Pain Assessment and Management free essay sample

Methods Data on patients in 2 intensive care units of a university-affiliated hospital were collected before and after 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 intensive care unit (130 patients before and 132 after) and in the medical/surgical/trauma unit (59 patients before and 52 after). Proportion of pain assessment intervals with pain assessment documented increased from 15% to 64% (P lt; . 001) in the cardiovascular unit and from 22% to 80% (P lt; . 001) in the other unit. Median total dose of opioid analgesics decreased from 5 mg to 4 mg in the cardiovascular unit (P = . 02) and increased from 27 mg to 75 mg (P = . 002) in the other unit. Median total dose of benzodiazepines decreased from 12 mg to 2 mg (P lt; . 001) in the cardiovascular unit and remained unchanged in the other unit. Increased documentation of pain assessment was associated with increased age in the cardiovascular unit and with decreased maximum scores on the Sequential Organ Failure Assessment in the other unit. Conclusion Implementation of the tool increased frequency of pain assessment and appeared to influence administration of analgesics in both units. (American Journal of Critical Care. 2013;22:246-255) CNE 1. 0 Hour Notice to CNE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following 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. To read this article and take the CNE test online, visit www. ajcconline. org and click â€Å"CNE Articles in This Issue. † No CNE test fee for AACN members.  ©2013 American Association of Critical-Care Nurses doi: http://dx. doi. org/10. 4037/ajcc2013200 246 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 www. ajcconline. org S 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 selfreport 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 now available that facilitate detection of pain experienced by critically ill patients unable to communicate. Systematic pain assessment, with either patient self-reporting or use of behavioral pain assessment tools as appropriate, can improve patients’ outcomes. In a large multicenter observational study,12 pain assessment was associated with reductions in the duration of mechanical ventilation and ICU stay. In a small study13 involving patients in a neurotrauma ICU, introduction of the Nonverbal Pain Scale9 increased documentation of pain assessments and decreased recalled severity of the pain patients experienced. More recently, Gelinas et al14 reported increased pain documentation and decreased administration of analgesic and sedative agents after introduction of the Critical-Care Pain Observation Tool (CPOT) in a small mixed ICU population (30 patients before, 30 at 3 months, and 30 at 12 months after implementation). However, few studies have evaluated the effect of these tools on pain assessment and management practices; most published studies7,8,14 have been conducted by investigators involved in the development and or validation of the tools. Our goal was to determine the effect of implementing the CPOT7 in 2 ICUs of a university-affiliated hospital that provide services to a mixed population of patients, including trauma and cardiothoracic surgery patients. We hypothesized that implementation of the CPOT would increase documentation of pain assessment and influence administration of analgesics and sedatives. Our primary objective was to determine the effects on the frequency of documentation of pain assessment (pain scores and narrative) and on the administration of analgesics and sedatives in patients unable to self-report pain. Our secondary objectives were to determine patient factors associated with documented pain assessment and opioid administration and to examine the impact of CPOT implementation on ICU length of stay and the duration of mechanical ventilation. Methods About the Authors Louise Rose is a Lawrence S. Bloomberg limited-term professor in critical care, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Lynn Haslam is an advanced practice nurse, Department of Anaesthesia, and Leasa Knechtel is the director of nursing education, Sunnybrook Health Sciences Centre, Toronto, Ontario, Craig Dale is an advanced practice nurse, Department of Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, and a PhD candidate, Lawrence S. Bloomberg Faculty of Nursing, and Michael McGillion is an assistant professor, Lawrence S. Bloomberg Faculty of Nursing, and a member of the board of directors of the Canadian Pain Society. Corresponding author: Louise Rose, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St, Toronto, Ontario, Canada, M5T IP8 (e-mail: louise. rose @utoronto. ca). Study Design, Participants, and Setting A before-and-after design was used to examine the effect of CPOT implementation in 2 ICUs at Sunnybrook Health Sciences Centre, a 600bed university-affiliated hospital in Toronto, Ontario. The ICUs were a 20-bed mixed medical/surgical/trauma ICU (CRCU) that admits more than 1100 patients annually and a 14-bed cardiovascular ICU (CVICU) that admits 1150 patients each year. Both ICUs functioned as closed intensivistled units. Each week, the 20-bed CRCU was overseen by 2 intensivists; the 14-bed CVICU was supervised by 1 intensivist. A team of medical trainees, including fellows and residents, supported each intensivist to provide 24-hour care. These ICUs employed more than 100 (CRCU) and 65 registered nurses (CVICU) in full- and part-time positions. The CPOT consists of 4 domains: facial expression, body movement, muscle tension, and compliance with the ventilator (or vocalization for nonintubated patients). Each domain is scored from 0 to 2, with a maximum score of 8. The tool has content validity, moderate to high interrater reliability, discriminate validity, and moderate criterion Systematic pain assessment improves patients’ outcomes, reducing mechanical ventilation time and length of stay. www. ajcconline. org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 247 Two intensive care units were used, a 20-bed mixed unit and a 14-bed cardiovascular unit. validity. 7,16,17 Before implementation of the CPOT, the pain management policies of the ICUs did not include use of a behavioral pain assessment tool, although individual nurses self-reported that they used various tools, including the CPOT. 18 The recommended frequency of pain assessment, or pain assessment intervals (PAIs), for surgical patients was h ourly for 6 hours postoperatively and then a minimum of every 4 hours. Nonsurgical patients were expected to have pain assessment documented a minimum of every 4 hours. For the baseline phase of the study, patients were recruited from September 2008 to January 2009. After a 4-month implementation phase, patients were recruited from June to October 2009. Patients were eligible if they were unable to communicate verbally or via other means, as determined by documented failure to follow verbal commands or a motor score of 5 or less on the Glasgow Coma Scale. Each patient’s inability to communicate was confirmed with the patient’s bedside nurse. Patients were excluded if they were receiving neuromuscular blockers at the time of screening, were readmitted to the ICU and had previously been enrolled in the study, or were in the ICU during both study phases. ventilation, and length of ICU stay. In order to guide extraction of narrative descriptions of pain assessment, a reference compendium of potential behavioral descriptors was compiled from published behavioral pain assessment tools. 7-9,11,19,20 Data abstractors were instructed to record verbatim all documentation potentially related to pain assessment and management, including ambiguous documentation. The abstractors excluded any reference to pain behaviors elicited during routine neurological assessment. Random audits of data extraction were done to ensure consistency of nurses’ narratives of pain documentation recorded by research staff. Tool Implementation Before use of the CPOT was implemented, all nurses attended educational sessions that included video demonstration of pain behaviors and instruction on application of CPOT. Videos were provided by Dr Gelinas, who developed the CPOT and who used the videos in the study of CPOT implementation. 4 Existing unit protocols and ICU flow sheets were modified to incorporate the CPOT. Point-ofcare CPOT scoring guides were available at every bedside, posters were displayed in prominent locations, and educational materials were posted on the ICUs’ Web portal and published in newsletters. The senior nursing team provided focused 1-on-1 bedside education during implementation and monitored compliance via monthly random chart audits. Results of monthly audits were e-mailed to staff, posted on notice boards, and discussed at staff meetings. Auditing for compliance with the pain assessment policy was incorporated into individual performance reviews. Senior nurses and physicians were involved in tool selection and championed implementation through existing quality and education forums. Statistical Methods Assessment of the primary outcome, the frequency of documentation of pain assessment, required a sample size of 524 PAIs (524 before and 524 after) in each participating ICU to detect a 10% difference in the frequency of the documentation with 90% power and a = . 5. Descriptive statistics were used to summarize demographic characteristics and doses of medications. Continuous variables were described by using measures of central tendency and spread (means and standard deviations or medians and interquartile ranges, depending on data distribution). Frequencies, proportions, and 95% confidence intervals were used to describe categorical variables. The overall For extraction of pain assessment descriptors, potential behavior al descriptors were compiled from published tools. Data Collection Research staff prospectively screened the eligibility of all consecutive patients admitted to the 2 ICUs. In order to minimize the impact of data collection on critical care nurses’ practices of documenting pain assessment, the relevant data were extracted from each study patient’s record retrospectively after the patient had been discharged from the ICU. Demographic data included age, sex, admission type, primary reason for ICU admission, and number of invasive catheters or tubes. Additional information collected included frequency and type of documentation (either pain score or arrative description) of pain assessment from the time of inclusion in the study until the patient regained the ability to communicate (indicated by a motor score of 6 on the Glasgow Coma Scale or nursing documentation) or a maximum of 72 hours; type, delivery method, and dose of analgesic and sedative medications administered; and daily scores on the Sequential Organ Failure As sessment (SOFA), duration of mechanical 248 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 www. ajcconline. org Table 1 Patients’ demographics No. %) of patients CVICU Before (n = 130) Age, median (IQR), y Male sex Admission category Surgical Trauma Medical Reason for ICU admission Cardiovascular Respiratory Gastrointestinal Neurologic Trauma Metabolic Genitourinary Hematologic Sepsis Number of invasive catheters/tubes, median (IQR) Maximum SOFA score,b median (IQR) 70 (61-76) 91 (70) 123 (95) 0 (0) 7 (5) 123 (95) 3 (2) 0 (0) 2 (2) 0 (0) 2 (2) 0 (0) 0 (0) 0 (0) 9 (8-9) 6 (3-8) After (n = 132) 67 (60-75) 93 (70) 124 (94) 2 (2) 6 (4) 125 (95) 3 (2) 1 (1) 0 (0) 2 (2) 0 (0) 0 (0) 3 (2) 1 (1) 9 (8-10) 4 (3-6)a Before (n = 59) 57 (38-75) 42 (71) 13 (22) 28 (48) 18 (30) 1 (2) 14 (24) 2 (3) 9 (15) 28 (48) 1 (2) 2 (3) 0 (0) 2 (3) 8 (7-9) 8 (5-11) CRCU After (n = 52) 54 (43-63) 40 (77) 6 (12) 23 (44) 23 (44) 2 (4) 5 (10) 7 (14) 6 (12) 23 (44) 0 (0) 0 (0) 3 (6) 6 (12 ) 6 (6-7)a 8 (6-11) Abbreviations: CRCU, medical/surgical/trauma unit; CVICU, cardiovascular intensive care unit; ICU, intensive care unit; IQR, interquartile range. a b P lt; . 05 before and after study phases. 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 documented before and after CPOT implementation was determined for each ICU and the results were compared by using c2 tests. Median pain assessments per patient and medication doses before and after CPOT implementation were compared by using Wilcoxon rank sum tests. Duration of mechanical ventilation and ICU stay were determined by using time-to-event methods, which account for censoring due to death, and were compared by using log-rank tests. Multiple Poisson regression was used to examine prospectively chosen patient factors associated with pain assessment in each ICU. In order to examine patient characteristics associated with median opioid equivalent total dose, multivariable models were constructed according to ICU and study phase. Models were assessed for collinearity and goodness of fit. All tests were 2-tailed, and P = . 05 was considered significant. Analyses were performed by an independent statistician who used SAS 9. 1 software (SAS Institute). Analysis of the narrative descriptions of pain has been described in detail elsewhere. 21 Results A total of 189 patients were recruited before implementation of the CPOT and 184 patients after implementation. Demographic characteristics for both study phases according to ICU are shown in Table 1. Patient characteristics in the 2 study phases were similar except for median maximum SOFA scores in the CVICU and number of catheters in the CRCU cohort. In both units, the number of PAIs did not differ significantly during the study phases. In the CVICU, the proportion of PAIs with pain assessment documented increased from 15% to 64% (P lt; . 001) and from 22% to 80% (P lt; . 001) in the CRCU. The median number of PAIs for each patient with documented pain assessment increased after CPOT implementation in both ICUs (Table 2). Because an increase in documentation of a behavioral pain score after implementation of the CPOT was anticipated, the frequency of documentation of narrative assessments of behavioral and physiological indicators of pain was determined. The number of narrative assessments increased in the CVICU and were unchanged in the CRCU (Table 2). For the CVICU patients, the median maximum www. ajcconline. org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 249 Table 2 Documentation of pain assessment No. of patients, median (IQR) CVICU Documentation Eligible hoursa PAIs PAIs with pain assessment (all) PAIs with pain assessment Narrative episodes (all) Narrative episodes (eligible) (eligible)b Before (n = 130) 1321, 3 (2-6) 633, 3 (2-6) 180, 1 (0-2) 96, 0 (0-1) 254, 1 (0-2) 130, 0 (0-1) After (n = 132) 893, 3 (2-6) 519, 3 (2-5) 341, 2 (1-3) 333, 2 (1-3) 172, 1 (1-2) 147, 1 (1-2) P . 20 . 18