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Notice to CNE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understanding ofthe following objectives:

1. Describe key elements of the behavioral assess-ment Critical-Care Pain Observation Tool(CPOT).

2. Evaluate effects of CPOT with change in prac-tice for documentation and administration ofanalgesics and sedatives.

3. Compare results among studies regarding com-pliance with pain assessment documentationand practice recommendations.

To read this article and take the CNE test online,visit www.ajcconline.org and click CNE Articlesin This Issue. No CNE test fee for AACN members.

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 auniversity-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 inten-

sive 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< .001) in the car-

diovascular unit and from 22% to 80% (P< .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 totaldose of benzodiazepines decreased from 12 mg to 2 mg (P.99

.68

800(100-2650)

47(15-82)

0.6

(0.4-1.0)

0.2(0.1-0.3)

2(2-2)

0.0(0.0-0.0)

5(3-9)

1.4(0.8-3.0)

1.6(1.6-1.6)

24(24-24)

100(100-225)

14(9-18)

1(1-3)

12(4-60)

3(1-19)

150(90-400)

15(10-50)

5

(5-5)

0.1

(0.1-0.1)

100(50-670)

14(4-50)

0.6

(0.4-0.8)

0.2(0.1-0.3)

4(3-7)

1.2(0.6-2.0)

1.0(1.0-1.0)

31(31-31)

100(100-200)

17(11-21)

1(1-4)

2(2-5)

1(0.3-2)

103(30-225)

15(9-27)

5

(3-7)

0.5

(0.2-0.7)

300(100-725)

10(4-21)

1.6

(0.7-3.0)

0.1(0.0-0.3)

15(2-17)

0.2(0.0-0.3)

27(11-73)

1.0(0.4-2.3)

350(200-500)

13(8-18)

3(1-6)

2(1-3)

0.1(0.0-0.2)

603(378-1375)

23(11-34)

10

(2-80)

0.3

(0.0-1.4)

775(313-2712)

20(8-83)

2.2

(1.9 -2.4)

0.1(0.0-0.2)

16(11-20)

0.2(0.2-0.3)

75(30-258)

2(0.6-8.0)

0(0-0)

0.2(0.1-0.8)

5(2-9)

2(2-2)

0.0(0.0-0.2)

418(118-1513)

14(3-30)

8

(5-13)

0.1

(0.1-0.2)

Before

(n=130)No. No. No. No.P PDrug

After

(n=132)

Before

(n=59)

After

(n=52)

CRCUCVICU

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.
http://www.ajcconline.org/http://www.ajcconline.org/


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CVICU may have thought that most patients had

pain related to procedures and incision sites28 and

routinely administered preemptive analgesics. Pos-

sibly CPOT implementation enabled nurses to bet-

ter detect the presence or absence of pain and to

titrate administration of analgesics accordingly.

Because of the minimal differences in patient

characteristics across the 2 ICUs after CPOT imple-

mentation, increased administration of opioids in

the CRCU might be due to improved detection and

management of pain. However, in other studies,

implementation of a behavioral pain tool had theopposite effect on opioid administration. Glinas

et al14 detected a reduction in opioid administration

and postulated that this effect was due to improved

guidance in pain management decisions and ability

to discriminate pain from other symptoms as well

as a reduction in the number of trauma patients

after implementation. Similarly, decreased use of

opiates and better pain control were achieved in a

large before-and-after study29 in which protocols for

management of analgesia, sedation, and delirium

were implemented that included targeting of anal-

gesia to pain scores. Divergent findings such asthese on opioid usage are context dependent and

expected. Targeting either increased or decreased

administration of analgesics as a desirable outcome

has limited clinical usefulness. Rather, administra-

tion of analgesics must be based on the intensity

and nature of the pain problem for individual

patients so that the patients receive appropriate

doses of the medications.

Although implementation of CPOT increased

documentation of pain assessment and potentially

inconsistently. For example, Payen et al27 found that

only half of the patients treated with opioids on day

2 of the patients ICU stay had documented assess-

ments of pain. Other studies13,14 on implementation

of behavioral pain assessment tools had low base-

line rates of documented pain assessment. In a recent

multicenter 1-day point prevalence study13 of 10

routine care processes involving 50 ICUs and more

than 650 patients, variability was detected in com-

pliance in all care practices, but documentation of

pain scores was one of the practices with the lowest

compliance (35%; IQR, 17%-62%). We notedincreased pain documentation for older patients in

the CVICU and for patients with decreased organ

failure in the CRCU. Possibly nurses thought that

older adults need more frequent pain assessments

than do younger patients. Competing priorities for

nurses time may influence the nurses ability to

complete and document pain assessment in patients

with higher severity of illness.

We found that implementation of CPOT had

different effects on opioid and benzodiazepine

administration in the 2 study ICUs. In the CVICU,

a small but significant decrease occurred in use ofopioid analgesics and a large decrease in the

administration of benzodiazepines. In the CRCU,

the amount of opioid analgesics administered

increased dramatically, and benzodiazepine usage

was unchanged. The decreases in the CVICU may

have been due to both implementation of sedation

strategies targeting minimal sedation and provision

of the CPOT to guide pain assessment. Before

implementation of the CPOT, and in the absence

of a systematic pain assessment tool, nurses in the

252 JCCAMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 www.ajcconline.org

Table 4

Multivariable analysis of patients characteristicsassociated with documented pain assessment

PAIs

Age

Maximum SOFA score

Sex

Admission category Surgical Trauma Medical

1.15 (1.11-1.19)

0.99 (0.98-1.00)

0.98 (0.92-1.05)

0.86 (0.52-1.44)

11.28 (0.66-2.50)1.0 (1.00-1.00)

1.16 (1.13-1.19)

1.01 (1.00-1.02)

1.03 (1.00-1.07

1.17 (0.96-1.41

12.48 (1.27-4.81)1.26 (0.95-1.68)

1.19 (1.14-1.25)

0.99 (0.98-1.00)

0.99 (0.93-1.06)

1.13 (0.73-1.76)

10.89 (0.48 -1.64)1.41 (0.79-2.51)

1.12 (1.10-1.14)

1.00 (0.99-1.00

0.98 (0.96-1.00)

0.94 (0.78-1.13)

10.95 (0.75-1.20)0.91 (0.73-1.14)

.99


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influenced use of analgesics and benzodiazepines,

approximately 40% of CPOT scores indicating the

presence of pain were not followed by administra-

tion of an analgesic. Our intervention included nurse

education emphasizing the need for analgesics for

patients with CPOT scores of 3 or greater but did

not include revision of orders to formalize pre-scription of an analgesic in response to high CPOT

scores. A recent survey30 of pain assessment prac-

tices across Canada indicated infrequent targeting

of analgesia to a pain score or other assessment

parameters by physicians. However, the potential

for improved patient outcomes as a result of imple-

mentation of systematic pain assessment linked to

an intervention strategy to treat pain and prevent

escalation of pain cannot be overlooked. Chanques

et al31 reported that such a strategy reduced the inci-

dence of pain, pain severity, the duration of mechan-

ical ventilation and rate of nosocomial infections.The lack of influence on duration of ICU stay and

mechanical ventilation in our study may have

occurred because pain assessment findings were

not directly linked to prescribing of analgesics.

LimitationsBecause of the limitations of the study design,

our results may have been influenced by unac-

counted confounders such as other ongoing qual-

ity initiatives; in particular, a sedation score and

algorithm targeting low levels of sedation were

introduced at the same time as the CPOT. Other

potential confounders include turnover of physicians

and nurses and differences in patient characteristics,

although the cohort groups were equivalent in

terms of measured baseline characteristics except

for a lower maximum SOFA scores in the CVICU

patients and fewer invasive catheters in the CRCU

patients after implementation of the CPOT. Our

results may also be subject to performance bias despite

our attempts to avoid influencing pain assessment

practices by collecting most data from the medical

record after patients were discharged from the ICU.

Ascertainment bias may have occurred despite ran-

dom audits of the accuracy of data extraction becausethe persons who extracted information from nurses

narratives were not blinded to the study period or

the study purpose. Because the data collection was

retrospective, we were unable to accurately deter-

mine assessment of response to analgesics. The exact

time of assessment was not well documented, and

the documentation did not directly describe response

to treatment; narrative notation is often documented

by nurses in retrospect rather than real time. We were

5 PAIs short of our target sample size in the CVICU

after CPOT implementation because 5 patients were

excluded during data cleaning. Because we used an

extremely conservative estimate of effect in calculat-

ing our sample size and the observed effect size was

large, this limitation does not influence interpreta-

tion of our results. Additionally, we were unable to

present data on PAIs with documented pain assess-ment per day of ICU stay; we discontinued data col-

lection as soon as patients were able to communicate,

making direct comparison with the results of other

studies problematic.

ConclusionImplementation of the CPOT increased the fre-

quency of pain assessment and most likely influ-

enced administration of opioid analgesics in the 2

ICUs. Few episodes of pain were detected by using

the CPOT, although approximately 40% of pain

episodes were not addressed with administration ofanalgesia, suggesting the need to link pain manage-

ment to assessment findings. The effectiveness of

the CPOT for optimizing appropriate administra-

tion of an analgesic in critically ill patients unable

to self-report needs to be evaluated in randomized

controlled trials.

ACKNOWLEDGMENTSWe thank Alex Kiss for his advice and assistance withstatistical analyses.

FINANCIAL DISCLOSURESThis study was supported by a grant from the SunnybrookHealth Sciences Centre Practice Based Research Fund.

REFERENCES1. Rotondi A, Chelluri L, Sirio C, et al. Patients recollections

of stressful experiences while receiving prolonged mechan-ical ventilation in an intensive care unit. Crit Care Med.2002;30(4):746-752.

2. Puntillo KA. Pain experiences of intensive care unit patients.Heart Lung. 1990;19:526-533.

3. Whipple J, Lewis K, Quebbeman E, et al. Analysis of painmanagement in critically ill patients. Pharmacotherapy.1995;15:592-599.

4. Arroyo-Novoa C, Figueroa-Ramos M, Puntillo K, et al. Painrelated to tracheal suctioning in awake acutely and criticallyill adults: a descriptive study. Intensive Crit Care Nurs.2008;24:20-27.

5. Ethier C, Burry L, Martinez-Motta C, et al; Canadian CriticalCare Trials Group. Recall of intensive care unit stay in

www.ajcconline.org JCCAMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 253

eLettersNow that youve read the article, create or contribute to anonline discussion on this topic. Visit www.ajcconline.organd click Submit a response in either the full-text orPDF view of the article.

SEE ALSOFor more about pain management, visit the CriticalCare NurseWeb site, www.ccnonline.org, and read thearticle by Arbour and Glinas, Setting Goals for PainManagement When Using a Behavioral Scale: Exam-ple With the Critical-Care Pain Observation Tool.(December 2011).


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20. Puntillo KA, Stannard D, Miaskowski C, Kehrle K, GleesonS. Use of a pain assessment and intervention notation(PAIN) tool in critical care nursing practice: nurses evalua-tions. Heart Lung. 2002;31:303-314.

21. Haslam L, Rose L, Dale C, Knechtel L. Pain descriptors forcritically ill patients unable to self-report. J Adv Nurs. 2012;68(5):1082-1089.

22. Moreno R, Vincent J, Matos R, et al. The use of maximumSOFA score to quantify organ dysfunction/failure in inten-sive care: results of a prospective, multicentre study. Work-ing Group on Sepsis-Related Problems of the ESICM.Intensive Care Med. 1999;25(7):686-696.

23. Glinas C, Harel F, Fillion L, Puntillo K, Johnston C. Sensi-tivity and specificity of the Critical-Care Pain ObservationTool for the detection of pain in intubated adults after car-diac surgery. J Pain Symptom Manage. 2009;37(1):58-67.

24. Rose L, Baldwin I, Crawford T, Parke R. Semirecumbentpositioning in ventilator-dependent patients: a multicenter,observational study. Am J Crit Care. 2010;19(6):e100-e108.

25. Umoh N, Fan E, Mendez-Tellez P, et al. Patient and inten-sive care unit organizational factors associated with lowtidal volume ventilation in acute lung injury. Crit Care Med.2008;36:1463-1468.

26. Ilan R, Fowler R, Geerts R, Pinto R, Sibbald W, Martin C.Knowledge translation in critical care: factors associatedwith prescription of commonly recommended best practicesfor critically ill patients. Crit Care Med. 2007;35:1696-1702.

27. Payen J-F, Chanques G, Mantz J, et al. Current practices in

sedation and analgesia for mechanically ventilated criti-cally ill patients: a prospective multicenter patient-basedstudy. Anesthesiology. 2007;106(4):687-695.

28. Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam J-J,Jaber S. A prospective study of pain at rest: incidence andcharacteristics of an unrecognized symptom in surgicaland trauma versus medical intensive care unit patients.Anesthesiology. 2007;107:858-860.

29. Skrobik Y, Ahern S, Leblanc M, Marquis F, Awissi D,Kavanagh B. Protocolized intensive care unit management ofanalgesia, sedation, and delirium improves analgesia andsubsyndromal delirium rates. Anesth Analg. 2010;111:451-463.

30. Rose L, Smith O, Glinas C, et al. Critical care nurses painassessment and management practices: a survey in Canada.Am J Crit Care. 2012;21(4):251-259.

31. Chanques G, Jaber S, Barbotte E, et al. Impact of systematicevaluation of pain and agitation in an intensive care unit.Crit Care Med. 2006;34:1691-1699.

patients managed with a sedation protocol or a sedationprotocol with daily sedative interruption: a pilot study. J CritCare. 2011;26:127-132.

6. Kwekkeboom K, Herr K. Assessment of pain in the criticallyill. Crit Care Nurs Clin North Am. 2001;13:181-194.

7. Glinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Valida-tion of the Critical-Care Pain Observation Tool in adultpatients. Am J Crit Care. 2006;15:420-427.

8. Payen J-F, Bru O, Bosson J-L, et al. Assessing pain in criti-cally ill sedated patients by using a behavioral pain scale.Crit Care Med. 2001;29:2258-2263.

9. Odhner M, Wegman D, Freeland N, Steinmetz A, IngersollG. Assessing pain control in nonverbal critically ill adults.Dimens Crit Care Nurs. 2003;22(6):260-267.

10. Feldt K. The Checklist of Nonverbal Pain Indicators (CNPI).Pain Manage Nurs. 2000;1:13-21.

11. Puntillo KA, Morris AB, Thompson CL, Stanik-Hutt J, WhiteCA, Wild LR. Pain behaviors observed during six commonprocedures: results from Thunder Project II. Crit Care Med.2004;32:421-427.

12. Payen J, Bosson J, Chanques G, Mantz J, Labarere J;DOLOREA Investigators. Pain assessment is associatedwith decreased duration of mechanical ventilation in theintensive care unit: a post hoc analysis of the DOLOREAstudy. Anesthesiology. 2009;111(6):1308-1316.

13. Topolovec-Vranic J, Canzian S, Innis J, Pollmann-MudryjM, White McFarlan A, Baker A. Patient satisfaction anddocumentation of pain assessments and management after

implementing the Adult Nonverbal Pain Scale. Am J CritCare. 2010;19:345-354.

14. Glinas C, Arbour C, Michaud C, Vaillant F, Desjardins S.Implementation of the Critical-Care Pain Observation Tool onpain assessment/management nursing practices in an inten-sive care unit with nonverbal critically ill adults: a beforeand after study. Int J Nurs Stud. 2011;48(12):1495-1504.

15. Rubenfeld G, Angus D. Are intensivists safe? Ann InternMed. 2008;148:877-879.

16. Glinas C, Johnston C. Pain assessment in the critically illventilated adult: validation of the Critical-Care Pain Obser-vation Tool and physiologic indicators. Clin J Pain. 2007;23:497-505.

17. Glinas C, Arbour C. Behavioral and physiologic indicatorsduring a nociceptive procedure in conscious and uncon-scious mechanically ventilated adults: similar or different?J Crit Care. 2009;24:628.e627-628.e617.

18. Rose L, Haslam L, Dale C, et al. Survey of assessment and

management of pain for critically ill adults. Intensive CritCare Nurs. 2011;7:121-128.

19. Aissaoui Y, Zeggwagh A, Zekraoui A, Abidi K, Abouqal R.Validation of a behavioural pain scale in critically ill,sedated, and mechanically ventilated patients. AnesthAnalg. 2005;101:1470-1476.

254 JCCAMERICAN JOURNAL OF CRITICAL CARE, May 2013, Volume 22, No. 3 www.ajcconline.org

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CNE Test Test ID A132232: Behavioral Pain Assessment Tool for Critically Ill Adults Unable To Self-Report PainLearning objectives: 1. Describe key elements of the behavioral assessment Critical-Care Pain Observation Tool (CPOT). 2. Evaluate effects of CPOT with changein practice for documentation and administration of analgesics and sedatives. 3. Compare results among studies regarding compliance with pain assessmentdocumentation and practice recommendations.

Program evaluation Yes NoObjective 1 was met Objective 2 was met Objective 3 was met Content was relevant to my

nursing practice My expectations were met This method of CE is effective

for this content The level of difficulty of this test was:

easy medium difficultTo complete this program,

it took me hours/minutes.

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.

1. Which of the following has been identif ied as the most signif icant barrierto effec tive assessment and management of pain in the intensive care u nit?a. Patient inability to self reportb. Nurses perception of pain managementc. Family interventionsd. Documentation

2. Those conducting the Critical-Care Pain Observation Tool (CPOT) studyhypothesized that implementation of CPOT would do which of the following?a. Not affect documentation of pain assessment and would increase administration of

analgesicsb. Negatively affect documentation and decrease administration of analgesicsc. Increase documentation of pain assessment and influence administration of analgesicsd. Decrease documentation of pain assessment and increase administration of sedatives

3. Which of the following is the recommended pain a ssessment interval forpostsurgical patients?a. Every 15 minutes for 1 hour then a minimum of every 2 hoursb. Hourly for 6 hours then a minimum of every 4 hoursc. Hourly for 2 hours then every 2 hours for 12 hoursd. Hourly for the entire shift and as needed

4. Patients were eligible for the study if they met 1 of 2 criteria. The f irstcriterion refers to the patientsi nability to commun icate as determined bynot being able to follow verbal commands. What was the second criterion?a. A Mini-Mental Status Exam score less than 24b. A motor score of 5 or less on the Glasgow Coma Scalec. A vital capacity greater than 15mL/kg body weightd. Ability to maintain a mean arterial blood pressure between 70 and 110 mmHg

5. Data abstractors excluded reference to pa in behaviors dur ing which of thefollowing i nterventions?a. Routine neurological assessmentsb. Pain assessment after narcotic administrationc. Administration of analgesia for mild paind. Patient mobility

6. Which of the following was use d to exami ne prospectively chosen patientfactors associ ated with pai n assessment in each intensive care unit (ICU)?a. Kaplan-Meier methodb. Nonlinear regressionc. Multiple Poisson regressiond. Discriminant analysis

7. Which of the following admissions categories provided the most patients forthe study?a. Surgicalb. Traumac. Medicald. Respiratory

8. As a result of CPOT implementation, the media n number of pai n assessmentintervals for each patient:a. Increasedb. Decreasedc. Did not change

9. Study f indings indicated successful i mplementation of the CPOT wasassociated w ith which of the following?a. Increased patient assessment intervalsb. Minimized analgesia administrationc. Better detection for the presence of paind. Compliance with pain assessment documentation.

10. Which of the following supported the assumption that CPOT implementation

resulted in i mproved detection and u se of opioids in the med ical/surgical/trauma ICU?a. Frequency of analgesic use was targeted and met.b. Protocols created provided guidelines for pain discrimination.c. There was improved benchmarking and compliance.d. There were minimal differences in patient characteristics.

11. Which of the following outcomes is a nticipated with implementation ofa systematic pain a ssessment to treat and prevent escalation of pai n?a. Decreased length of stayb. Improved patient satisfactionc. Improved patient outcomesd. Decreased postsurgical infection rates

12. Which of the following measures did the authors employ to minimi zeperformance bias relating to pai n assessment practices?a. Data was collected from the medical record following discharge from the ICU.b. Participant criteria were focused on the patients ability to communicate.c. Nursing staff was required to complete education prior to the study.d. Data was recorded for 2 weeks before and after CPOT implementation.

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Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: CERP A Test writer: Jean Shinners, PhD, RN-BC

9. a b c d

8. a b c

7. a b c d

6. a b c d

5. a b c d

4. a b c d

3. a b c d

2. a b c d

1. a b c d

10. a b c d

12. a b c d

11. a b c d

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