.2)
Propofol, total 11 150 20 103 .33 20 603 28 418 .46
(90-400) (30-225) (378-1375) (118-1513)
Propofol, per hour 15 15 .43 23 14 .28
(10-50) (9-27) (11-34) (3-30)
Haloperidol, total 2 5 3 5 >.99 2 10 3 8 >.99
(5-5) (3-7) (2-80) (5-13)
Haloperidol, per hour 0.1 0.5 .44 0.3 0.1 .68
(0.1-0.1) (0.2-0.7) (0.0-1.4) (0.1-0.2)

Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit.

a 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 indi- medication and of the effect of the medication is a
cated poor compliance with various evidence-based central tenet of medication administration that
practice recommendations, indicating that imple- guides initiation, escalation, and discontinuation of
mentation of the recommendations remains a therapy. However, systematic assessment of pain in
challenge in the ICU. Assessment of the need for critically ill patients remains infrequent and is done AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 251

Downloaded from at Mobile User on May 20, 2013

Table 4
Multivariable analysis of patients characteristics
associated with documented pain assessment


Before CPOT After CPOT Before CPOT After CPOT

IRR (95% CI) P IRR (95% CI) P IRR (95% CI) P IRR (95% CI) P

PAIs 1.15 (1.11-1.19) <.001 1.16 (1.13-1.19) <.001 1.19 (1.14-1.25) <.001 1.12 (1.10-1.14) <.001
Age 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
Maximum SOFA score 0.98 (0.92-1.05) .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 1 1 1 1
Trauma 1.28 (0.66-2.50) .46 2.48 (1.27-4.81) .007 0.89 (0.48 -1.64) .71 0.95 (0.75-1.20) .66
Medical 1.0 (1.00-1.00) >.99 1.26 (0.95-1.68) .10 1.41 (0.79-2.51) .25 0.91 (0.73-1.14) .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.

inconsistently. For example, Payen et al27 found that CVICU may have thought that most patients had
only half of the patients treated with opioids on day pain related to procedures and incision sites28 and
2 of the patients ICU stay had documented assess- routinely administered preemptive analgesics. Pos-
ments of pain. Other studies13,14 on implementation sibly CPOT implementation enabled nurses to bet-
of behavioral pain assessment tools had low base- ter detect the presence or absence of pain and to
line rates of documented pain assessment. In a recent titrate administration of analgesics accordingly.
multicenter 1-day point prevalence study13 of 10 Because of the minimal differences in patient
routine care processes involving 50 ICUs and more characteristics across the 2 ICUs after CPOT imple-
than 650 patients, variability was detected in com- mentation, increased administration of opioids in
pliance in all care practices, but documentation of the CRCU might be due to improved detection and
pain scores was one of the practices with the lowest management of pain. However, in other studies,
compliance (35%; IQR, 17%-62%). We noted implementation of a behavioral pain tool had the
increased pain documentation for older patients in opposite effect on opioid administration. Glinas
the CVICU and for patients with decreased organ et al14 detected a reduction in opioid administration
failure in the CRCU. Possibly nurses thought that and postulated that this effect was due to improved
older adults need more frequent pain assessments guidance in pain management decisions and ability
than do younger patients. Competing priorities for to discriminate pain from other symptoms as well
nurses time may influence the nurses ability to as a reduction in the number of trauma patients
complete and document pain assessment in patients after implementation. Similarly, decreased use of
with higher severity of illness. opiates and better pain control were achieved in a
We found that implementation of CPOT had large before-and-after study29 in which protocols for
different effects on opioid and benzodiazepine management of analgesia, sedation, and delirium
administration in the 2 study ICUs. In the CVICU, were implemented that included targeting of anal-
a small but significant decrease occurred in use of gesia to pain scores. Divergent findings such as
opioid analgesics and a large decrease in the these on opioid usage are context dependent and
administration of benzodiazepines. In the CRCU, expected. Targeting either increased or decreased
the amount of opioid analgesics administered administration of analgesics as a desirable outcome
increased dramatically, and benzodiazepine usage has limited clinical usefulness. Rather, administra-
was unchanged. The decreases in the CVICU may tion of analgesics must be based on the intensity
have been due to both implementation of sedation and nature of the pain problem for individual
strategies targeting minimal sedation and provision patients so that the patients receive appropriate
of the CPOT to guide pain assessment. Before doses of the medications.
implementation of the CPOT, and in the absence Although implementation of CPOT increased
of a systematic pain assessment tool, nurses in the documentation of pain assessment and potentially


Downloaded from at Mobile User on May 20, 2013

influenced use of analgesics and benzodiazepines, after CPOT implementation because 5 patients were
approximately 40% of CPOT scores indicating the excluded during data cleaning. Because we used an
presence of pain were not followed by administra- extremely conservative estimate of effect in calculat-
tion of an analgesic. Our intervention included nurse ing our sample size and the observed effect size was
education emphasizing the need for analgesics for large, this limitation does not influence interpreta-
patients with CPOT scores of 3 or greater but did tion of our results. Additionally, we were unable to
not include revision of orders to formalize pre- present data on PAIs with documented pain assess-
scription of an analgesic in response to high CPOT ment per day of ICU stay; we discontinued data col-
scores. A recent survey30 of pain assessment prac- lection as soon as patients were able to communicate,
tices across Canada indicated infrequent targeting making direct comparison with the results of other
of analgesia to a pain score or other assessment studies problematic.
parameters by physicians. However, the potential
for improved patient outcomes as a result of imple- Conclusion
mentation of systematic pain assessment linked to Implementation of the CPOT increased the fre-
an intervention strategy to treat pain and prevent quency of pain assessment and most likely influ-
escalation of pain cannot be overlooked. Chanques enced administration of opioid analgesics in the 2
et al31 reported that such a strategy reduced the inci- ICUs. Few episodes of pain were detected by using
dence of pain, pain severity, the duration of mechan- the CPOT, although approximately 40% of pain
ical ventilation and rate of nosocomial infections. episodes were not addressed with administration of
The lack of influence on duration of ICU stay and analgesia, suggesting the need to link pain manage-
mechanical ventilation in our study may have ment to assessment findings. The effectiveness of
occurred because pain assessment findings were the CPOT for optimizing appropriate administra-
not directly linked to prescribing of analgesics. tion of an analgesic in critically ill patients unable
to self-report needs to be evaluated in randomized
Limitations controlled trials.
Because of the limitations of the study design,
our results may have been influenced by unac- We thank Alex Kiss for his advice and assistance with
counted confounders such as other ongoing qual- statistical analyses.
ity initiatives; in particular, a sedation score and
algorithm targeting low levels of sedation were This study was supported by a grant from the Sunnybrook
introduced at the same time as the CPOT. Other Health Sciences Centre Practice Based Research Fund.
potential confounders include turnover of physicians
and nurses and differences in patient characteristics, eLetters
Now that youve read the article, create or contribute to an
although the cohort groups were equivalent in online discussion on this topic. Visit
terms of measured baseline characteristics except and click Submit a response in either the full-text or
PDF view of the article.
for a lower maximum SOFA scores in the CVICU
patients and fewer invasive catheters in the CRCU
patients after implementation of the CPOT. Our SEE ALSO
For more about pain management, visit the Critical
results may also be subject to performance bias despite Care Nurse Web site,, and read the
our attempts to avoid influencing pain assessment article by Arbour and Glinas, Setting Goals for Pain
Management When Using a Behavioral Scale: Exam-
practices by collecting most data from the medical
ple With the Critical-Care Pain Observation Tool.
record after patients were discharged from the ICU. (December 2011).
Ascertainment bias may have occurred despite ran-
dom audits of the accuracy of data extraction because REFERENCES
1. Rotondi A, Chelluri L, Sirio C, et al. Patients recollections
the persons who extracted information from nurses of stressful experiences while receiving prolonged mechan-
narratives were not blinded to the study period or ical ventilation in an intensive care unit. Crit Care Med.
the study purpose. Because the data collection was 2. Puntillo KA. Pain experiences of intensive care unit patients.
retrospective, we were unable to accurately deter- Heart Lung. 1990;19:526-533.
3. Whipple J, Lewis K, Quebbeman E, et al. Analysis of pain
mine assessment of response to analgesics. The exact management in critically ill patients. Pharmacotherapy.
time of assessment was not well documented, and 1995;15:592-599.
4. Arroyo-Novoa C, Figueroa-Ramos M, Puntillo K, et al. Pain
the documentation did not directly describe response related to tracheal suctioning in awake acutely and critically
to treatment; narrative notation is often documented ill adults: a descriptive study. Intensive Crit Care Nurs.
by nurses in retrospect rather than real time. We were 5. Ethier C, Burry L, Martinez-Motta C, et al; Canadian Critical
5 PAIs short of our target sample size in the CVICU Care Trials Group. Recall of intensive care unit stay in AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 253

Downloaded from at Mobile User on May 20, 2013

patients managed with a sedation protocol or a sedation 20. Puntillo KA, Stannard D, Miaskowski C, Kehrle K, Gleeson
protocol with daily sedative interruption: a pilot study. J Crit S. Use of a pain assessment and intervention notation
Care. 2011;26:127-132. (PAIN) tool in critical care nursing practice: nurses evalua-
6. Kwekkeboom K, Herr K. Assessment of pain in the critically tions. Heart Lung. 2002;31:303-314.
ill. Crit Care Nurs Clin North Am. 2001;13:181-194. 21. Haslam L, Rose L, Dale C, Knechtel L. Pain descriptors for
7. Glinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Valida- critically ill patients unable to self-report. J Adv Nurs. 2012;
tion of the Critical-Care Pain Observation Tool in adult 68(5):1082-1089.
patients. Am J Crit Care. 2006;15:420-427. 22. Moreno R, Vincent J, Matos R, et al. The use of maximum
8. Payen J-F, Bru O, Bosson J-L, et al. Assessing pain in criti- SOFA score to quantify organ dysfunction/failure in inten-
cally ill sedated patients by using a behavioral pain scale. sive care: results of a prospective, multicentre study. Work-
Crit Care Med. 2001;29:2258-2263. ing Group on Sepsis-Related Problems of the ESICM.
9. Odhner M, Wegman D, Freeland N, Steinmetz A, Ingersoll Intensive Care Med. 1999;25(7):686-696.
G. Assessing pain control in nonverbal critically ill adults. 23. Glinas C, Harel F, Fillion L, Puntillo K, Johnston C. Sensi-
Dimens Crit Care Nurs. 2003;22(6):260-267. tivity and specificity of the Critical-Care Pain Observation
10. Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI). Tool for the detection of pain in intubated adults after car-
Pain Manage Nurs. 2000;1:13-21. diac surgery. J Pain Symptom Manage. 2009;37(1):58-67.
11. Puntillo KA, Morris AB, Thompson CL, Stanik-Hutt J, White 24. Rose L, Baldwin I, Crawford T, Parke R. Semirecumbent
CA, Wild LR. Pain behaviors observed during six common positioning in ventilator-dependent patients: a multicenter,
procedures: results from Thunder Project II. Crit Care Med. observational study. Am J Crit Care. 2010;19(6):e100-e108.
2004;32:421-427. 25. Umoh N, Fan E, Mendez-Tellez P, et al. Patient and inten-
12. Payen J, Bosson J, Chanques G, Mantz J, Labarere J; sive care unit organizational factors associated with low
DOLOREA Investigators. Pain assessment is associated tidal volume ventilation in acute lung injury. Crit Care Med.
with decreased duration of mechanical ventilation in the 2008;36:1463-1468.
intensive care unit: a post hoc analysis of the DOLOREA 26. Ilan R, Fowler R, Geerts R, Pinto R, Sibbald W, Martin C.
study. Anesthesiology. 2009;111(6):1308-1316. Knowledge translation in critical care: factors associated
13. Topolovec-Vranic J, Canzian S, Innis J, Pollmann-Mudryj with prescription of commonly recommended best practices
M, White McFarlan A, Baker A. Patient satisfaction and for critically ill patients. Crit Care Med. 2007;35:1696-1702.
documentation of pain assessments and management after 27. Payen J-F, Chanques G, Mantz J, et al. Current practices in
implementing the Adult Nonverbal Pain Scale. Am J Crit sedation and analgesia for mechanically ventilated criti-
Care. 2010;19:345-354. cally ill patients: a prospective multicenter patient-based
14. Glinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. study. Anesthesiology. 2007;106(4):687-695.
Implementation of the Critical-Care Pain Observation Tool on 28. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam J-J,
pain assessment/management nursing practices in an inten- Jaber S. A prospective study of pain at rest: incidence and
sive care unit with nonverbal critically ill adults: a before characteristics of an unrecognized symptom in surgical
and after study. Int J Nurs Stud. 2011;48(12):1495-1504. and trauma versus medical intensive care unit patients.
15. Rubenfeld G, Angus D. Are intensivists safe? Ann Intern Anesthesiology. 2007;107:858-860.
Med. 2008;148:877-879. 29. Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi D,
16. Glinas C, Johnston C. Pain assessment in the critically ill Kavanagh B. Protocolized intensive care unit management of
ventilated adult: validation of the Critical-Care Pain Obser- analgesia, sedation, and delirium improves analgesia and
vation Tool and physiologic indicators. Clin J Pain. 2007; subsyndromal delirium rates. Anesth Analg. 2010;111:451-463.
23:497-505. 30. Rose L, Smith O, Glinas C, et al. Critical care nurses pain
17. Glinas C, Arbour C. Behavioral and physiologic indicators assessment and management practices: a survey in Canada.
during a nociceptive procedure in conscious and uncon- Am J Crit Care. 2012;21(4):251-259.
scious mechanically ventilated adults: similar or different? 31. Chanques G, Jaber S, Barbotte E, et al. Impact of systematic
J Crit Care. 2009;24:628.e627-628.e617. evaluation of pain and agitation in an intensive care unit.
18. Rose L, Haslam L, Dale C, et al. Survey of assessment and Crit Care Med. 2006;34:1691-1699.
management of pain for critically ill adults. Intensive Crit
Care Nurs. 2011;7:121-128.
19. Aissaoui Y, Zeggwagh A, Zekraoui A, Abidi K, Abouqal R. To purchase electronic or print reprints, contact The
Validation of a behavioural pain scale in critically ill, InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
sedated, and mechanically ventilated patients. Anesth Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,
Analg. 2005;101:1470-1476. (949) 362-2049; e-mail,


Downloaded from at Mobile User on May 20, 2013

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 7. Which of the following admissions categories provided the most patients for
to effective assessment and management of pain in the intensive care unit? the study?
a. Patient inability to self report a. Surgical
b. Nurses perception of pain management b. Trauma
c. Family interventions c. Medical
d. Documentation d. Respiratory

2. Those conducting the Critical-Care Pain Observation Tool (CPOT) study 8. As a result of CPOT implementation, the median number of pain assessment
hypothesized that implementation of CPOT would do which of the following? intervals for each patient:
a. Not affect documentation of pain assessment and would increase administration of a. Increased
analgesics b. Decreased
b. Negatively affect documentation and decrease administration of analgesics c. Did not change
c. Increase documentation of pain assessment and influence administration of analgesics
d. Decrease documentation of pain assessment and increase administration of sedatives 9. Study f indings indicated successful implementation of the CPOT was
associated with which of the following?
3. Which of the following is the recommended pain assessment interval for a. Increased patient assessment intervals
postsurgical patients? b. Minimized analgesia administration
a. Every 15 minutes for 1 hour then a minimum of every 2 hours c. Better detection for the presence of pain
b. Hourly for 6 hours then a minimum of every 4 hours d. Compliance with pain assessment documentation.
c. Hourly for 2 hours then every 2 hours for 12 hours
d. Hourly for the entire shift and as needed 10. Which of the following supported the assumption that CPOT implementation
resulted in improved detection and use of opioids in the medical/surgical/
4. Patients were eligible for the study if they met 1 of 2 criteria. The f irst trauma ICU?
criterion refers to the patients inability to communicate as determined by a. Frequency of analgesic use was targeted and met.
not being able to follow verbal commands. What was the second criterion? b. Protocols created provided guidelines for pain discrimination.
a. A Mini-Mental Status Exam score less than 24 c. There was improved benchmarking and compliance.
b. A motor score of 5 or less on the Glasgow Coma Scale d. There were minimal differences in patient characteristics.
c. A vital capacity greater than 15mL/kg body weight
d. Ability to maintain a mean arterial blood pressure between 70 and 110 mmHg 11. Which of the following outcomes is anticipated with implementation of
a systematic pain assessment to treat and prevent escalation of pain?
5. Data abstractors excluded reference to pain behaviors during which of the a. Decreased length of stay
following interventions? b. Improved patient satisfaction
a. Routine neurological assessments c. Improved patient outcomes
b. Pain assessment after narcotic administration d. Decreased postsurgical infection rates
c. Administration of analgesia for mild pain
d. Patient mobility 12. Which of the following measures did the authors employ to minimize
performance bias relating to pain assessment practices?
6. Which of the following was used to examine prospectively chosen patient a. Data was collected from the medical record following discharge from the ICU.
factors associated with pain assessment in each intensive care unit (ICU)? b. Participant criteria were focused on the patients ability to communicate.
a. Kaplan-Meier method c. Nursing staff was required to complete education prior to the study.
b. Nonlinear regression d. Data was recorded for 2 weeks before and after CPOT implementation.
c. Multiple Poisson regression
d. Discriminant analysis

1. a 2. a 3. a 4. a 5. a 6. a 7. a 8. a 9. a 10. a 11. a 12. a

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.

b b b b b b b b b b b b
c c c c c c c c c c c c
d d d d d d d d d d d
Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP A Test writer: Jean Shinners, PhD, RN-BC
Program evaluation Name
Yes No

Objective 1 was met
Objective 2 was met City State ZIP

For faster processing, take

Objective 3 was met
Content was relevant to my Country AACN Customer ID#

this CNE test online at

nursing practice

Phone E-mail address*
My expectations were met
Visa M/C AMEX Check
(CNE Articles in This Issue)
This method of CE is effective Payment by:

or mail this entire page to:
for this content

AACN, 101 Columbia,

The level of difficulty of this test was: Card # Expiration Date
easy medium difficult
Aliso Viejo, CA 92656.
To complete this program,
it took me hours/minutes. *E-mail address required to receive notification of completion, access to your test results, and
certificate for passing scores.

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12).
AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Downloaded from at Mobile User on May 20, 2013