Pain Assessment and Management in Critically

Pain Assessment and Management in Critically Louise Rose Lawrence S. Bloomberg Professor in Critical Care Nursing, University of Toronto Adjunct Scientist, Mt Sinai Hospital and Li Ka Shing Institute, St Michael s Hospital Director of Research, Provincial Centre of Weaning Excellence, Toronto East General Hospital

BEHAVIOURAL PAIN ASSESSMENT TOOLS

Adult Nonverbal Pain Scale (Odhner) Checklist of Non-Verbal Pain Indicators (Feldt) Behaviour Pain Score (Payen) Pain Behaviour Assessment Tool (Puntillo)

Critical-Care Pain Observation Tool

Uni-dimensional Use single or several domains e.g. behaviour Multi-dimensional e.g. behaviour and physiologic signs Indicate pain presence NOT severity BPS (Payen) and CPOT (Gelinas) valid and reliable Some issues with existing tools ambiguity of items lack of specificity for pain need for further psychometric testing

Available Tools: Cautions Patients must be able to exhibit all behaviours no limb movement will under represent pain Various scales use different total scores and cutoffs misinterpretation and confusion Numeric scale too similar to NRS which describes pain intensity as well as identifies pain presence

PAIN ASSESSMENT

3711 observation hours =1213 pain assessment intervals Total 377 pain assessments = 223 intervals with pain assessments Pain assessment in 10.2% of hours = 18.4% of mandated pain assessments documented

PAIs: Behavioural descriptors (N = 679)

3442 surveys sent 1251 ON 1251 AB, QC, BC 1251 all other 842 surveys received Response rate 24.5% YT 33%, QC 32%, AB 26%, MB 24% NS 23%, SK 22%, BC 19%, ON 18%, NF 18%, NB 17%, PEI 17%, NWT/Nu 3% 802 evaluable surveys

Frequent assessment and documentation of pain considered equally important for patients able and unable to communicate (94% vs 94%) Less likely to use behavioural pain assessment tool compared to selfreport tool (33% vs 89% P <0.001) Behavioural pain assessment tools considered less important in guiding pain assessment compared to self-report tools (74% vs 88% P <0.001) 61.3% reported pain scores discussed often or routinely during nurseto-nurse handover 41.5% nurses described targeting of analgesic administration (pain score/other assessment parameters) as prescribed by Drs

Most likely suggestive of pain Least likely suggestive of pain

Use of a behavioural pain tool > 50% of the time was associated with: awareness of published guidelines odds ratio 2.5 (95% CI 1.7-3.7) tool availability in the clinical setting OR 2.6 (95% CI 1.6-4.3) No association with education on pain tools, availability of a protocol, ICU experience, hospital type or province

Knowledge of published guidelines 29% had read any published guidelines or practice recommendations for pain assessment and management 8% familiar with SCCM Sedation and Analgesia Guidelines (2002) 8% familiar with American Society of Pain Management Nursing (ASPMN) Recommendations (2006) 22% familiar with Registered Nurses Association of Ontario Best Practice Guidelines on pain (2007)

Nurses were less likely to use a behavioural pain assessment tool for patients unable to communicate, rated them less important, and had low awareness of practice recommendations Suggests inadequate uptake of evidence and practice recommendations for pain assessment and management of critically ill patients, particularly for those unable to communicate pain Low penetration of practice recommendations may impact availability of pain assessment tools, practice norms and patient outcomes at the local level Need for novel knowledge-translation interventions to improve routine pain assessment and management practices

LINKING PAIN ASSESSMENT TO MANAGEMENT

Nurse satisfaction

EFFECT OF THE CRITICAL-CARE PAIN OBSERVATION TOOL ON PAIN ASSESSMENT AND MANAGEMENT: BEFORE AND AFTER STUDY Data recorded max 72 hours 130 patients before and 132 after CPOT (CVICU) 59 patients before and 52 after (MSICU) CVICU: PAIs with PA documented from 15.2% to 64.2% (P<0.0001) median total dose of opioid analgesia from 5 mg to 4 mg in the CVICU patients (P=0.02) MSICU: PAIs with PA documented from 21.9% to 79.7% (P<0.0001) median total dose of opioid analgesia from 27 mg to 75mg (P = 0.002)

Basic Tenets of Pain Management All health professionals should advocate for effective pain control Ongoing assessment using a systematic approach is essential Presume pain is present when patients unable to selfreport Early recognition and control = easier to prevent pain escalation Start analgesia prior to or with sedation that has little to no analgesic effect ERSTAD et al. Chest 135(4) 2009

405 symptom assessments in 171 pts

Thank you for your attention louise.rose@utoronto.ca