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Setting Goals for Pain Management When Using a Behavioral Scale: Example With the Critical-Care Pain Observation Tool
process may be facilitated when evidence is available and a cutoff score has been established for the use of the selected behavioral pain scale to be implemented. A cutoff score refers to the score on a specific scale associated with the best probability of correctly ruling in or ruling out a patient with a specific conditionin this case, pain. The use of a cutoff score with behavioral pain scales can help to determine when pain is highly likely to be present and can guide clinicians in determining whether an intervention to alleviate pain is required or not. Also, the cutoff score can help to evaluate the effectiveness of pain management interventions. Cutoff scores are established by using a criterion (ie, a reference standard in the field). In the case of pain, the patients self-report is known as the reference standard criterion. To our knowledge, the Critical-Care Pain Observation Tool (CPOT) is one of the few behavioral pain scales with a cutoff score that has been empirically established by using patients self-reports and appropriate statistical analyses. The CPOT (see Table) includes 4 behaviors rated from 0 to 2, yielding a total score from 0 to 8.1 The CPOT

My facility will be starting to use the Critical-Care Pain Observation Tool (CPOT) in the next month. We currently titrate the dosages of our infused pain medications to meet the goal of a score of 0 to 2 on a nonverbal pain scale. I need to put a goal for the CPOT on our pain doctors order formdo you have a suggestion? I know that if the patient were verbal, I would be using the patients acceptable level of pain as the goal.

Caroline Arbour, RN, BSc, and Cline Glinas, RN, PhD, reply:

Authors
Caroline Arbour is a PhD nursing candidate at McGill University School of Nursing, Montreal, Quebec, Canada. Cline Glinas is an assistant professor at McGill University School of Nursing, a nurse scientist at the Centre for Nursing Research of the Jewish General Hospital and a project director at the Lady Davis Insititute, Montreal, Quebec, Canada.
Corresponding author: Caroline Arbour, McGill University School of Nursing, Wilson Hall, 3506 University Street, Montreal, Quebec, H3A 2A7 (e-mail: [email protected]). To purchase electronic and print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected].
2011 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2011914

The implementation of a newly developed behavioral pain assessment tool for nonverbal patients often provides the opportunity for the revision of pain management protocols in critical care settings. An issue often encountered by clinicians when revising such protocols is the establishment of directives (eg, cutoff pain score) related to the use of the new pain assessment tool for the administration or the titration of dosages of analgesics. Answering this question is not easy and may require discussions among health care professionals in many disciplines (eg, nurses, intensivists, anesthetists, pharmacists) to set up standards of care and treatment related to pain assessment and pain management in your critical care department. Nevertheless, such a

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Table
Indicator

The Critical-Care Pain Observation Toola

Score Relaxed, neutral Tense 0 1 Description No muscle tension observed Presence of frowning, brow lowering, orbit tightening, and levator contraction or any other change (eg, opening eyes or tearing during nociceptive procedures) All previous facial movements plus eyelid tightly closed (the patient may have mouth open or may be biting the endotracheal tube) Does not move at all (does not necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed

Facial expression

Grimacing
0 1 2

Body movements

Absence of movements or normal position Protection Restlessness

1 2

Compliance with the ventilator (intubated patients)

Tolerating ventilator or movement Coughing but tolerating Fighting ventilator

0 1 2 0 1 2 0 1 2 __/8

Alarms not activated, easy ventilation Coughing, alarms may be activated but stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated Talking in normal tone or no sound Sighing, moaning Crying out, sobbing No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, inability to complete them

or Vocalization (nonintubated patients)

Talking in normal tone or no sound Sighing, moaning Crying out, sobbing

Muscle tension Evaluation by passive flexion and extension of upper limbs when patient is at rest or evaluation when patient is being turned Total
a Adapted

Relaxed Tense, rigid Very tense or rigid

with permission from Glinas et al.1

was tested in 5 studies1-5 with a total of 255 adults with various diagnoses (ie, medical, surgical, and trauma) and hospitalized in the intensive care unit (ICU). The CPOT has shown good psychometric properties (ie, validity and interrater reliability) for the detection of pain in ICU adults. Validation is still in progress with brain-injured ICU patients, who seem to react differently to pain (Le Q, Glinas C, Arbour C, Rodrigue N, unpublished data, 2011; Arbour C, Glinas C, unpublished data, 2011).3 Results of previous studies2,5 indicate

that the CPOT cutoff score is between 2 and 3. In addition to these empirical findings, relevant clinical recommendations for pain assessment in nonverbal patients were established in the position statement of the American Society for Pain Management Nursing.6 For instance, in the position statement, it is strongly suggested that clinicians pay attention to the change in behaviors when patients are exposed to potential sources of pain or after the administration of an analgesic. On the basis of evidence and clinical

recommendations, the clinician could suspect the presence of pain when the CPOT score is greater than 2 or when the CPOT score increases by 2 points or more, which would trigger an intervention for pain management. Accordingly, a decrease of 2 points or more in the CPOT score would indicate that the intervention was effective in relieving pain.

Case Example
A patient is admitted to the ICU after cardiac surgery. He is

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undergoing mechanical ventilation and is too drowsy to communicate effectively with the staff by using signs (eg, nodding head or pointing on a communication board). However, he seems to be uncomfortable as he becomes agitated each time he is touched. The nurse in charge is puzzled about whether to administer an analgesic or a sedativeboth are prescribed on the postoperative care protocol. She first assesses the presence of pain and gets a score of 4 of 8 on the CPOT as the patient frequently grimaces and attempts to sit in the bed. Given that a CPOT score higher than 2 strongly suggests the presence of pain, the nurse gives a dose of subcutaneous analgesic. Thirty minutes after the administration of the analgesic, the patient is displaying a relaxed face and is cautiously moving his hand from time to time toward the surgical wound on his chest. The CPOT score is now 1 of 8, indicating pain relief as the score decreased from 4 to 1 (ie, more than 2 points).

can be shown to be valid only with a specific group of people and in a given context.7 Finally, and as illustrated in the case example just described, a behavioral pain scale is not only useful for the assessment or reassessment of pain in nonverbal patients, it can also help nurses discriminate between pain and other states such as anxiety and fear and can guide the administration of analgesics or sedatives accordingly.8,9 Thinking about implementing the CPOT on your unit? A free video that demonstrates how to use the CPOT is available at http://pointers .audiovideoweb.com/stcasx/il83win 10115/CPOT2011-WMV.wmv/play .asx (funded and created by Kaiser Permanente Northern California Nursing Research). CCN
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after cardiac surgery. J Pain Symptom Manag. 2009;37:58-67. Herr K, Coyne PJ, Key T, et al. Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manag Nurs. 2006;7:44-52. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 4th ed. Oxford, United Kingdom: Oxford University Press; S2008. Arbour C, Glinas C, Michaud C. Impact of the implementation of the CPOT on pain management and clinical outcomes in mechanically ventilated trauma ICU patients. J Trauma Nurs. 2011;18:52-60. Glinas C, Arbour C, Michaud C, Vaillant F, Desjardins S. The impact of the implementation of the Critical-Care Pain Observation Tool on pain assessment/management nursing practices in the intensive care unit with nonverbal critically ill adults. Int J Nurs Stud. In press.

Summary
Clinicians interested in implementing a new behavioral pain scale on their unit should verify if a cutoff score has been empirically established for that scale. If not, directives about the use of the scale in clinical practice must be established with the help of the multidisciplinary team before the scale is used. Clinicians should also make sure that the selected behavioral pain scale has been tested in the same type of patients in whom the scale is to be used at the bedside. Indeed, a scale

Financial Disclosures
None reported.

References
1. Glinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006;15:420-427. 2. Glinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain. 2007; 23:497-505. 3. Glinas C, Arbour C. Behavioral and physiologic indicators during a nociceptive procedure in conscious and unconscious mechanically ventilated adults: similar or different? J Crit Care. 2009;24:628.e7-628.e17. 4. Glinas C, Fillion L, Puntillo KA. Item selection and content validity of the CriticalCare Pain Observation Tool: an instrument to assess pain in critically ill nonverbal adults. J Adv Nurs. 2009;65:203-216. 5. Glinas C, Harel F, Fillion L, Puntillo K, Johnston C. Sensitivity and specificity of the Critical-Care Pain Observation Tool for the detection of pain in intubated adults

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