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

Comparison of the accuracy and the response time to behavioral pain scales (BPS and CPOT) during painful procedures in the intensive care unit

BACKGROUND

Pain is one of the most common symptoms in the patients hospitalized in intensive care units, and its correct and timely diagnosis is important. Identifying tools that accurately assess pain in a shorter time will help patients better manage pain. The aim of this study was to compare the accuracy and the duration of response to behavioral pain scales (BPS and CPOT) during painful procedures in the intensive care unit.

MATERIALS AND METHODS

The descriptive-comparative study was conducted in two groups, each including 16 nurses, in the intensive care unit of Besat Hospital in Hamadan in 2022. Each group separately evaluated the patients' pain during position change and secretion suction based on BPS and CPOT scales along with an evaluator. At the same time, the accuracy of the scores given by each nurse and the duration of pain diagnosis were compared using the determined evaluator, and the results were analysed.

RESULTS

Comparing the durations of response to the scales, the average duration of response for BPS and CPOT tools were 13.21 and 13.63, respectively; in general, their difference was significant (P < 0.001). Examining the accuracy of the nurses and the evaluators in pain evaluation revealed a significant difference between the two tools, and the results of adaptability were higher for CPOT, in all cases, in comparison with BPS (P = 0.024).

CONCLUSIONS

The results showed that CPOT assesses the pain more accurately compared to BPS, but the duration of pain evaluation is a little longer via CPOT. The results of the study can help the nurses working in ICUs by choosing more accurate tools with shorter evaluation duration.

Validation Testing of the European Portuguese Critical-Care Pain Observation Tool

Aim. The study aim was to validate the Portuguese version of the Critical-Care Pain Observation Tool (CPOT) in the critically ill adult population of Portugal. Methods. A prospective, observational cohort study was conducted to evaluate the CPOT in mechanically ventilated patients who were admitted to an intensive care unit. A consecutive sample of 110 patients was observed at rest pre-procedure, during a nociceptive procedure (NP) which includes turning/positioning and endotracheal or tracheal suctioning and 20 min post-procedure. Two raters participated in the data collection. The discriminative validity, criterion validity, convergent validity and inter-rater reliability of the CPOT were examined. Results. The inter-rater reliability was excellent (0.93 ≤ α ≤ 1.00) at rest and fair to moderate (0.39 ≤ α ≤ 0.60) during the NP. The CPOT could discriminate between conditions with higher scores during the NP when compared to CPOT scores at rest (p < 0.001). The optimal CPOT cut-off score was >2, with a sensitivity of 71% and a specificity of 80%, and self-reported pain was the gold standard criterion. Significant correlations (<0.40) were found between CPOT scores, the heart rate and the respiratory rate during the nociceptive procedure. Conclusions. The CPOT appears to be a valid alternative for both ventilated and non-ventilated patients who are unable to communicate.

Nurse's Evaluation of a Pain Management Algorithm in Intensive Care Units

BACKGROUND

Many patients have memories of pain during intensive care unit stay. To improve pain management, practice guidelines recommend that pain management should be guided by routine pain assessment and suggest an assessment-driven, protocol-based, stepwise approach. This recommendation prompted the development of a pain-management algorithm.

AIM

Evaluate the feasibility and clinical utility of this algorithm.

DESIGN

A descriptive survey.

SETTINGS

One medical/surgical intensive care unit, one surgical intensive care unit, and one postanesthesia care unit at two hospitals in Norway.

PARTICIPANTS/SUBJECTS

Nurses working at the three units.

METHODS

A pain-management algorithm, including three pain assessment tools and a guide to pain assessment and pain management, was developed and implemented in three intensive care units. Nurses working at the three units (n = 129) responded to a questionnaire regarding the feasibility and clinical utility of the algorithm used.

RESULTS

Our results suggested that nurses considered the new pain-management algorithm to have relatively high feasibility, but somewhat lower clinical utility. Less than half of respondents thought that pain treatment in clinical practice had become more targeted using the tree pain-assessment tools (45%) and the algorithm for pain assessment and pain management (24%).

CONCLUSIONS

Pain-management algorithms may be appropriate and useful in clinical practice. However, to increase clinical utility and to achieve more targeted pain treatment, more focus on pain-treatment actions and reassessment of patients' pain is needed. Further focus in clinical practice on how to implement an algorithm and more focus on pain-treatment action and reassessment of patients' pain is needed.

A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults

This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.

The Effect of Foot Massage on Pain of the Intensive Care Patients: A Parallel Randomized Single-Blind Controlled Trial

MATERIALS AND METHODS

This randomized, parallel, single-blind controlled trial study was performed on 75 ICU patients. Patients were allocated into three groups (massage by a nurse, massage by the patient's family, and control group) by the minimization method. Swedish massage was provided for the patients in experimental groups (each foot for 5 minutes) once a day for six days. The pain was examined in all three groups before, immediately, and one week after the intervention.

RESULTS

The mean scores of pain in the groups of foot massage by the patient's family and by a nurse showed a significant reduction at the end of the study (from 4.48 to 3.36 and 4.76 to 2.96, respectively). The control group had significantly more pain after the intervention than the family-based massage group and the nurse-based massage group (P < 0.05). Although significant difference was found in the mean scores of pain between the massage provided by a nurse and that provided by the patient's family immediately after the intervention (P < 0.05), it was not significant one week after the intervention (P > 0.05).

CONCLUSION

Using foot massage, by both nurses and family members can reduce the pain of ICU patients. This intervention may improve the nursing care quality with the least cost and complications.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial

BACKGROUND

Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes.

OBJECTIVES

To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients.

METHODS

Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed.

RESULTS

A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47).

CONCLUSION

Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

Nurses' Assessment Practices of Pain Among Critically Ill Patients

BACKGROUND

Systematic pain assessment is necessary to ensure effective pain management. Despite the availability of recommendations, guidelines, and valid tools for pain assessment, the actual implementation in clinical practice is inconsistent.

AIMS

The purpose of this study was to investigate intensive care nurses' pain assessment practices among critically ill patients in Jordanian hospitals.

DESIGN

A descriptive cross sectional design was used in this study.

SETTINGS

This study was conducted in 22 intensive care unites located in eight hospitals in Jordan.

PARTICIPANTS/SUBJECTS

Convenience sampling was used to recruit a sample of 300 nurses working in intensive care units.

METHODS

The Pain Assessment and Management for the Critically Ill survey was used to collect data. Descriptive statistics, χ², and correlational analysis were used to analyze data.

RESULTS

A total of 89.7% of nurses (N = 300) used pain assessment tools with patients able to communicate, and the numeric rating scale was the most commonly used tool. A total of 81.7% of the nurses used a pain assessment tool with patients unable to communicate, and the Adult Nonverbal Pain Scale was the most commonly used tool. Nurses' perceived importance of pain assessment was positively associated with frequent use of pain assessment tools. Nurses perceived the use of pain assessment tools for patients able to communicate as being more important than the use of pain assessment tools for patients unable to communicate.

CONCLUSIONS

The majority of intensive care unit nurses used pain assessment tools for patients both able and unable to communicate; however, the most valid and reliable tools were not used often. Nurses were not aware of the pain behaviors most indicative of pain among critically ill patients.

Challenges faced by nurses in using pain assessment scale in patients unable to communicate: a qualitative study

Background

One helpful strategy adopted for pain management in non-verbal, intubated patients is the use of a proper pain assessment scale. The purpose of the present study is to achieve a better and deeper understanding of the existing nurses' challenges in using pain assessment scales among patients unable to communicate.

Methods

This qualitative study was conducted using content analysis. Purposive sampling was used to select the participants and continued until data saturation. The participants included 20 nurses working in intensive care units. Data was collected using semi-structured interviews and analysis was done using an inductive approach.

Results

Four categories and ten sub-categories were extracted from the experiences of the nurses working in the intensive care units in terms of nursing challenges in using non-verbal pain assessment scales. The four categories included "forgotten priority", "organizational barriers", "attitudinal barriers", and "barriers to knowledge".

Conclusions

The findings of the present study have shown that various factors might influence on the use of non-verbal pain assessment scales in patients unable to communicate. Identifying these challenges for nurses can help take effective steps such as empowering nurses in the use of non-verbal pain assessment scales, relieving pain, and improving the quality of care services.

The Critical care Pain Observation Tool is reliable in non-agitated but not in agitated intubated patients

OBJECTIVE

The Critical-Care Pain.

OBSERVATION

Tool is one of the instruments developed to assess pain in patients who are unable to communicate verbally. The study aimed to survey the psychometric properties of Critical-Care Pain.

OBSERVATION

Tool in four groups of non-verbal patients according to their Richmond Agitation Sedation Score (RASS).

STUDY DESIGN AND METHODOLOGY

65 critically ill patients (medical, surgical, trauma) were assessed using the critical care pain observation tool on six occasions (before, during and after nociceptive and non-nociceptive procedures). Patients were divided into four groups according to their RASS score: 1. All patients (RASS -3 to +2), 2. Sedated patients (RASS -3 to -1), 3. Restless patients (RASS +1), 4. Agitated patients (RASS +2).

RESULTS

Discriminant and criterion validity, confirmatory factor analysis and internal reliability showed good validity and reliability in the critical care pain observation tool in all groups except agitated patients. The results showed that, in general, the CPOT has good version of the critical care pain observation tool has good psychometric properties to evaluate pain in non-verbal patients admitted to intensive care units who have a RASS score ranging from -3 to +1, but it is not a good tool to evaluate pain in patients who are agitated according to RASS.

Video education for critical care nurses to assess pain with a behavioural pain assessment tool: A descriptive comparative study

AIM

To evaluate the impact of video education on critical care nurses' knowledge and skills in using a behavioural pain assessment tool for intensive care patients and to explore the nurses' experiences with video education.

METHODS

Forty-eight nurses in one intensive care unit watched an educational video on the use of the Critical-Care Pain Observation Tool, then assessed pain in two patients with the tool and took a knowledge test. The researcher made parallel pain assessments. Interrater reliability of patients' pain assessment between nurses and the researcher was determined to examine nurses' skills in using the tool after education. Twenty nurses were interviewed about their experiences with the video education. Interviews were analysed with deductive thematic analysis.

RESULTS

The knowledge test scores indicated that the nurses learned the principles of how to use the tool. The interrater reliability of pain assessments reached a moderate level of agreement during the painful procedure, with a weighted kappa coefficient value of 0.48, CL [0.37, 0.58]. The nurses perceived video education positively, but requested additional interaction.

CONCLUSIONS

Video education is useful in teaching the principles of using a pain assessment tool. Additional clinical training is required for nurses to reach adequate skills in using the tool.

A Study on the Psychometric Properties of Revised-nonverbal Pain Scale and Original-nonverbal Pain Scale in Iranian Nonverbal-ventilated Patients

Background and Aims:

The nonverbal pain scale is one of the instruments which study pain in nonverbal-ventilated patients with regard to the changes of behavioral and physiological indices. The purpose of the study is to survey the psychometric properties of revised-nonverbal pain scale (R-NVPS) and original-nonverbal pain scale (O-NVPS) in ventilated patients hospitalized in critical care units.

Materials and Methods:

Four nurses studied pain in sixty patients hospitalized in trauma, medical, neurology, and surgical critical care units using R-NVPS and O-NVPS at six times (before, during, and after nociceptive and nonnociceptive procedures). The test was repeated in 37 patients after 8–12 h.

Results:

Cronbach's alpha coefficient for R-NVPS and O-NVPS was 0.8 and 0.76, respectively. The inter-rater correlation coefficient during different times was r = 0.89–0.96 for R-NVPS and r = 0.80–0.87 for O-NVPS. Test-retest correlation coefficient for R-NVPS and O-NVPS was r = 0.55–0.86 and r = 0.51–0.75, respectively. The meaningful difference in pain score between nociceptive and nonnociceptive procedures (P < 0.001) and a higher pain score in patients who confirmed pain (P < 0.001) showed a discriminant and criterion validity for both scales of NVPS, respectively.

Conclusions:

R-NVPS and O-NVPS can both be used as valid and reliable scales in studying pain in ventilated patient. However, in comparing the items, “respiration” (R-NVPS) had a higher sensitivity than “physiology II” (O-NVPS) in assessing pain.

Pain rather than induced emotions and ICU sound increases skin conductance variability in healthy volunteers

BACKGROUND

Assessing pain in critically ill patients is difficult. Skin conductance variability (SCV), induced by the sympathetic response to pain, has been suggested as a method to identify pain in poorly communicating patients. However, SCV, a derivate of conventional skin conductance, could potentially also be sensitive to emotional stress. The purpose of the study was to investigate if pain and emotional stress can be distinguished with SCV.

METHODS

In a series of twelve 1-min sessions with SCV recording, 18 healthy volunteers were exposed to standardized electric pain stimulation during blocks of positive, negative, or neutral emotion, induced with pictures from the International Affective Picture System (IAPS). Additionally, authentic intensive care unit (ICU) sound was included in half of the sessions. All possible combinations of pain and sound occurred in each block of emotion, and blocks were presented in randomized order.

RESULTS

Pain stimulation resulted in increases in the number of skin conductance fluctuations (NSCF) in all but one participant. During pain-free baseline sessions, the median NSCF was 0.068 (interquartile range 0.013-0.089) and during pain stimulation median NSCF increased to 0.225 (interquartile range 0.146-0.3175). Only small increases in NSCF were found during negative emotions. Pain, assessed with the numeric rating scale, during the sessions with pain stimulation was not altered significantly by other ongoing sensory input.

CONCLUSION

In healthy volunteers, NSCF appears to reflect ongoing autonomous reactions mainly to pain and to a lesser extent, reactions to emotion induced with IAPS pictures or ICU sound.

Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation

PURPOSE

This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay.

MATERIALS AND METHODS

The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events.

RESULTS

Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics.

CONCLUSION

Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.

Pain and Agitation Management in Critically Ill Patients

Pain and agitation may be difficult to assess in a critically ill patient. Pain is best assessed by self-reporting pain scales; but in patients who are unable to communicate, behavioral pain scales seem to have benefit. Patients' sedation level should be assessed each shift and preferably by a validated ICU tool, such as the RASS or SAS scale. Pain is most appropriately treated with the use of opiates, and careful consideration should be given to the pharmacokinetic and pharmacodynamic properties of various analgesics to determine the optimal agent for each individual patient. Sedation levels should preferably remain light or with the use of a daily awakening trial. Preferred treatment of agitation is analgosedation with the addition of nonbenzodiazepine sedatives if necessary. There are risks associated with each agent used in the treatment of pain and agitation, and it is important to monitor patients for effectiveness, signs of toxicity, and adverse drug reactions.

Development of a pain management algorithm for intensive care units

OBJECTIVES

To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm.

BACKGROUND

Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist.

METHODS

Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest.

RESULTS

An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63).

CONCLUSIONS

The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

The Impact of Pain Assessment on Critically Ill Patients' Outcomes: A Systematic Review

In critically ill patients, pain is a major problem. Efficient pain management depends on a systematic, comprehensive assessment of pain. We aimed to review and synthesize current evidence on the impact of a systematic approach to pain assessment on critically ill patients' outcomes. A systematic review of published studies (CINAHL, PUBMED, SCOPUS, EMBASE, and COCHRANE databases) with predetermined eligibility criteria was undertaken. Methodological quality was assessed by the EPHPP quality assessment tool. A total of 10 eligible studies were identified. Due to big heterogeneity, quantitative synthesis was not feasible. Most studies indicated the frequency, duration of pain assessment, and types of pain assessment tools. Methodological quality assessment yielded “strong” ratings for 5/10 and “weak” ratings for 3/10 studies. Implementation of systematic approaches to pain assessment appears to associate with more frequent documented reports of pain and more efficient decisions for pain management. There was evidence of favorable effects on pain intensity, duration of mechanical ventilation, length of ICU stay, mortality, adverse events, and complications. This systematic review demonstrates a link between systematic pain assessment and outcome in critical illness. However, the current level of evidence is insufficient to draw firm conclusions. More high quality randomized clinical studies are needed.

Validation of the Behavioural Indicators of Pain Scale ESCID for pain assessment in non-communicative and mechanically ventilated critically ill patients: a research protocol

AIM

To investigate the validity and reliability of the Behavioural Indicators of Pain Scale (ESCID) in medically and surgically non-communicative and mechanically ventilated critical patients.

BACKGROUND

Scales based on behavioural indicators of pain are suggested to measure pain in non-communicative critically ill patients. Scales proposed thus far have a range not comparable to those used with patients who can report their pain. A scale with a 0-10 range and more behavioural indicators is proposed to improve the detection and measurement of pain.

DESIGN

A multicentre prospective observational design to validate a scale-measuring instrument.

METHODS

Three hundred non-communicative and mechanically ventilated critical patients from 20 different intensive care units will be observed for 5 minutes before, during and 15 minutes after three procedures: turning, tracheal suctioning and soft friction with gauze on healthy tissue. Two independent observers will assess the pain of subjects with the Behavioural Pain Scale and the ESCID scale simultaneously. Descriptive and inferential statistics will be used. Student's t-test will be used to compare components of the twos scales. Inter-rater and intrarater agreement will be investigated. The reliability scale will be measured using Cronbach's alpha. Approval date for this protocol was January 2012.

DISCUSSION

A greater number of behavioural indicators in the ESCID scale than in previously validated scales, with a 0-10 score range, can improve the detection and measurement of pain in non-communicative and mechanically ventilated critical patients. Funding granted in 2011 by the Spanish Health Research Fund (PI 11/00766, Health Ministry).

TRIAL REGISTRATION

Study registered with www.clinicaltrials.gov (NCT01744717).

Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: A survey conducted by the Indian Society of Critical Care Medicine

Background and Aim:

Use of sedation, analgesia and neuromuscular blocking agents is widely practiced in Intensive Care Units (ICUs). Our aim is to study the current practice patterns related to mobilization, analgesia, relaxants and sedation (MARS) to help in standardizing best practices in these areas in the ICU.

Materials and Methods:

A web-based nationwide survey involving physicians of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Society of Anesthesiologists (ISA) was carried out. A questionnaire included questions on demographics, assessment scales for delirium, sedation and pain, as also the pharmacological agents and the practice methods.

Results:

Most ICUs function in a semi-closed model. Midazolam (94.99%) and Fentanyl (47.04%) were the most common sedative and analgesic agents used, respectively. Vecuronium was the preferred neuromuscular agent. Monitoring of sedation, analgesia and delirium in the ICU. Ramsay's Sedation Scale (56.1%) and Visual Analogue Scale (48.07%) were the preferred sedation and pain scales, respectively. CAM (Confusion Assessment Method)-ICU was the most preferred method of delirium assessment. Haloperidol was the most commonly used agent for delirium. Majority of the respondents were aware of the benefit of early mobilization, but lack of support staff and safety concerns were the main obstacles to its implementation.

Conclusion:

The results of the survey suggest that compliance with existing guidelines is low. Benzodiazepines still remain the predominant ICU sedative. The recommended practice of giving analgesia before sedation is almost non-existent. Delirium remains an underrecognized entity. Monitoring of sedation levels, analgesia and delirium is low and validated and recommended scales for the same are rarely used. Although awareness of the benefits of early mobilization are high, the implementation is low.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit

OBJECTIVE

To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002.

METHODS

The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding.

CONCLUSION

These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.