Conflict of Interest Disclosure

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1 Eve Broughton MSN, RN, ACNS-BC, Pain-C, CNRN Larry Hoth BSN, RN, CCRN Bernadette Montano MS, RN Mary Doyle, PhD, RN, CPHQ Conflict of Interest Disclosure Conflicts of Interest for ALL listed contributors. None Eve L. Broughton Lawrence Hoth Bernadette Montano Mary Doyle A conflict of interest is a particular financial or non financial circumstance that might compromise, or appear to compromise, professional judgment. Anything that fits this should be included. Examples are owning stock in a company whose product is being evaluated, being a consultant or employee of a company whose product is being evaluated, etc. Taken in part from On Being a Scientist: Responsible Conduct in Research. National Academies Press Objectives 1. The Road Traveled 2. Roadblocks and Detours 3. The Open Road 1

2 The Road Traveled 2010 to 2013 Brainstormed Literature search A lot of reading Developing the PICO Determining the tools Writing the proposal Submitting to the IRB Hitting a road block; a detour;.and finally Data Collection Literature Review We have now run the searches 3 times, once each year since the start. Data covers time frame from Confirmed thoughts Pain is a stressor, Pain undertreated over time can affect long term QOL. ICU patients on D/C from ICU, reported pain as undertreated when they were intubated. Many scales have been developed to assess the unconscious child and adult patient. Three tools float to the top when it comes to assessment of the unconscious intubated adult ICU patient. Behavior Tools are considered the best alternative when patients are unconscious. Physiologic monitors/indicators should not be used as a primary indicator of pain (although more research is now being done in this area) ASPMN: supports use of either the Behavior pain scale (BPS) or Critical Care Pain Observation Tool (CPOT) in unconscious patients, ventilated or not ventilated. (2006) Faces, Legs, Arms, Cry and Consolability Scale (FLACC), BPS and CPOT all have reliability and validity data to support (some better than others.) All have been tested in an ICU setting in unconscious ventilated patients. CPOT can be used in both conscious and unconscious patients ventilated or not; is an 8 point scale. BPS is a 12 point scale (BPS may have some inter relater reliability concerns.) Findings of Interest 2

3 2010 Questions Raised: The Beginning Why did the FLACC become a tool for Adults in our VA? Implemented in or around 2001 Are our RNs pleased with the FLACC, do they feel it accurately assesses the unconscious ICU patient? Can we provide a larger study for reliability, validity, and inter rater reliability testing? Should we look at the NVPS? Why? Why Not? Can we identify a tool that our ICU nurses find easy to use, provide consistency in assessment? Is there one tool which nurses feel positively improves patient outcomes? One tool that the nurses feel that demonstrates that their interventions positively improve patient outcomes (i.e. that lowers pain scores)? How can our study improve upon what we have learned? Can we change practice? Do we need to change practice? Assessment Tools VAS NRS BPS CPOT FLACC Comfort NVPS PAIN PBAT BPRS CCPRS PAIN Algorithm FLACC Meets BPS And The Payen, J.F, Bru, O., Boaaon, J., Lagrasta, A., Novel, E., Deschaux, I., et.al. (2001). Assessing pain in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine, 29(12),

4 Critical Care Pain Observation Tool (CPOT) Gelinas, 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), Original PICO P: Population: ICU patients at the SAVAHCS ventilated and/or possible unresponsive I: Intervention: Pain Assessment using an alternate scale C: Comparison: Current standard of Care the FLACC (Face, Legs, Arms, Cry, Consolability) O: Outcomes: To identify the best tool for assessing ICU patients who are either unresponsive or ventilated. Road Block (Spinning our Wheels) and a Detour EBP vs Research: either way we needed to go to the IRB. Changing the PICO as we determine what we were really looking at. IRB/mentor felt it was research. Intervention and Help of our Mentor The IRB who determined it was an EBP The Blessing with Forward motion 4

5 PICO P: Population: ICU patients at the SAVAHCS ventilated and/or possible unresponsive I: Intervention: Pain Assessment using an alternate scale C: Comparison: Current standard of Care the FLACC (Face, Legs, Arms, Cry, Consolability) O: Outcomes: To identify the best liked/easy to use tool for assessing pain in ICU patients who are ventilated and unresponsive. The Slow Meandering Road: Methods and Data collection So You think you know how to get data??!! Developed a survey, front back with all 3 tools on it. SAVAHCS ICU is busy, we always have someone on a ventilator. But not after we started the survey. We had a couple of days of no vents. No problem, just multiple it out. We ll be done in 3 or 5 weeks. Ha Ha.. The Methods and Data Collection: As reality set in. Findings 3 5 weeks turned into almost 8 months! The goal was to obtain 100 completed paired surveys total using observations with the bedside nurse and EPB team nurse Of the 100 pairs, there were 4 extra pairs of forms; a total of 27 pairs that could not be used due to incompletion, incorrect information, or missing forms due to out of sequence numbering. Total of 77 pairs or 154 individual surveys were usable 5

6 Findings ICU NURSE tool preference results : CPOT 54 or 70% BPS 15 or 20% FLACC 4 or 5% Reported no preference 4 EPB Team nurse tool preference results: CPOT 64 or 83% BPS 6 or 8% FLACC 3 or 4% No preference 2 Selected both CPOT & BPS 2 Findings Most common reason for tool preferences by the ICU nurses were: CPOT: 65% listed reasons more detailed/descriptive; accurate; appropriate; more options BPS: the majority of comments related to the behavioral description and pain assessment specific to a ventilator patient FLACC: ease of use; most applicable Findings Most common reasons for tool preference by the team nurses: CPOT: 50% selected the tool because more descriptive/choices/options 19% more parameters for ventilators BPS listed reasons more accurate, concise, appropriate for sedation/wakefulness FLACC easy to use; familiarity; identifying pain 6

7 Data Analysis (Got to love Statistical Data) Data Analysis Looking at comparison of Team RNs vs ICU RNs First pass was exciting with Excel software Correlations of.58 to.67 BUT Gave data to our statistician Spearman Analysis shows no correlation between RN groups So, an old proverb, experience is what you get when you don t get what you want. Data Analysis. 7

8 Data Analysis. Conclusions The CPOT was the tool best liked by both ICU staff and the EBP team The CPOT was by comments the easiest tool to use for assessing pain in ICU patients who are ventilated and unresponsive. Statistical Data does not support the nurses preference as any better than the FLACC Limitations Education and buy in to and from the ICU staff could have been improved Template/Tool had errors Timeliness of data collection got away from the team and may have affected the outcomes Could have opened the focus of the patient population a bit broader. Did not reach goal of surveys due to incomplete forms 8

9 The Open Road Presented to the ICU nurses January 2013 Presented at the Spring 2013 SAVAHCS EBP Conference American Society of Pain Management Nurses (ASPMN) October 2013 (submitted and here we are) American Association of Critical Care Nurses (AACN) May 2014 and/or the Society of Critical Care Medicine (SCCM) Publish What is next on this road? Good Question PICIS/Critical Care Manager/ICU Electronic Documentation Software is to be installed at SAVAHCS. CPOT is the assessment tool we are looking at the RN s prefer it it is an option with BPS, VAS and FLACC in Pain Assessment. ANCC also has made the change to CPOT or BPS as a national Guideline for ICU pain assessment. Oh! That means a SAVAHCS policy change as the current standard is 0 10 scale May mean a VHA add an alternate option for ICU patients VA wide. Can we do a larger project with other VA s, we know we have interest. Bibliography Aissaoui, Y., Zeggwagh, A.A., Zekraoui, A., Abidi, K., & Abouqal, R. (2005). Validation of a Behavioral Pain Scale in critically ill, sedated, and mechanically ventilated patients. Anesthesia & Analgesia, 101(5), Arbour, C. & Gelinas, C. (2011). Setting goals for pain management when using a behavioral scale: Example with the critical care observation tool. Critical Care Nurses, 31(6), Arbour, C., Gelinas, 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), Bambi, S., Solaro, M., (2012). Letter to the Editor. CPOT: Is there any missing link? Pain Management Nursing, 13(1), 67. Barr, J., Fraser, G.L., Puntillo, K., et.al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), Bell, L., (2012). Pain scales and pain management. American Journal of Critical Care, 21(4), 260. Briggs, M. (1995). Principle of acute pain assessment. Nursing Standard, 9(19), Buckenmaier, C.C., Galloway, K.T., Polomano, R.C., McDuffie, M., Kwon, N., & Gallagher, R.M. (2013). Acute and Perioperative Pain Section, Preliminary validation of the department of defense and veterans pain rating scale (DVPRS) in a military population. Pain Medicine, 14, Cadden, K. A., (2007). Better pain management, 38(8), Cade, C.H., (2008). Clinical tools for the assessment of pain in sedated critically ill patients. Nursing in Critical Care, 13(6), Coffman, S., Alvarez, Y., Pyngolil, M., Petit, R., Hall,C & Smyth, M., (1997). Nursing assessment and management of pain in critically ill children. Heart and Lung, 26(3), Cnzian, S, Topolovec Vranic, J., White McFarlan, A., & Baker, A., (2007). Impact of implementing a new pain assessment tool for nonverbal patients in a trauma neurosurgical critical care Unit. St Michael s Hospital, International. American Journal of Critical Care, 16(3), 302. Gelinas, C. (2011). When and how to evaluate inter rater reliability of patient assessment tools. American Association of Critical Care Nurses, Advanced Critical Care, 23(4),

10 Bibliography (cont.) Gelinas, 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), Gelinas, C., Loiselle, C.G.,LeMay, S., Ranger, M., Bouchard, E., & McCormack, D., (2008). Theoretical, psychometric, and pragmatic issues in pain measurement. Pain Management Nursing, 9(3), Gelinas, C. & Johnston, C., (2007). Pain assessment in the critically ill ventilated adult: Validation of the Critical Care Pain Observation Tool and physiologic indicators. Clinical Journal of Pain, 23(6), Gelinas, C., Tousignant Laflamme, Y., Tanguay, A., & boutgault, P. (2011). Exploring the validity of the bispectral index, the critical care observation tool and vital signs for the detection of pain in sedated and mechanically ventilated critical ill adults: a pilot study. Intensive and Critical Care Nursing, 27, Granja, C., Lopes, A., Moreira, S., Dias, C., Costa Pereira, A., Carneiro, A. (2005). Patients recollections of experiences in the intensive care unit may affect their quality of life. Critical Care, 9(2), R96 R109. Herr, K., Coyne, P.J., McCaffery, M., Manworren, R., & merkel, S., (2011). Pain assessment in the patient unable to self report: position statement with clinical practice recommendations. Pain mangment Nursing, 12(4), Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., et. al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), Katz, N. (2002). Journal of Pain and Symptom Management, 24(15), S38 S47. Klepstad, P. & Rosland, J.H. (2011). No pain, much gain. ACTA Anaesthesiologica Scandinavica, 55, Li, D and Puntillo, K., (2004). Ask the experts. Critical Care Nurse, 24(5), Li, D. Puntillo, K. & Miaskowski, C., (2008). A review of objective pain measures for use with critical care adult patients unable to self report. The Journal of Pain, 9(1), Marmo, L. & Fowler, S., (2010). Pain assessment tool in the critically ill post open heart surgery patient population. Pain Management Nursing, 11(3), McCarberg, B.H., Nicholson, B.D., Todd, K.H., Palmer, T., & Penles, L. (2008). The impact of pain on quality of life and the unmet needs of pain management: Results from pain sufferers and physicians in an internet survey. American Journal of Therapeutics, 15, Bibliography (cont.) Merkle, S.I., Voepel Lewis, T., Shayevitz, J.R., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing, 23(2). 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), 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), Payen, J.F, Bru, O., Boaaon, J., Lagrasta, A., Novel, E., Deschaux, I., et.al. (2001). Assessing pain in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine, 29 (12), Puntillo, K. A., Miaskowski, C., & Summer, G. (2003?). Pain. Pathophysiological Phenomena in Nursing, Chapter 12, 3 rd ed, pp Putillo, K.A., Stannard, D., Miakowski, C., Kehrle, K., & Gleeson, S. (2002). Use of a pain assessment and intervention notation (P.A.I.N.) tool in critical care nursing practice: Nurses' evaluations. Heart & Lung, 31(4), Schelling, G., Richter, M., Roozendaal, B., Rothenhauster, H., Krauseneck, T., Stoll, C., Nollert, G., Schmidt, M., & Kapfhammer, H., (2003). Exposure to high stress in the intensive care unit may have negative effects on health related quality of life outcomes after cardiac surgery. Critical Care Medicine, 31(7), Vazquez, M., Pardavila, M., Lucia, M., Aquado, Y., Margall, A., & Asiain, C. (2011). Pain assessment in turning procedures for patients with invasive mechanical ventilation. Nursing in Critical Care, 16(4), 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, Young, j., Siffleet, J., Nikoletti, N., & Shaw, T. (2006). Use of a behavioral pain scale to assess pain in ventilated, unconscious and /or sedated patients. Intensive and Critical Care Nursing, 22, Credits and Thanks The SAVAHCS EBP Committee Nurse Executives old and new The Tucson Library staff The ICU managers and staff Dr. Ringenberg who understands the difference between EBP and research Dr. Mary Doyle 10

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