Implementation of the critical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study

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Abstract

Background

The Critical-Care Pain Observation Tool (CPOT) is one of the few behavioural pain scales which have been developed and validated for the purpose of detecting pain in nonverbal critically ill adults.

Objectives

This study aimed to complete a pre and post evaluation of the implementation of the CPOT on pain assessment/management nursing practices in the Intensive Care Unit (ICU) with nonverbal critically ill adults.

Design

A before-and-after study design was used. Setting/Participants: The Intensive Care Unit (ICU) of a university affiliated health care centre in Montérégie (Canada) was selected for the implementation of the CPOT. All ICU nurses were trained to use the CPOT. Medical files were selected if the patient was 18 years or older, had been mechanically ventilated for a period ≥ 24 hours, was unable to communicate, and had intact motor function.

Methods

This implementation study included three steps: 1) pre-implementation phase, 2) implementation phase, and 3) post-implementation phase. The pre-implementation phase included the review of 30 medical files to describe the current nursing practice in pain assessment and management prior to the introduction of the CPOT. During the implementation phase, 60 ICU nurses attended standardized training sessions on the use of the CPOT and practiced the scoring with the CPOT using patients’ videotapes. In the post-implementation phase, the interrater reliability of ICU nurses when using the CPOT was tested using three patients’ videotapes. Also, pain assessment and management nursing practices were evaluated by reviewing 30 medical files at 3 months, and 30 others at 12 months post-implementation.

Results

Nurses’ percentage of agreement when scoring patients with the CPOT by viewing the videotapes was high post-implementation of the tool (>87%). Reports of pain assessments were more frequently charted in the medical files in the post-implementation phase (10.5 to 12 assessments in a 24-hour period) compared with the pre-implementation phase (3 assessments in a 24-hour period). Interestingly, fewer analgesic and sedative agents were administered during the post-implementation phase.

Conclusions

The CPOT was successfully implemented and seemed to have positive effects on pain assessment and management nursing practices in the ICU. Further research is warranted to look at its impact on patient outcomes.

Introduction

When patients are not able to provide their self-report of pain verbally or with other signs (e.g., head nodding, pointing to a scale), the use of a valid behavioural pain scale is strongly recommended for the detection of the presence of pain (Herr et al., 2006)]. The Behavioural Pain Scale (BPS) (Payen et al., 2001) and the Critical-Care Pain Observation Tool (CPOT) (Gélinas et al., 2006) have been suggested by critical care experts in recent review papers (Cade, 2008, Li et al., 2008, Sessler et al., 2002) as well as in the clinical recommendations of the American Society of Pain Nursing Management (ASPNM) (Herr et al., 2006). Although the psychometric properties (i.e. interrater reliability, discriminant validation, and criterion validation) of both scales have been supported for the purpose of pain assessment in critically ill adults with various diagnoses in the ICU (Ahlers et al., 2008, Ahlers et al., 2010, Aïssaoui et al., 2005, Gélinas et al., 2006; Gelinas and Arbour, 2009; Gelinas and Johnston, 2007; Marmo and Fowler, 2010, Payen et al., 2001, Young et al., 2006), their implementation in the clinical settings is still recent, and few studies have evaluated their impact on pain assessment and pain management practices in the ICU.

According to the implementation of the BPS, a two-phase prospective controlled study showed a significant increase (p ≤ .001) in the frequency of pain assessments in 24 hours of ICU stay in patients of the post-implementation group (n = 130) in comparison with patients of the pre-implementation group (n = 100) (Chanques et al., 2006). These pain evaluations occurred at specific times during the day, and the BPS was used in both groups (by independent observers in the pre-implementation group, and by nurses in the post-implementation group). Also, the number of pain episodes (as defined by the authors by the frequency of a BPS score > 5) was significantly lower in the post-implementation group: 63 vs. 42% (p = .002). The BPS cut-off score of > 5 was determined using descriptive statistics when nonverbal patients were exposed to nociceptive procedures known to be painful (e.g. turning, endotracheal suctioning) compared with rest (Payen et al., 2001). However, a scale cut-off score should rather be determined using ROC curve analysis used for such purpose. In a before-and-after study, William and colleagues (2008) found a significant increase (p <  .001) in the administration of sedatives with or without analgesics after the implementation of the BPS (before group n = 369, and after group n = 400).

Regarding the CPOT, a cut-off score (> 2) for the presence of pain was empirically determined using ROC curve analysis in verbal critically ill patients (Gélinas et al., 2009a). This can allow the detection of the presence of pain as well as the evaluation of the effectiveness of pain management interventions. So far, one retrospective pilot study was conducted to complete a pre and post evaluation of its implementation on pain assessment and pain management practices in mechanically ventilated ICU patients with a trauma diagnosis (n = 30) (Arbour et al., 2011). Reports of pain assessments (i.e., 4 versus 12 per patient per 24 hours) and identification of pain episodes (i.e., 1 versus 4 per patient per 24 hours) were more frequent post-implementation of the tool. Interestingly, fewer analgesics were administered in the post-implementation group but these interventions appeared to be more efficient in comparison with those of the pre-implementation group. Those pilot results focussed on a specific ICU group of trauma patients. Therefore, the evaluation of the implementation of a behavioural pain scale on pain assessment and pain management nursing practices in nonverbal critically ill patients needs to be further examined.

Section snippets

AIM AND OBJECTIVES

This study aimed to evaluate the implementation of the CPOT on pain assessment and management nursing practices in the ICU with nonverbal critically ill patients.

Specificobjectives were:

  • 1)

    To examine interrater reliability of ICU nurses (i.e. percentage of agreement) when using the CPOT during the implementation, and 12 months post-implementation.

  • 2)

    To describe ICU nurses’ pain assessment practices (i.e., reports of pain assessments and reassessments, and behaviours indicative of the presence of

Design

A before-and-after study design was used to evaluate the implementation of the CPOT on pain assessment/management nursing practices. Description of the implementation phases are illustrated in Fig. 1.

Setting and Sample

The Intensive Care Unit (ICU) of a university affiliated health care centre in Montérégie (Canada) was selected for the implementation of the CPOT for three reasons: 1) the implementation of best practice guidelines for pain management (RNAO, 2002) was a priority for the Direction of Nursing, 2)

Sample Description

Characteristics of patients whose medical files were included in the study are presented in Table 1. In each group, more than 55% were males, and mean age was between 59 and 60 years old. More than half had a medical diagnosis while some had trauma, and very few were admitted in the ICU post-surgery or for a cardiac reason. No statistical differences were found between the three groups.

Interrater Reliability of ICU Nurses in Using the CPOT

Percentage of agreement of ICU nurses when scoring patients at rest was high (95-100%) both at pre and

Discussion

The CPOT was successfully implemented and seemed to have positively influenced nursing practices of pain assessment and pain management in the ICU. Nurses learned to use the CPOT, and the reports of pain assessments and reassessments as well as reports of the presence of pain appeared to be more frequent post-implementation of the tool. Interestingly, a decrease in the administration of analgesics and sedatives was observed at post-implementation. The CPOT also appeared to be useful in the

CONCLUSION

Now that valid behavioural pain scales developed for nonverbal critically ill adult patients are available and can be easily taught and implemented in the ICU, it is urgent that clinical recommendations be implemented into practice. Involving physicians in updating pain management protocols to include interventions based on CPOT scores would also be crucial to achieve better pain relief, and to improve patient outcomes.

Acknowledgments

This study was supported by a grant offered by FRESIQ (Fonds de la recherche en sciences infirmières du Québec) from Montreal (Canada), and the Canadian Nurses Foundation (CNF). We wish to thank Mélissa Paquin, clinical educator nurse, who was responsible for the training of ICU nurses. Also, thank you to head assistant nurses and B.Sc. nurses who provided their colleagues with clinical support during the implementation of the CPOT, and all ICU nurses for their involvement in using the CPOT in

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