Can Integrating the Critical-Care Pain Observation Tool into Practice Improve Pain Management?
Abstract & Commentary
By Linda L. Chlan, RN, PhD, Dean's Distinguished Professor of Symptom Management Research, The Ohio State University, College of Nursing. Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.
SYNOPSIS: Using the Critical-Care Pain Observation Tool to routinely assess pain in non-verbal ICU patients improved both the frequency of documented pain assessments and the administration of analgesics in two Canadian ICUs.
SOURCE: Rose L, et al. Behavioral pain assessment tool for critically ill adults unable to self-report pain. Am J Crit Care 2013;22:246-255.
Critically ill patients experience pain from a variety of procedures and/or have underlying medical conditions that exacerbate pain levels. Further, non-verbal patients receiving mechanical ventilation recall experiencing pain while in the ICU. Despite clinicians’ best efforts, patients still experience pain, and the challenge of assessing pain in non-responsive or non-verbal patients remains. One instrument that uses behavioral responses associated with pain is the Critical-Care Pain Observation Tool (CPOT). The CPOT consists of four domains: facial expression, body movement, muscle tension, and compliance with the ventilator or vocalization for non-intubated patients. Each domain is scored 0-2; the maximum score is 8 with higher scores indicative of pain. Unfortunately, simple tools such as the CPOT are not routinely used to assess pain in the ICU. Thus, the authors of this paper aimed to determine the effects of instituting the CPOT for routine pain management on the frequency of pain assessments documented and the influence on analgesia and sedation administration in non-verbal ICU patients.
This before-and-after designed study was conducted in a 600-bed hospital in Toronto. Patients and staff on a 20-bed medical-surgical-trauma unit (MSTU) and a 14-bed cardiovascular ICU (CVICU) participated in the study. A 4-month baseline/before phase consisted of educational sessions with unit protocols and flow sheets modified to incorporate the CPOT. In addition, one-on-one beside nurse education was also provided. To reduce any bias, data were abstracted retrospectively from any patient chart that met the inclusion criteria of inability to communicate verbally or a motor score of ≤ 5 on the Glasgow Coma Scale. A total of 524 pain assessment intervals (PAIs), or frequency of pain assessments, were completed before implementation of the CPOT on 189 individual patients, and 524 in the after phase with 184 individual patients. Data were also abstracted from the medical record on patient demographic characteristics and doses of analgesic and sedative medications. Audits for adherence to the desired every-4-hour pain assessment documentation were obtained retrospectively from the medical record and incorporated into individual staff nurse performance reviews.
Patient characteristics in age, gender, and illness severity were similar in the before- and after-study phases. The proportion of PAIs in the CVICU increased from 15% in the before phase to 64% in the after phase. Likewise, the MSTU saw an increase in PAIs from 22% to 80%. Neither unit ever achieved the target goal of 100% PAIs. Medication administration practices also changed after implementation of the CPOT on the participating ICUs. The CVICU reported a significant decrease in opioid administration, while the MSTU saw an increase. Administration of benzodiazepines decreased in the CVICU but was unchanged in the MSTU. There was no difference in length of mechanical ventilation after CPOT implementation in either ICU. While overall opioid administration improved on both ICUs, the authors reported that 40% of PAIs with CPOT scores indicating a need for analgesia were not followed up with opioid administration. The authors concluded that further work is needed to link pain assessment findings to actual pain management strategies.
The management of pain and other distressful symptoms in critically ill patients unable to verbalize the intensity of these symptoms remains an immense challenge for the critical care clinician. Further, in order to palliate symptoms such as pain with appropriate administration of analgesic medications, some idea of the intensity of pain is required. This paper by Rose and colleagues documents the implementation of one behavioral pain assessment tool, the CPOT, on two Canadian ICUs using a before-and-after design. While this design is not as powerful as a randomized clinical trial, several important points are advanced by the study’s findings. Despite the best efforts of the research team, 100% attainment of pain documentations was never achieved. These efforts included pain assessment practice adherence to standards in annual performance reviews. The highest rate achieved was an 80% adherence rate to documentation of pain assessments. A surprising finding was that a full 40% of CPOT assessments indicated the need for analgesia administration, but this was not carried out. This indicates the need for further practice change initiatives aimed at improving pain management practices.
While the challenge remains to effectively manage symptoms in non-verbal ICU patients, the CPOT may be one instrument that can improve pain management practices.