1

Pursuing Best Practice: Improving Pain Measurement and Interventions for Non-verbal

Adults in the Intensive Care Unit

Dawn Hippensteel MS, BSN, RN, GCNS-BC

Tamara Burket, DNP, RN, ACNS-BC, GCNS-BC, CCRN-K, FGNLA

UPMC Pinnacle• Multi-site system includes 8 Acute Care Hospitals in

Central Pennsylvania• 1,360 Licensed Beds

• 3 NICHE Hospitals• UPMC Harrisburg• UPMC Community Osteopathic, • UPMC West Shore

• Similar Medical ICU’s at two Community Hospital Sites, each with• 12 beds• 30 staff

UPMC Pinnacle:West Shore Campus

Community Osteopathic Campus

2

Objectives

•Discuss application of the IOWA EBP Model to implement practice change

•Discuss the efficacy of the CPOT tool compared to the FLACC in non verbal adult patients in the ICU

Description of the Clinical Problem

• Pain in nonverbal critically ill patients is common, and often unrecognized and untreated.

• Rapidly growing ICU population is >85

• Community and West Shore ICU population > 65yo is 61.6%

• Nurses have a pivotal role in pain management

• Accurate pain assessment is essential

Introduction

• Nurses questioned the current pain scale for non-verbal patients• FLACC (Faces, Legs, Activity, Cry, and Consolability )

• Concerned that a tool designed for infants/ children was not adequate

• Pain reassessment documentation was inconsistent and only completed 33-60% of the time

3

Introduction• Nurses on the pain committee requested a best practice

investigation

• They also noted the Critical Care Pain Observation Tool (CPOT) was available in the new EMR but was not in our policy

• The CPOT did not correlate with pain scoring in the MAR

• 2 Clinical Nurse Specialists (CNSs) developed this into a doctoral project

Why the CPOT was chosen for investigation

• Nurses had noticed the Critical Care Pain Observation Tool (CPOT) was available in the new EMR but was not in our policy

• Some nurses found they were able to access the tool and use it

• The literature was full of current information evaluating the CPOT against other pain assessment tools for non-verbal patients

• The CPOT compared to many other scales was shown to be a better tool

• The CPOT has been shown to be valid and reliable for intubated and extubated patients that can’t use a numerical scale.

• Many ICU scales address intubated patients, but not necessarily cognitively limited patients; extubated patients and some intubated patients can communicate enough to use standard numerical pain scales

The IOWA EBP Model

4

IOWA Model• Problem focused triggers + Knowledge focused triggers

• Priority• Appropriate pain management

• Form a team• Initial team was the CNS and the CNS/DNP student• Pain Committee/ unit pain champions• And later collaboration with EMR team

Problem Knowledge

Tool used for non-verbal pain assessmentAccurate pain assessment essentialPain reassessment data below benchmarkImprove the process of pain assessment

Is there a better tool researched in literature?What do national standards and guidelines say?What do we believe about patient care/ re: pain?What do our organizational standards say?

IOWA Model

• Literature was reviewed

• The CPOT was found to be a valid and reliable tool

• Information was brought back to the pain committee

• CPOT worked for others; will it work for our organization?

PICO Question

Will implementation of the CPOT by nurses caring for nonverbal patients in the intensive care unit improve pain assessment, documentation, and implementation of recommended nursing interventions as measured by pain scores and documented interventions before, during, and one hour after repositioning when compared to current practice/use of the FLACC tool?

5

Goals were Established

1. Implementation of the CPOT by nurses caring for nonverbal patients in the intensive care unit to improve pain assessment

2. Assess the impact of the use of CPOT to nurses’ work flow

3. Assess nurse’s satisfaction with CPOT

4. Recommend a nonverbal pain scale that might be adopted by the organization to assess pain in nonverbal Intensive Care Unit Patients

Kouzes & Posner

Presence/ Modeling the Way

• CNSs, mangers, and pain champions encouraged staff participation by being actively on the unit and engaged.

• Updates on how close we were to completion were regular

6

Methods• Outcomes:

• pain assessment/ reassessment• feasibility and reliability

• Two similar ICUs were chosen in 2 community hospitals.• Community Osteopathic served as the control

• West Shore was the intervention unit

• Project plan and teams created• Baseline data collected

• CNSs, pain champions, unit committees, nurse educators

• Education on pain and pain reassessment

Baseline

Unit Pre- test Post-Test

Non ImplementationControl/ Community

83% 90%

ImplementationIntervention/ West Shore

85% 90%

X2 Pre and Post Tests for Pain Education on Similar Units Supports Similarity at Baseline

X2= .001O of freedom= 1

p=.911635

Pain Assessment

•Pain assessments were done on 75 patients in each of the 2 units

•Assessments were done:• At rest• During turning and repositioning• One hour after any intervention

• To align with pain reassessment times

7

Data Collection-Control

• FLACC tool/ scoring• Date and time

• Before turning with

• During turn and reposition

• One hour after turning

• Pain intervention and time• Medication

• Non-pharmacological

• Pain and pain reassessment data tracked by the unit

Intervention

• FLACC tool/ scoring• Date and time

• Before turning with

• During turn and reposition

• One hour after turning

• CPOT tool/scoring• Date and time

• Before turning with

• During turn and reposition

• One hour after turning

• Brief Questionnaire

• Pain and pain reassessment data tracked by the unit.

FLACC Scale 0 points 1 points 2 points Score before

turn and

reposition

T1

Score during

turn and

reposition

T2

Score one hour

after turn and

reposition

T3

Time and date

Faces No particular

expression or

smile

Occasional grimace or

frown, withdrawn or

disinterested

Frequent to constant

quivering chin or

clenched jaw

Legs Normal position

or relaxed

Uneasy, restless,

tense

Kicking, or legs drawn up

Activity Lying quietly,

normal position,

moves easily

Squirming, shifting

back and forth, tense

Arched, ridged or jerking

Crying No cry (awake or

asleep)

Moans or whimpers,

occasional complaint

Crying steadily, screams

or sobs, frequent

complaints

Consolability Content, relaxed Reassured by

occasional touching,

hugging or being

talked to, distractible

Difficult to console or

comfort

Total Score

Over

Tools utilized/ FLACC

Pain interventions used:Medications/time____________________________________________________________________________________________________________________________________________________________________________________________________________________Other interventions/time______________________________________________________________________________________________________________________________________________________________________________________________________

CPOT scale 0 points 1 point 2 points Score before turn and reposition

T1

Score during turn and reposition

T2

Score one hour after turn and reposition

T3

Time and Date:

Facial Expression No muscular tension observedRelaxed, neutral

Presence of frowning, brow lowering, orbit tightening, levator contraction/ Tense

Al pervious facial movements plus eyelids tightly closed

Body Movements Does not move at all (doesn’t necessarily mean absence of pain)Absence of movement

Slow Cautious movements, touching or rubbing pain site, seeking attention through movements/ Protection

Pulling tube, attempts to sit up, moving limbs, trashing, not following commands striking at staff, attempt to climb out of bed/ Restlessness

Muscle tension/ Evaluation by passive flexion and extension of upper extremities

No resistance to passive movements/ Relaxed

Resistance to passive movements/ Tense, rigid

Strong resistance to passive movements, inability to complete them/ Very tense or rigid

Compliance with ventilator (intubated patients)

Alarms not activated, easy ventilation/ Tolerating ventilator or movement

Alarms stop spontaneously/ Coughing but tolerating

Asynchrony: blocking ventilation, alarms frequently activated/ Fighting ventilator

OR Vocalization (extubated patients)

Talking in normal tone of voice or no sound

Sighing, Moaning Crying out, sobbing

Total Score

Question yes No

Is the CPOT easy to complete?

Do you believe the CPOT improved your ability to manage your patient's pain compared to FLAC/FACES?

I prefer using the CPOT compared to the FLACC.

Questionnaire, Adapted from: Gélinas, et al. (2014). Nurses’ evaluations of the CPOT use at 12 month post implementation in the

intensive care unit.

Tools utilized/ CPOT

8

Results Goal 1:

Implementation of the CPOT by nurses caring for nonverbal patients in the intensive care unit improves pain assessment

FLACC group medicated 41/80 or 51.25% of the timeFLACC/CPOT (implementation group) medicated 62/75 or 82.66% of the time

X Medicated Not Medicated

FLACC 41 39 80

FLACC/CPOT 63 13 75

X Medicated/ Non-medicated

Implementation versus Non-Implementation

2

X2= 17.5628O of freedom= 1

p=.000028

Results: Goal 1

•WS Unit Monthly Compliance Data for Reassessment of Pain *

Target % Jan. Feb. Mar.Educate

Apr.Imple-ment

MayImple-ment

JuneImple-ment

JulyImple-ment

Aug.

100 60 33 100 90 80 70 100 80

*Further Develop Champion

*Counsel Staff

*Meet with Manager

*Attend Steering

*Increase Visibility

*ENCOURAGE THE HEART

Results Goal 2: Assess the impact of the use of CPOT to nurses’ work flow

• Create a space in the unit for nurses to give feedback on the process

• Bulletin board with the following areas: Barrier, Suggested Improvement, Resolution

• Daily response to nurses’ comments for first 2 weeks, then every other day, then weekly as needed

9

Goal 2

Barrier/Concern

• “2 sided form long, easy to miss”

• “Written form is too much work”

• “But I use the CPOT”

• “My patient is paralyzed”

Response/Resolution

• Form placed on one page

• End goal is for one, easy electronic tool

• Not policy, indirect access

• Not for paralyzed patients

Other feedback Goal 2

RN Response

• “I like that it accounts for the patient bucking the vent…”• “I like that CPOT includes ventilation ease.”• “It measures activity better, like rigidity…”• “Better recognition of pain with CPOT due to sedation/intubation”• “CPOT is easy.”• “CPOT is easier to work with! Preferred over FLACC.”• “…seems easier to use, organize…”

•

Results Goal 3: Assess nurse’s satisfaction with CPOT

1) Is the CPOT easy to complete?

2) Do you believe the CPOT improved your ability to manage your patient’s pain compared to FLACC/Faces?

3) I prefer using the CPOT compared to the FLACC

Adapted from: Gélinas, C., Ross, M., Boitor, M., Desjardins, S., Vaillant, F., & Michaud, C. (2014).

Nurses' evaluations of the CPOT use at 12‐month post‐implementation in the intensive care unit.

Nurses’ CPOT Feasibility/Satisfaction: Brief QuestionnairePlease rate the following questions. Choose a “yes” or “no” response

for each question. THANK YOU!

10

Goal 3

• Was the CPOT easy to complete?- 70/73 or 95.89% of the time

• Did it subjectively improve nursing practice when compared to current practice?- 56/73 or 76.71% of the time

• Were the nurses satisfied with the use of CPOT in ICU?

- 63/73 or 86.30% of the time

Results Goal 4: Recommend a nonverbal pain scale that might be adopted by the organization to assess pain in nonverbal Intensive Care Unit Patients

•Results disseminated

•CPOT recommended

•Rolling out house wide March 2018

Presence/ Presents

• Staff on both the control unit and the intervention unit were rewarded for their efforts at the conclusion of this project.

11

Cost/Benefit Analysis Project Development Cost

Description Cost Total

Materials: Misc. Supplies• Paper, ink, markers …one unit • $200.99

$ 200.99

Education of staff• .5 hr. x 30 at $27.00/hr. • $405.00

$405.00

Additional Team Meetings• Champion

6 hr. x 2 at $27.00/hr.

• $324.00 $324.00

Leadership Costs• Planning/Time on Unit

CNS rate 155 hr. at $45.00/hr.• $6,975.00 $6,975.00

Total Cost/Unit = $7,904.00

Benefits

Description Savings Total

Avg. LOS 3 days x 6 nonverbal

patients

• Cost = $6,144.00-$7,956.00

x 6 = $18,432.00-$23,868.00

CPOT reduced LOS by half• $3072.00-$3978.00

• x 3 = $9,216.00-$11,934.00

• -$7,904.00= $1,312.00-

$,4030.00

$1,312.00-$4,030.00

Potential Savings for 6

patient LOS=

$1,312.00-$4,030.00

References• Al Darwish, Z. Q., Hamdi, R., & Fallatah, S. (2016). Evaluation of Pain Assessment Tools in Patients Receiving

Mechanical Ventilation. AACN Advanced Critical Care, 27(2), 162-172.

• Arbour, C., Gélinas, C., & Michaud, C. (2011). Impact of the implementation of the Critical-Care Pain Observation Tool (CPOT) on pain management and clinical outcomes in mechanically ventilated trauma intensive care unit patients: A pilot study. Journal of Trauma Nursing, 18(1), 52-60.

• Barr, J., Fraser, G. L., Puntillo, K., Ely, E. W., Gélinas, C., Dasta, J. F., ... & Coursin, D. B. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit: executive summary. Am J Health Syst Pharm, 70(1), 53-58.

• Belcher, J. V. (2016, September). Transformational Leadership in Evidence-Based Practice: An Integrative Review. In Leadership Connection 2016 (17-20 September). STTI.

• Benner, P. (1984). From novice to expert. Menlo Park.

• Buttes, P., Keal, G., Cronin, S. N., Stocks, L., & Stout, C. (2014). Validation of the critical-care pain observation tool in adult critically ill patients. Dimensions of Critical Care Nursing, 33(2), 78-81.

• Centers for Medicare and Medicaid Services, Baltimore, MD. (Accessed on September 11, 2017 at www.cms.gov.

References

• Coles, J. (2014). Appreciative inquiry: an emerging approach to delivering quality nursing care. Kentucky nurse, 62(1), 7.

• Cooperrider, D. L., & Whitney, D. (2001). A positive revolution in change: Appreciative inquiry. Public administration and public policy, 87, 611-630.

• Davidson, J. E., Winkelman, C., Gélinas, C., & Dermenchyan, A. (2015). Pain, agitation, and delirium guidelines: Nurses’ involvement in development and implementation. Critical Care Nurse, 35(3), 17-31.

• Echegaray-Benites, C., Kapoustina, O., & Gélinas, C. (2014). Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive and Critical Care Nursing, 30(5), 257-265.

• Ge, X., Tao, J. R., Wang, J., Pan, S. M., & Wang, Y. W. (2015). Bayesian estimation on diagnostic performance of Face, Legs, Activity, Cry, and Consolability and Neonatal Infant Pain Scale for infant pain assessment in the absence of a gold standard. Pediatric Anesthesia, 25(8), 834-839.Nursing in Critical Care, 19(6), 272-280.

• Gélinas, C., Ross, M., Boitor, M., Desjardins, S., Vaillant, F., & Michaud, C.(2014). Nurses' evaluations of the CPOT use at 12‐month post‐implementation in the intensive care unit. Dimensions ofCritical Care Nursing, 33(2), 78-81.

12

References

• Gélinas, C., Harel, F., Fillion, L., Puntillo, K. A., & Johnston, C. C. (2009). Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. Journal of Pain and Symptom Management, 37(1), 58-67.

• Gélinas, C., & Johnston, C. (2007). Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. The Clinical Journal of Pain, 23(6), 497-505.

• Gélinas, C., Fillion, L., Puntillo, K. A., Viens, C., & Fortier, M. (2006). Validation of the critical-care pain observation tool in adult patients. American Journal of Critical Care, 15(4), 420-427.

• Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., ... & Wild, L. (2006). Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44-52.

• Ista, E., van Dijk, M., & van Achterberg, T. (2013). Do implementation strategies increase adherence to pain assessment in hospitals? A systematic review. International journal of Nursing Studies, 50(4), 552-568.

• Kiavar, M., Azarfarin, R., Totonchi, Z., Tavakoli, F., Alizadehasl, A., & Teymouri, M. (2016). Comparison of Two Pain Assessment Tools,“Facial Expression” and “Critical Care Pain Observation Tool” in Intubated Patients After Cardiac Surgery. Anesthesiology and Pain Medicine, 6(1).

References

• Kouzes, J. M., & Posner, B. Z. (2006). The leadership challenge (Vol. 3). John Wiley & Sons

• Kowal, C. D. (2009). Implementing the Critical Care Pain Observation Tool using the Iowa Model. The Journal of the New York State Nurses' Association, 41(1), 4-10.

• Linde, S. M., Badger, J. M., Machan, J. T., Beaudry, J., Brucker, A., Martin, K., ... & Roy, R. D. N. (2013). Reevaluation of the critical-care pain observation tool in intubated adults after cardiac surgery. American Journal of Critical Care, 22(6), 491-497.

• Merskey, H., & Bogduk, N. (1994). Classification of chronic pain, IASP Task Force on Taxonomy. Seattle, WA: International Association for the Study of Pain Press (Also available online at www. iasp-painorg).

• Mohr, B. J., & Watkins, J. M. (2002). The essentials of appreciative inquiry: A roadmap for creating positive futures. Pegasus Communications, Incorporated.

• Marmo, L., & Fowler, S. (2010). Pain assessment tool in the critically ill post–open heart surgery patient population. Pain Management Nursing, 11(3), 134-140.

• http://nursing-informatics.com/N4111/AI_5DCyclenewer.jpg

• Odhner, M., Wegman, D., Freeland, N., Steinmetz, A., & Ingersoll, G. L. (2003). Assessing pain control in nonverbal critically ill adults. Dimensions of Critical Care Nursing, 22(6), 260-267.

References

• Paulson-Conger, M., Leske, J., Maidl, C., Hanson, A., & Dziadulewicz, L. (2011). Comparison of two pain assessment tools in nonverbal critical care patients. Pain Management Nursing, 12(4), 218-224.

• Pudas‐Tähkä, S. M., Axelin, A., Aantaa, R., Lund, V., & Salanterä, S. (2009). Pain assessment tools for unconscious or sedated intensive care patients: a systematic review. Journal of Advanced Nursing, 65(5), 946-956.

• Rahu, M. A., Grap, M. J., Ferguson, P., Joseph, P., Sherman, S., & Elswick, R. K. (2015). Validity and sensitivity of 6 pain scales in critically ill, intubated adults. American Journal of Critical Care, 24(6), 514-523.

• RICHER, M. C., Ritchie, J., & Marchionni, C. (2009). ‘If we can't do more, let's do it differently!': using appreciative inquiry to promote innovative ideas for better health care work environments. Journal of Nursing Management, 17(8), 947-955.

• Rose, L., Haslam, L., Dale, C., Knechtel, L., & McGillion, M. (2013). Behavioral pain assessment tool for critically ill adults unable to self-report pain. American Journal of Critical Care, 22(3), 246-255.

• Stites, M. (2013). Observational pain scales in critically ill adults. Critical Care Nurse, 33(3), 68-78.

13

References

• Stichler, J. F. (2011). Adapting to change. Health Environments Research & Design Journal, 4(4), 8-11.

• Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., ... & Goode, C. J. (2001). The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.

• Vázquez, M., Pardavila, M. I., Lucia, M., Aguado, Y., Margall, M., & Asiain, M. C. (2011). Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nursing in critical care, 16(4), 178-185.

• Voepel-Lewis, T., Zanotti, J., Dammeyer, J. A., & Merkel, S. (2010). Reliability and validity of the face, legs, activity, cry, consolability behavioral tool in assessing acute pain in critically ill patients. American Journal of Critical Care, 19(1), 55-61.