Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study

BACKGROUND

Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited.

AIMS

To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation.

METHODS

A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken.

RESULTS

A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes.

CONCLUSIONS

Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

Interrater Agreement between Bedside and Video Raters Using the CPOT-Neuro for Pain Assessment in Critically Ill Patients with a Brain Injury

This study aimed to examine the interrater agreement of Critical-Care Pain Observation Tool-Neuro (CPOT-Neuro) scores as a newly developed tool for pain assessment in patients with critical illness and brain injury between raters using two methods of rating (bedside versus video) during standard care procedures (i.e., non-invasive blood pressure and turning). The bedside raters were research staff, and the two video raters had different backgrounds (health and non-health disciplines). Raters received standardized 45 min training by the principal investigator. Video recordings of 56 patient participants with a brain injury at different levels of consciousness were included. Interrater agreement was supported with an Intraclass Correlation Coefficient (ICC) > 0.65 for all pairs of raters and for each procedure. Interrater agreement was highest during turning in the conscious group, with ICCs ranging from 0.79 to 0.90. The use of video recordings was challenging for the observation of some behaviors (i.e., tearing, face flushing), which were influenced by factors such as lighting and the angle of the camera. Ventilator alarms were also challenging to distinguish from other sources for the video rater from a non-health discipline. Following standardized training, video technology was useful in achieving an acceptable interrater agreement of CPOT-Neuro scores between bedside and video raters for research purposes.

Relationship Between Pain and Delirium in Critically Ill Adults

OBJECTIVES

Although opioids are frequently used to treat pain, and are an important risk for ICU delirium, the association between ICU pain itself and delirium remains unclear. We sought to evaluate the relationship between ICU pain and delirium.

DESIGN

Prospective cohort study.

SETTING

A 32-bed academic medical-surgical ICU.

PATIENTS

Critically ill adults (n = 4,064) admitted greater than or equal to 24 hours without a condition hampering delirium assessment.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Daily mental status was classified as arousable without delirium, delirium, or unarousable. Pain was assessed six times daily in arousable patients using a 0-10 Numeric Rating Scale (NRS) or the Critical Care Pain Observation Tool (CPOT); daily peak pain score was categorized as no (NRS = 0/CPOT = 0), mild (NRS = 1-3/CPOT = 1-2), moderate (NRS = 4-6/CPOT = 3-4), or severe (NRS = 7-10/CPOT = 5-8) pain. To address missingness, a Multiple Imputation by Chained Equations approach that used available daily pain severity and 19 pain predictors was used to generate 25 complete datasets. Using a first-order Markov model with a multinomial logistic regression analysis, that controlled for 11 baseline/daily delirium risk factors and considered the competing risks of unarousability and ICU discharge/death, the association between peak daily pain and next-day delirium in each complete dataset was evaluated.

RESULTS

Among 14,013 ICU days (contributed by 4,064 adults), delirium occurred on 2,749 (19.6%). After pain severity imputation on 1,818 ICU days, mild, moderate, and severe pain were detected on 2,712 (34.1%), 1,682 (21.1%), and 894 (11.2%) of the no-delirium days, respectively, and 992 (36.1%), 513 (18.6%), and 27 (10.1%) of delirium days (p = 0.01). The presence of any pain (mild, moderate, or severe) was not associated with a transition from awake without delirium to delirium (aOR 0.96; 95% CI, 0.76-1.21). This association was similar when days with only mild, moderate, or severe pain were considered. All results were stable after controlling for daily opioid dose.

CONCLUSIONS

After controlling for multiple delirium risk factors, including daily opioid use, pain may not be a risk factor for delirium in the ICU. Future prospective research is required.

Adaptation and Validation of the Standardized Swallowing Assessment Tool for Patients With Moderate-Severe Traumatic Brain Injury and Cervical Spinal Cord Injury

Oropharyngeal dysphagia is common in moderate-severe traumatic brain injury (TBI) and cervical spinal cord injury (SCI) patients and can have serious consequences. Delaying feeding in these patients can also be detrimental. Nonetheless, the psychometric properties of screening tools that can promptly identify dysphagia have never been tested in these neurotrauma populations. This study aimed to: (1) adapt, translate, and validate the content of the French-Canadian version of the the Standardized Swallowing Assessment (SSA) tool to meet the needs of moderate-severe TBI and cervical SCI patients, (2) examine its inter-rater reliability and criterion-concurrent validation, and (3) evaluate its clinical utility from the perspectives of critical care nurses. The SSA tool was adapted and translated using an integrated method for the cultural adaptation and translation of tools. Eleven experts participated in the adaptation of the SSA tool, which led to the clarification of one item, as well as a new step and instructions for the screening procedure. Content validation (i.e., item and scale relevance) was evaluated by multidisciplinary team members (n = 17). The mean content validity index (CVI) score was 0.97 for the entire scale, while the mean CVI scores for individual items ranged from 0.82 to 1.0. A total of 60 neurotrauma patients were enrolled for inter-rater reliability and criterion-concurrent validation. Interrater reliability was determined by comparing two scores: one score from nurses responsible for the care of enrolled patients and one score from the research nurse. The weighted kappa coefficients for inter-rater reliability were 0.86 for moderate-severe TBI patients (n = 30) and 0.73 for cervical SCI patients (n = 30). A speech language therapist (SLT) also assessed dysphagia and results were used as the standard clinical reference criterion to determine concurrent validity (sensibility and specificity) of the adapted SSA tool. The sensitivity and specificity were 92% and 50% for moderate-severe TBI, and 77% and 75% for cervical SCI, respectively. The positive predictive value (PPV) and the negative predictive value (NPV) were 65% and 87% in TBI patients, and 75% and 76% in SCI patients. Test accuracy was 71% and 77% for these same groups. The clinical utility of the tool was evaluated according to the following domains: appropriateness, accessibility of the required material, applicability, perceived effectiveness, and acceptability. Acceptability was the only domain with a level of agreement <80% (74%) among trauma critical care nurses (n = 49). Findings support the content validation and inter-rater reliability of the adapted French-Canadian version of the SSA tool in moderate-severe TBI and cervical SCI patients. Sensitivity was acceptable in both groups, but the specificity was lower, especially in moderate-severe TBI patients. Further validation of the adapted French-Canadian version of the SSA tool is needed in neurotrauma patients to confirm these results and to ensure safe dysphagia screening while avoiding oral feeding deferrals.

International Analgesia and Sedation Weaning and Withdrawal Practices in Critically Ill Adults: The Adult Iatrogenic Withdrawal Study in the ICU

OBJECTIVES

Iatrogenic withdrawal syndrome (IWS) associated with opioid and sedative use for medical purposes has a reported high prevalence and associated morbidity. This study aimed to determine the prevalence, utilization, and characteristics of opioid and sedative weaning and IWS policies/protocols in the adult ICU population.

DESIGN

International, multicenter, observational, point prevalence study.

SETTING

Adult ICUs.

PATIENTS

All patients aged 18 years and older in the ICU on the date of data collection who received parenteral opioids or sedatives in the previous 24 hours.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

ICUs selected 1 day for data collection between June 1 and September 30, 2021. Patient demographic data, opioid and sedative medication use, and weaning and IWS assessment data were collected for the previous 24 hours. The primary outcome was the proportion of patients weaned from opioids and sedatives using an institutional policy/protocol on the data collection day. There were 2,402 patients in 229 ICUs from 11 countries screened for opioid and sedative use; 1,506 (63%) patients received parenteral opioids, and/or sedatives in the previous 24 hours. There were 90 (39%) ICUs with a weaning policy/protocol which was used in 176 (12%) patients, and 23 (10%) ICUs with an IWS policy/protocol which was used in 9 (0.6%) patients. The weaning policy/protocol for 47 (52%) ICUs did not define when to initiate weaning, and the policy/protocol for 24 (27%) ICUs did not specify the degree of weaning. A weaning policy/protocol was used in 34% (176/521) and IWS policy/protocol in 9% (9/97) of patients admitted to an ICU with such a policy/protocol. Among 485 patients eligible for weaning policy/protocol utilization based on duration of opioid/sedative use initiation criterion within individual ICU policies/protocols 176 (36%) had it used, and among 54 patients on opioids and/or sedatives ≥ 72 hours, 9 (17%) had an IWS policy/protocol used by the data collection day.

CONCLUSIONS

This international observational study found that a small proportion of ICUs use policies/protocols for opioid and sedative weaning or IWS, and even when these policies/protocols are in place, they are implemented in a small percentage of patients.

Preliminary clinical testing to inform development of the Critical Care Pain Observation Tool for Families (CPOT-Fam)

Introduction

Many patients in the intensive care unit (ICU) cannot communicate. For these patients, family caregivers (family members/close friends) could assist in pain assessment. We previously adapted the Critical Care Pain Observation Tool (CPOT) for family caregiver use (CPOT-Fam). In this study, we conducted preliminary clinical evaluation of the CPOT-Fam to inform further tool development.

Methods

For preliminary testing, we collected (1) pain assessments of patients in the ICU from family caregivers (CPOT-Fam) and nurses (CPOT) and determined the degree of agreement (kappa coefficient, κ) and (2) collected openended feedback on the CPOT-Fam from family caregivers. For refinement, we used preliminary testing data to refine the CPOT-Fam with a multidisciplinary working group.

Results

We assessed agreement between family caregiver and nurse pain scores for 29 patients. Binary agreement (κ) between CPOT-Fam and CPOT item scores (scores ≥2 considered indicative of significant pain) was fair, κ = 0.43 (95% confidence interval [CI] 0.18-0.69). Agreement was highest for the CPOT-Fam items ventilator compliance/vocalization (weighted κ = 0.48, 95% CI 0.15-0.80) and lowest for muscle tension (weighted κ = 0.10, 95% [CI] -0.17 to 0.20). Most participants (n = 19; 69.0%) reported a very positive experience using the CPOT-Fam, describing it as "good" and "easy-to-use/clear/straightforward." We iteratively refined the CPOT-Fam over five cycles using the data collected until no further revisions were suggested.

Conclusion

Our preliminary clinical testing suggests that family involvement in pain assessment in the ICU is well perceived. The CPOT-Fam has been further refined and is now ready for clinical pilot testing to determine its feasibility and acceptability.

Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report

Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.

The Validity of Vital Signs for Pain Assessment in critically Ill Adults: A Narrative Review

OBJECTIVES

Pain assessment in the intensive care unit (ICU) is challenging because many patients are unable to self-report or exhibit pain-related behaviors. In such situations, vital signs (VS) through continuous monitoring are alternative cues for pain assessment. This review aimed to describe the reliability and validity of VS for ICU pain assessment.

DESIGN

Narrative review of the literature.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane.

REVIEW/ANALYSIS METHODS

A narrative review was conducted with a comprehensive search in four databases. Search terms included VS, pain assessment, and ICU.

RESULTS

Out of 1,359 results, 30 studies from 17 countries were included. Heart rate, blood pressure, and respiratory rate were most used for ICU pain assessment. Assessments were performed at rest before procedures, during nociceptive and non-nociceptive procedures, and after procedures. Increases in respiratory rate were clinically significant by more than 25% during nociceptive procedures (e.g., endotracheal suctioning, turning) compared with rest/pre-procedures in five studies. Correlations of VS with self-reported pain (reference standard measure) and behavioral pain scores (alternative measure) were absent or weak.

CONCLUSIONS

VS are not valid indicators for ICU pain assessment. Increases of respiratory rate may be a cue for the detection of pain. However, fluctuations in respiratory rate can be influenced by opioids or controlled ventilation mode. Our results dissuade the use of VS for pain assessment because of the lack of association with ICU pain reference standards. Other physiologic measures of pain in critically ill adults should be explored.

Prediction of acute postoperative pain based on intraoperative nociception level (NOL) index values: the impact of machine learning-based analysis

The relationship between intraoperative nociception and acute postoperative pain is still not well established. The nociception level (NOL) Index (Medasense, Ramat Gan, Israel) uses a multiparametric approach to provide a 0-100 nociception score. The objective of the ancillary analysis of the NOLGYN study was to evaluate the ability of a machine-learning aglorithm to predict moderate to severe acute postoperative pain based on intraoperative NOL values. Our study uses the data from the NOLGYN study, a randomized controlled trial that evaluated the impact of NOL-guided intraoperative administration of fentanyl on overall fentanyl consumption compared to standard of care. Seventy patients (ASA class I-III, aged 18-75 years) scheduled for gynecological laparoscopic surgery were enrolled. Variables included baseline demographics, NOL reaction to incision or intubation, median NOL during surgery, NOL time-weighted average (TWA) above or under manufacturers' recommended thresholds (10-25), and percentage of surgical time spent with NOL > 25 or < 10. We evaluated different machine learning algorithms to predict postoperative pain. Performance was assessed using cross-validated area under the ROC curve (CV-AUC). Of the 66 patients analyzed, 42 (63.6%) experienced moderate to severe pain. NOL post-intubation (42.8 (31.8-50.6) vs. 34.8 (25.6-41.3), p = 0.05), median NOL during surgery (13 (11-15) vs. 11 (8-13), p = 0.027), percentage of surgical time spent with NOL > 25 (23% (18-18) vs. 20% (15-24), p = 0.036), NOL TWA < 10 (2.54 (2.1-3.0) vs. 2.86 (2.48-3.62), p = 0.044) and percentage of surgical time spent with NOL < 10 (41% (36-47) vs. 47% (40-55), p = 0.022) were associated with moderate to severe PACU pain. Corresponding ROC AUC for the prediction of moderate to severe PACU pain were 0.65 [0.51-0.79], 0.66 [0.52-0.81], 0.66 [0.52-0.79], 0.65 [0.51-0.79] and 0.67 [0.53-0.81]. Penalized logistic regression achieved the best performance with a 0.753 (0.718-0.788) CV-AUC. Our results, even if limited by the small number of patients, suggest that acute postoperative pain is better predicted by a multivariate machine-learning algorithm rather than individual intraoperative nociception variables. Further larger multicentric trials are highly recommended to better understand the relationship between intraoperative nociception and acute postoperative pain.Trial registration Registered on ClinicalTrials.gov in October 2018 (NCT03776838).

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery

Background

Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults.

Aims

The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery.

Methods

Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores.

Results

Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters.

Conclusions

These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

Strategies to improve the quality of nurse triage in emergency departments: A realist review protocol

AIM

The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED).

DESIGN

Realist review protocol.

METHODS

This protocol follows the PRISMA-P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context-mechanism-outcome (CMO) models.

DISCUSSION

Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Development and preclinical testing of the critical care pain observation tool for family caregiver use (CPOT-Fam)

Background and Aims

Pain assessment in noncommunicative intensive care unit (ICU) patients is challenging. For these patients, family caregivers (i.e., family members, friends) may be able to assist in pain assessment by identifying individualistic signs of pain due to their intimate patient knowledge. This study adapted the critical care pain observation tool (CPOT) to facilitate pain assessment in adult ICU patients by family caregivers.

Methods

This study was conducted through three distinct phases: (1)CPOT adaptation for family caregiver use (to create the CPOT-Fam): A working group met monthly to adapt the CPOT and develop educational material and sample cases for practice scoring until consensus was reached.(2)CPOT-Fam preclinical testing: Family caregiver study participants viewed educational materials and scored four randomly selected sample cases using the CPOT-Fam. Scores were compared to reference scores to assess agreement and identify CPOT-Fam sections requiring revision. Open-ended feedback on the CPOT-Fam was collected.(3)CPOT-Fam revision: the CPOT-Fam was revised by the working group considering score agreement and feedback received from study participants.

Results

Of the n = 30 participants, n = 14 (47.0%) had experience with an ICU patient. Agreement between CPOT-Fam participant scores and reference scores were highest for the vocalization dimension (Is the patient making any sounds?; Intraclass correlation coefficient; ICC = 1.0) and lowest for the body movements dimension (What are the patient's body movements like?; ICC = 0.85. Participants indicated they found the CPOT-Fam to be "informative" and "easy-to-use" but "not graphic enough"; participants also indicated that descriptors like "lack of breath" and "struggling to move" are helpful with identifying individualistic behaviors of pain exhibited by their loved ones.

Conclusion

The CPOT-Fam shows ease of use and may be of value in involving family caregivers in ICU care. Clinical pilot testing is needed to determine feasibility and acceptability and identify further areas for refinement.

French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC

OBJECTIVE

The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings.

METHODS

The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence.

RESULTS

Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version.

CONCLUSIONS

A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.

Study protocol: development and pilot testing of the Critical Care Pain Observation Tool for families (CPOT-Fam)

Background

Patients in the intensive care unit (ICU) often have limited ability to communicate making it more difficult to identify and effectively treat their pain. Family caregivers or close friends of critically ill patients may be able to identify signs of pain before the clinical care team and could potentially assist in routine pain assessments. This study will adapt the Critical Care Pain Observation Tool (CPOT) for use by family members to create the CPOT-Fam and compare family CPOT-Fam assessments with nurse-provided CPOT assessments for a given patient.

Methods

This study will be executed in two phases:

1) Development of the CPOT-Fam — A working group of patient partners, ICU clinicians, and researchers will adapt the CPOT for use by family caregivers (creating the CPOT-Fam) and produce an accompanying educational module to deliver information on pain and how to use the tool. The CPOT-Fam will undergo preclinical testing with participants (i.e., members of the public and family caregivers of critically ill adults), who will complete the educational module and provide CPOT-Fam scores on sample cases. Feedback on the CPOT-Fam will be collected.

2) Pilot testing the CPOT — Fam family caregivers of critically ill adults will complete the educational module and provide information on the following: (1) demographics, (2) anxiety, (3) caregiving self-efficacy, and (4) satisfaction with care in the ICU. Family caregivers will then provide a proxy assessment of their critically ill loved one’s pain through the CPOT-Fam and also provide a subjective (i.e., questionnaire-based including open-ended responses) account of their loved one’s pain status. A comparison (i.e., agreement) will be made between family caregiver provided CPOT-Fam scores and ICU nurse-provided CPOT scores (collected from the provincial health information system), calculated independently and blinded to one another. Feasibility and acceptability of the CPOT-Fam will be determined.

Discussion

The results of this work will produce a family caregiver CPOT (i.e., CPOT-Fam), determine feasibility and acceptability of the CPOT-Fam, and compare pain assessments conducted by family caregivers and ICU nurses. The results will inform whether a larger study to determine a role for family caregivers in ICU pain assessment using the CPOT-Fam is warranted.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01102-3.

Acceptability and Feasibility of a Patient-Oriented Music Intervention to Reduce Pain in the Intensive Care: Protocol for a Randomized Crossover Pilot Trial (Preprint)

BACKGROUND

Many patients experience pain in the intensive care unit (ICU) despite receiving pain medication. Research has shown that music can help reduce pain. Music interventions studied so far have not used music streaming to generate playlists based on patient preferences while incorporating recommended tempo and duration. Previous research has focused on postoperative ICU patients able to self-report, which is underrepresentative of the ICU population that might benefit from a music intervention for pain management. We developed a new patient-oriented music intervention (POMI) that incorporates features based on theoretical, empirical, and experiential data intended to be used in the ICU. Such a music intervention should consider the expertise of ICU patients, family members, and nursing staff, as well as the practicality of the intervention when used in practice.

OBJECTIVE

The primary objectives of this study are to (1) evaluate the acceptability and feasibility of the POMI to reduce pain in ICU patients and (2) evaluate the feasibility of conducting a crossover pilot randomized controlled trial (RCT) for intervention testing in the ICU. A secondary objective is to examine the preliminary efficacy of the POMI to reduce pain in ICU patients.

METHODS

A single-blind 2×2 crossover pilot RCT will be conducted. Patients will undergo 1 sequence of 2 interventions: the POMI which delivers music based on patients' preferences via headphones or music pillow for 20-30 minutes and the control intervention (headphones or pillow without music). The sequence of the interventions will be inverted with a 4-hour washout period. Timing of the interventions will be before a planned bed turning procedure. Each patient will undergo 1 session of music. Twenty-four patients will be recruited. Patients able to self-report (n=12), family members of patients unable to self-report (n=12), and nursing staff (n=12) involved in the bed turning procedure will be invited to complete a short questionnaire on the POMI acceptability. Data will be collected on the feasibility of the intervention delivery (ie, time spent creating a playlist, any issue related to headphones/pillow or music delivery, environmental noises, and intervention interruptions) and research methods (ie, number of patients screened, recruited, randomized, and included in the analysis). Pain scores will be obtained before and after intervention delivery.

RESULTS

Recruitment and data collection began in March 2022. As of July 5, 2022, in total, 22 patients, 12 family members, and 11 nurses were recruited.

CONCLUSIONS

Methodological limitations and strengths are discussed. Study limitations include the lack of blinding for patients able to self-report. Strengths include collecting data from various sources, getting a comprehensive evaluation of the intervention, and using a crossover pilot RCT design, where participants act as their own control, thus reducing confounding factors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05320224; https://clinicaltrials.gov/ct2/show/NCT05320224.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40760.

Identification of the intraoperative antinociceptive effect of intravenous fentanyl using the Nociception Level (NOL) index versus clinical parameters in patients undergoing gynecological laparoscopic surgery: A secondary analysis of the NOLGYN study

BACKGROUND

While we typically assess nociception balance during general anaesthesia through clinical parameters such as heart rate (HR) and mean arterial pressure (MAP) variation, these parameters are not specific to nociception.

OBJECTIVE

We hypothesized that using the Nociception Level (NOL) index to assess the analgesic effect of a fentanyl bolus would be superior to standard clinical parameters.

DESIGN

Ancillary study of the NOLGYN study, a randomized controlled trial comparing intraoperative NOL-guided administration of fentanyl (NOL group) versus standardized care (SC group).

SETTING

University hospital in Montréal, Canada between November 2018, and December 2019.

PATIENTS

Women undergoing gynecological laparoscopic surgery.

INTERVENTION

In our evaluation of intraoperative nociception, we analyzed the analgesic effect of fentanyl using three parameters: MAP, HR, and the Nociception Level (NOL) index. All fentanyl injection events were extracted from the database.

MAIN OUTCOME MEASURE

The primary endpoint was the difference between values before and after each injection.

RESULTS

The median of the NOL index before fentanyl injection was 30.5 (IQR 19.4 to 40.7) versus 18.9 (IQR 11.5 to 27.4) after (P < 0.001). The median of MAP was 106.4 mmHg (IQR 99.9 to 113.4) before injection versus 103.2 mmHg (IQR 97.5 to 110.7) after (P < 0.001). The median of HR before injection was 74.2 (IQR 64.2 to 83.8) versus 72.4 (IQR 63.4 to 81.3) after (P < 0.001).

CONCLUSIONS

The NOL index, HR, and MAP all statistically discriminated the analgesic effect of fentanyl but only the NOL index proved clinically relevant to identify the analgesic effect of one fentanyl injection.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov (NCT03776838) registered in October 2018.

Psychological distress, depression symptoms and fatigue among Quebec nursing staff during the COVID-19 pandemic: A cross-sectional study

Aim

To describe the state of health of Quebec nursing staff during the pandemic according to their exposure to COVID‐19, work‐related characteristics and sociodemographic factors (gender, generational age group). State of health was captured essentially by assessing psychological distress, depression symptoms and fatigue.

Design and methods

A large‐scale cross‐sectional study was conducted with 1,708 nurses and licenced practical nurses in Quebec (87% women, mean age of 41 ± 11 years). The survey included several questionnaires and validated health‐related scales (psychological distress, depression symptoms and fatigue). The STROBE guidelines were followed in reporting the study's findings.

Results

Results showed that the prevalence of psychological distress and depression symptoms was moderate to severe. Women, generation Xers and Yers, nurses who cared for COVID‐19 patients and those with a colleague who was infected with COVID‐19 at work scored higher for fatigue, psychological distress and depression.

Exploration of a Multi-Parameter Technology for Pain Assessment in Postoperative Patients After Cardiac Surgery in the Intensive Care Unit: The Nociception Level Index (NOL)TM

Introduction

The aim of this study was to explore the use of a multi-parameter technology, the Nociception Level (NOL) index (Medasense Biometrics Ltd, Ramat Gan, Israel), for pain assessment in postoperative awake patients after cardiac surgery during non-nociceptive and nociceptive procedures in the intensive care unit (ICU).

Materials and Methods

A prospective cohort repeated-measures design was used. Patients were included if they were in the ICU after undergoing cardiac surgery and if they could self-report their pain. A non-invasive probe was placed on the patient’s finger for the continuous monitoring of the NOL index. Patients’ self-reports of pain and anxiety (0–10 Numeric Rating Scale or NRS), and behavioral scores with the Critical-Care Pain Observation Tool (CPOT) were obtained before and during a non-nociceptive procedure (ie, non-invasive blood pressure [NIBP] using cuff inflation), and before, during and after a nociceptive procedure (ie, chest tube removal [CTR]) for a total of five time points. Non-parametric tests were used to compare scores at different time points, and receiver operating characteristic curve analysis was performed.

Results

Fifty-four patients were included in the analysis. The NOL index, pain and anxiety scores were significantly higher during CTR compared to rest and NIBP (p < 0.001). During CTR, the NOL was associated with self-reported pain intensity and unpleasantness but not with anxiety and CPOT scores. The NOL showed a modest performance in detecting pain (NRS ≥1 and ≥5) in this sample with sensitivity and specificity ranging from 61% to 85%.

Conclusion

The NOL index was able to discriminate between a non-nociceptive and a nociceptive procedure and was associated with self-reported pain. Further validation testing of the NOL is necessary in a heterogeneous sample of ICU patients.

Description of the validity of the Analgesia Nociception Index (ANI) and Nociception Level Index (NOL) for nociception assessment in anesthetized patients undergoing surgery: a systematized review

Maintaining optimum analgesia in anesthetized patients is challenging due to the inability to self-report pain or exhibit pain-related behaviours. The Analgesia Nociception Index (ANI) (based on heart rate variability [HRV]) and the Nociception Level Index (NOL) (based on HRV, photoplethysmography, skin conductance, and temperature) both include HRV and provide continuous index monitoring for nociception assessment. The research question was: "What are the validation strategies of the NOL and ANI for nociception assessment in anesthetized patients?". The objectives were to describe and analyze the validation strategies and results. A systematized review was conducted using a comprehensive search with keywords under three concepts (nociception/pain, ANI/NOL, and validity) in four databases. A quality assessment using an adapted GRADE approach for measurement tools, and a risk of bias assessment using QUADAS-2 tool were performed by two reviewers. Out of 525 results, 15 validation studies were included. Strategies included hypothesis testing, discriminative, and criterion validation. Significant changes in ANI/NOL values were found in response to nociceptive stimuli at different opioid concentrations (hypothesis testing). Higher ANI/NOL values were observed during nociceptive stimuli (discriminative). AUCs ranging from 0.83 to 0.99 were obtained to detect nociceptive stimuli (criterion). Both technologies performed superiorly in detecting nociceptive stimuli compared to individual monitoring of HR and blood pressure. Although the aforementioned validation strategies are deemed appropriate, in the absence of a gold standard, criterion validation findings should be interpreted with caution. Moreover, reliability could be examined using test-retest with consistent ANI/NOL values during a stable time-interval.

Influence of caring for COVID-19 patients on nurse's turnover, work satisfaction and quality of care

Aim

This study aims to examine, through the lens of the Job Demands‐Resources model, the influence of caring for COVID‐19 patients on nurse's perception of chronic fatigue, quality of care, satisfaction at work and intention to leave their organisation and the profession.

Background

Studies have examined how fear of COVID‐19 contributes to the mental, physical and work adjustment among nurses. To date, few studies have been conducted examining how caring for patients with COVID‐19 contributes to work outcomes among nurses.

Methods

This is a cross‐sectional survey involving 1705 frontline nurses and licensed practical nurses in Quebec, Canada. From these, 782 reported caring for COVID‐19 patients.

Results

High chronic fatigue, poor quality of care, lower work satisfaction and higher intention to leave their organisation were found for nurses caring for COVID‐19 patients. Poorly prepared and overwhelmed nurses showed higher turnover intention than those well prepared and in control.

Conclusions

There is an urgent need to provide support to nurses during the pandemic, with a long‐term strategy to increase their retention.

Implications for Nursing Management

Nurse administrators play an important role in supporting their nurses during a pandemic in the form of education, training and policy development to positively impact quality of care and retention.

Determinants of pain assessment documentation in intensive care units

PURPOSE

The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation.

METHODS

A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed.

RESULTS

All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (β = 0.37), using only breakthrough doses (β = 0.24), and lower opioid doses (β = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25).

CONCLUSION

Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.

Strategies for the Prevention and Treatment of Iatrogenic Withdrawal from Opioids and Benzodiazepines in Critically Ill Neonates, Children and Adults: A Systematic Review of Clinical Studies

BACKGROUND

Critically ill patients are at high risk of iatrogenic withdrawal syndrome (IWS), due to exposure to high doses or prolonged periods of opioids and benzodiazepines.

PURPOSE

To examine pharmacological management strategies designed to prevent and/or treat IWS from opioids and/or benzodiazepines in critically ill neonates, children and adults.

METHODS

We included non-randomised studies of interventions (NRSI) and randomised controlled trials (RCTs), reporting on interventions to prevent or manage IWS in critically ill neonatal, paediatric and adult patients. Database searching included: PubMed, CINAHL, Embase, Cochrane databases, TRIP, CMA Infobase and NICE evidence. Additional grey literature was examined. Study selection and data extraction were performed in duplicate. Data collected included: population, definition of opioid, benzodiazepine or mixed IWS, its assessment and management (drug or strategy, route of administration, dosage and titration), previous drug exposures and outcomes measures. Methodological quality assessment was performed by two independent reviewers using the Cochrane risk of bias tool for RCTs and the ROBINS-I tool for NRSI. A qualitative synthesis of the results is provided. For the subset of studies evaluating multifaceted protocolised care, we meta-analysed results for 4 outcomes and examined the quality of evidence using GRADE post hoc.

RESULTS

Thirteen studies were eligible, including 10 NRSI and 3 RCTs; 11 of these included neonatal and paediatric patients exclusively. Eight studies evaluated multifaceted protocolised interventions, while 5 evaluated individual components of IWS management (e.g. clonidine or methadone at varying dosages, routes of administration and duration of tapering). IWS was measured using an appropriate tool in 6 studies. Ten studies reported upon occurrence of IWS, showing significant reductions (n = 4) or no differences (n = 6). Interventions failed to impact duration of mechanical ventilation, ICU length of stay, and adverse effects. Impact on opioid and/or benzodiazepine total doses and duration showed no differences in 4 studies, while 3 showed opioid and benzodiazepine cumulative doses were significantly reduced by 20-35% and 32-66%, and treatment durations by 1.5-11 and 19 days, respectively. Variable effects on intervention drug exposures were found. Weaning durations were reduced by 6-12 days (n = 4) for opioids and/or methadone and by 13 days (n = 1) for benzodiazepines. In contrast, two studies using interventions centred on transition to enteral routes or longer tapering durations found significant increases in intervention drug exposures. Interventions had overall non-significant effects on additional drug requirements (except for one study). Included studies were at high risk of bias, relating to selection, detection and reporting bias.

CONCLUSION

Interventions for IWS management fail to impact duration of mechanical ventilation or ICU length of stay, while effect on occurrence of IWS and drug exposures is inconsistent. Heterogeneity in the interventions used and methodological issues, including inappropriate and/or subjective identification of IWS and bias due to study design, limited the conclusions.

Translation of the Fear of COVID-19 Scale into French-Canadian and English-Canadian and Validation in the Nursing Staff of Quebec

Introduction: During the COVID-19 pandemic, Quebec has been one of the most affected provinces in Canada. Rising fear of COVID-19 is inevitable among healthcare workers, and a new scale was developed to measure this type of fear, the Fear of COVID-19 Scale (FCV-19S). Aims: To translate the FCV-19S into French-Canadian and English-Canadian, and to validate both versions in the nursing staff from Quebec. Methods: A cross-sectional online survey was sent to approximately 15 000 nursing staff including nurses and licensed practical nurses among those who had consented to their respective Order to be contacted for research. The forward-backward method was used to translate the FCV-19S into French-Canadian and English-Canadian. Both versions along with stress and work-related questionnaires, were used to establish validity. Results: A total of 1708 nursing staff, with a majority of women, completed the survey (1517 and 191 completed the French-Canadian and English-Canadian versions). A unidimensional scale was confirmed for both versions with Cronbach alphas of 0.90 and 0.88. Discriminative values showed higher fear levels in women, and in generation X (40-56 years old). Higher fear levels were also found in nursing staff working in long-term care facilities, provided care to COVID-19 patients who died, and those who felt less prepared to provide safe care. Convergent associations were found between fear levels, stress, work satisfaction, and turnover intention. Discussion and conclusion: A rigorous approach was used to translate the fear of COVID-19 scale into French-Canadian and English-Canadian. Both Canadian versions of the FCV-19S supported a valid unidimensional scale in Quebec nursing staff.

French Translation, Adaptation, and Initial Validation of the Nurses' Attitudes and Perceptions of Pain Assessment in Neonatal Intensive Care Questionnaire (NAPPAQ)

PURPOSE

The purpose of this study was to translate, adapt and conduct initial psychometric validation of the French version of the Nurses' Attitudes and Perceptions of Pain Assessment in neonatal intensive care Questionnaire (NAPPAQ) developed by Polkki in 2010.

BACKGROUND

Assessing nurses' perceptions, attitudes and knowledge about pain management in preterm infants is important to improve neonatal practices.

METHODS

A sample of French-speaking nurses (n = 147) from Quebec and France working in neonatal intensive care was selected to validate the 46-item questionnaire. A French translation of the NAPPAQ, which includes Part I and II, was undertaken prior to its administration. The FIPM questionnaire was added as a Part III. Internal consistency and instrument structure were examined using Cronbach's alphas, inter-item and inter-scale correlations and exploratory factor analysis.

RESULTS

The NAPPAQ-FIPM is divided into three parts. Part I of the French version had a Cronbach's alpha of 0.64 and was composed of five factors. Part II had good total internal consistency (0.79) and adequate structure, established by inter-item correlations. Part III had good total internal consistency (0.76), and factor analysis findings suggested the presence of five factors.

CONCLUSIONS

The NAPPAQ-FIPM can be used for research purposes. Parts II and III obtained adequate psychometrics results. However, further refinement of Part I could improve its content and internal structure.

The Effect of Psychological Interventions on the Prevention of Chronic Pain in Adults: A Systematic Review and Meta-analysis

OBJECTIVE

Up to 50% of patients develop high-impact chronic pain after an acute care experience and many psychological variables have been identified in this process. We conducted a systematic review and meta-analysis of randomized controlled trials to assess the effect of psychological interventions within 3 months after pain onset.

METHODS

We searched databases for articles published from databases inceptions until July 2019. We used standardized mean differences with 95% confidence intervals to assess treatment effect.

RESULTS

In all, 18 trials were found eligible; 11 of which were included in the meta-analyses. Trials were mainly performed in back pain patients in the middle to late adulthood. Regarding pain intensity, the effect of psychological interventions compared with standard treatments was nonsignificant at 3, 6, and 12 months. We found a moderate significant effect size in favor of psychological interventions compared with standard treatments with regard to disability at 12 months and a small significant effect with regard to coping with pain at 3 months when compared with information alone. Most of meta-analysis findings were associated with a low level of evidence.

DISCUSSION

This systematic review and meta-analysis showed no significant effect of psychological interventions on pain intensity. A positive and significant trend related to these interventions was shown on disability and coping with pain, when compared with standard treatment and information, respectively. However, these findings must be interpreted with caution considering the limited sample of trials. More rigorous randomized controlled trials performed in patients with a high-risk psychological profile are required to elucidate the efficacy of psychological interventions in preventing chronic pain.

Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study

Background

Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients.

Methods

A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15).

Results

Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69.

Conclusions

The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03561-1.

Initial testing of the use of the Safer Nursing Care Tool in a Canadian acute care context

Aim

Initial testing of England's Safer Nursing Care Tool for adult in‐patient acute care wards in a university‐affiliated Canadian hospital.

Background

Safe‐nursing staffing decisions have significant impacts on patients' safety and quality of care. The Safer Nursing Care Tool was developed in England to provide managers with a validated formula for making appropriate nursing staffing decisions. The tool has been widely used and studied in the UK but has yet to be tested in a Canadian context.

Method

Ten high service quality acute care wards from a university‐affiliated Canadian hospital tested the use of the Safer Nursing Care Tool. Service quality, patients' dependency/acuity and staff activity data were benchmarked against information collected in 726 comparable UK wards.

Results

Higher bed occupancy and patient dependency/acuity mix were found in the 10 Canadian wards compared to their UK counterparts. Overall staff activity was comparable between UK and Canadian wards.

Conclusion

The Safer Nursing Care Tool can be applied in this Canadian hospital, and further testing in other hospitals and specialties is required.

Implication for Nursing Management

The Safer Nursing Care Tool is a valid staffing tool to use that, when combined with professional judgement, can help managers to properly establish nursing staff in acute care wards.

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 Music on Pain in the Adult Intensive Care Unit: A Systematic Review of Randomized Controlled Trials

CONTEXT

Multimodal analgesic approaches are recommended for intensive care unit (ICU) pain management. Although music is known to reduce pain in acute and chronic care settings, less is known about its effectiveness in the adult ICU.

OBJECTIVES

Determine the effects of music interventions on pain in the adult ICU, compared with standard care or noise reduction.

METHODS

This review was registered on PROSPERO (CRD42018106889). Databases were searched for randomized controlled trials of music interventions in the adult ICU, with the search terms ["music*" and ("critical care" or "intensive care")]. Pain scores (i.e., self-report rating scales or behavioral scores) were the main outcomes of this review. Data were analyzed using a DerSimonian-Laird random-effects method with standardized mean difference (SMD) of pain scores. Statistical heterogeneity was determined as I² > 50% and explored via subgroup analyses and meta-regression.

RESULTS

Eighteen randomized controlled trials with a total of 1173 participants (60% males; mean age 60 years) were identified. Ten of these studies were included in the meta-analysis based on risk of bias assessment (n = 706). Music was efficacious in reducing pain (SMD -0.63 [95% CI -1.02, -0.24; n = 10]; I² = 87%). Music interventions of 20-30 minutes were associated with a larger decrease in pain scores (SMD -0.66 [95% CI -0.94, -0.37; n = 5]; I² = 30%) compared with interventions of less than 20 minutes (SMD 0.10 [95% CI -0.10, 0.29; n = 4]; I² = 0%). On a 0-10 scale, 20-30 minutes of music resulted in an average decrease in pain scores of 1.06 points (95% CI -1.56, -0.56).

CONCLUSION

Music interventions of 20-30 minutes are efficacious to reduce pain in adult ICU patients able to self-report.

Risk factors for severe opioid-induced respiratory depression in hospitalized adults: A case-control study

Background: Opioids are commonly prescribed to hospitalized adults to promote adequate pain relief, yet they can cause potentially fatal respiratory depression.

Aim: The aim of this study was to examine the risk factors for the development of severe opioid-induced respiratory depression (OIRD) in hospitalized adults to ensure adequate monitoring of high-risk patients.

Methods: A retrospective case–control study was conducted using data from the medical records of a university-affiliated hospital in Canada. Cases were eligible if they were adults (≥18 years old) and received opioid analgesia within 24 h of naloxone administration for respiratory depression. Controls had the same eligibility criteria, except for respiratory depression and naloxone administration. The case–control ratio was 1:1, and they were matched based on sex, type of unit, opioid molecule and the presence/absence of medication errors.

Results: A total of 133 cases and 133 controls were included. Following cumulative risk factor analysis, renal failure (odds ratio [OR] = 2.176, 95% confidence interval [CI], 1.021–4.640, P = 0.044), the first 24 h of opioid administration (OR = 1.899, 95% CI, 1.090–3.309, P = 0.024), concomitant central nervous system (CNS) depressants (OR = 1.785, 95% CI, 1.023–3.113, P = 0.041), and increasing age (OR = 1.019, 95% CI, 1.002–1.035, P = 0.028) were positively associated with severe OIRD.

Conclusions: Some adult hospitalized patients were at higher risk of experiencing severe OIRD, such as those with renal failure, those in their first 24 h of opioid administration, those receiving CNS depressants in addition to opioids, and those with an advanced age. These results will assist with the screening of patients at higher risk for severe OIRD, which is key to implementing appropriate monitoring and enhancing the safety of opioid use in hospital settings.

Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool

BACKGROUND

The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process.

OBJECTIVE

To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT.

METHODS

Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT.

RESULTS

The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version.

CONCLUSION

The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.

Exploration of the Nociception Level (NOL™) Index for Pain Assessment during Endotracheal Suctioning in Mechanically Ventilated Patients in the Intensive Care Unit: An Observational and Feasibility Study

BACKGROUND

Many patients in the intensive care unit (ICU) suffer from pain and are non-communicative. Therefore, alternative pain measures are necessary. Although behavioral pain measures are available, physiological measures are lacking. The Nociception Level index (NOL™) provides a value from combination of multiple physiological parameters to measure pain and its use in the ICU is new.

AIM

To explore the use of a multiple physiological parameter measure for pain assessment, the NOL™ index, in mechanically ventilated patients able to self-report pain in the ICU.

METHODS

A prospective cohort study was performed. Data were collected before, during, and 15 minutes after a non-nociceptive procedure (noninvasive blood pressure using cuff inflation) and a nociceptive procedure (endotracheal suctioning). NOL index, 0 to 10 pain intensity, and Critical-Care Pain Observation Tool (CPOT) scores were also obtained. Data were analyzed using Friedman and Mann-Whitney tests. Feasibility of study procedures was described.

RESULTS

Out of 28 patients who consented, 17 remained eligible and data were analyzed for 15. Technical issues prevented obtaining a NOL signal in 2 patients. NOL values were higher during endotracheal suctioning (median = 41.6) compared with before (median = 11.2) and after the procedure (median = 11.8) and compared with cuff inflation (median = 15.1; Friedman test, p < .001). NOL values were associated with pain intensity and CPOT scores (Mann-Whitney tests, p < .05).

CONCLUSIONS

The study procedures with the NOL were found feasible; NOL values could discriminate between nociceptive and non-nociceptive procedures, and values were associated with reference pain measures. Further NOL testing is required in other ICU patient groups and procedures.

French-Canadian translation of a self-report questionnaire to monitor opioid therapy for chronic pain: The Opioid Compliance Checklist (OCC-FC)

Context: Chronic noncancer pain (CNCP) is a frequent condition among Canadians. The psychosocial and economic costs of CNCP for individuals, their families, and society are substantial. Though opioid therapy is often used to manage CNCP, it is also associated with risks of misuse. The Opioid Compliance Checklist (OCC) was developed to monitor opioid misuse in patients taking opioids for CNCP. The objective of the present study was to provide a French-Canadian translation of the eight-item OCC, the OCC-FC. Methods: The eight-item OCC was translated for use in Québec using published guidelines for the translation and adaptation of self-report measures, including an expert committee and a double forward-backward translation process. A pretest of the adapted eight-item OCC was also conducted among 30 patients with CNCP. Results: A French-Canadian version of the OCC was generated. When ambiguity in the items was detected during expert committee consultation or pretest administration, modifications made were kept to a strict minimum to facilitate future comparisons across studies using the original English and translated French-Canadian version. Discussion: This study provides a culturally adapted tool that will contribute to identifying French-Canadian patients with CNCP who misuse opioids over the course of opioid therapy. This translation of the OCC has the strong potential to be useful in research and clinical settings.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Feasibility of a Hybrid Web-Based and In-Person Self-management Intervention Aimed at Preventing Acute to Chronic Pain Transition After Major Lower Extremity Trauma (iPACT-E-Trauma): A Pilot Randomized Controlled Trial

Objective 1) To assess the feasibility of research methods to test a self-management intervention aimed at preventing acute to chronic pain transition in patients with major lower extremity trauma (iPACT-E-Trauma) and 2) to evaluate its potential effects at three and six months postinjury. Design A pilot randomized controlled trial (RCT) with two parallel groups. Setting A supraregional level 1 trauma center. Methods Fifty-six adult patients were randomized. Participants received the intervention or an educational pamphlet. Several parameters were evaluated to determine the feasibility of the research methods. The potential efficacy of iPACT-E-Trauma was evaluated with measures of pain intensity and pain interference with activities. Results More than 80% of eligible patients agreed to participate, and an attrition rate of ≤18% was found. Less than 40% of screened patients were eligible, and obtaining baseline data took 48 hours postadmission on average. Mean scores of mild pain intensity and pain interference with daily activities (<4/10) on average were obtained in both groups at three and six months postinjury. Between 20% and 30% of participants reported moderate to high mean scores (≥4/10) on these outcomes at the two follow-up time measures. The experimental group perceived greater considerable improvement in pain (60% in the experimental group vs 46% in the control group) at three months postinjury. Low mean scores of pain catastrophizing (Pain Catastrophizing Scale score < 30) and anxiety and depression (Hospital Anxiety and Depression Scale scores ≤ 10) were obtained through the end of the study. Conclusions Some challenges that need to be addressed in a future RCT include the small proportion of screened patients who were eligible and the selection of appropriate tools to measure the development of chronic pain. Studies will need to be conducted with patients presenting more serious injuries and psychological vulnerability or using a stepped screening approach.

Validation of the Withdrawal Assessment Tool-1 in Adult Intensive Care Patients

BACKGROUND

The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults.

OBJECTIVE

To evaluate the validity and reliability of the WAT-1 in critically ill adults.

METHODS

A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined.

RESULTS

During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%.

CONCLUSION

Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.

Effects of Massage in Reducing the Pain and Anxiety of the Cardiac Surgery Critically Ill-a Randomized Controlled Trial

Objective

To evaluate the effectiveness of hand massage on the pain and anxiety of the cardiac surgery critically ill.

Design

A three-arm randomized controlled trial.

Setting

This study was conducted in a medical-surgical intensive care unit in Canada.

Subjects

Adult patients who underwent elective cardiac surgery, who were able to speak French/English and to self-report symptoms, without a high risk of postoperative complications were eligible.

Methods

Patients were randomly allocated to standard care plus either two 20-minute hand massages (experimental), two 20-minute hand holdings (active control), or two 20-minute rest periods (passive control/standard care). Pain intensity, pain unpleasantness, anxiety, muscle tension, and vital signs were evaluated before, after, and 30 minutes later for each intervention.

Results

From the 83 patients recruited, 60 were randomized (20 massage, 19 hand holding, 21 standard care). After controlling for baseline scores, the massage group reported significantly lower pain intensity, pain unpleasantness, and anxiety for the first data collection set compared with both hand holding and standard care (analysis of covariance, P < 0.02), with an average decrease of two points on a 0-10 scale. No statistically significant differences were noted between hand holding and standard care for any of the symptoms. Similar results were observed for the second data collection set (N = 43). Patients had decreased muscle tension post massage. Vital signs did not differ significantly between groups.

Conclusions

Findings suggest that a 20-minute hand massage in addition to routine postoperative pain management can concomitantly reduce pain intensity, pain unpleasantness, and anxiety by two points on average on a 0-10 scale.

Validation of the Adolescent Pediatric Pain Tool for the Multidimensional Measurement of Pain in Children and Adolescents Diagnosed with Osteogenesis Imperfecta

Background: The Adolescent Pediatric Pain Tool (APPT) is a self-reported, multidimensional assessment of pain location, intensity, and quality in children and adolescents. Yet, it has not been validated for use in children and adolescents with osteogenesis imperfecta (OI). Aims: This study aimed to validate and evaluate the feasibility of the APPT for pain assessment in children and adolescents with OI. Methods: A prospective observational study was conducted at a university-affiliated pediatric hospital in Canada. Thirty-three children and adolescents with OI participated by completing the APPT pre-bisphosphonate intravenous infusion and 1 week post-bisphosphonate intravenous infusion. Main outcomes were internal consistency, convergent and discriminative validity, and feasibility. Results: The Kuder-Richardson test of internal consistency was 0.863, 0.661, and 0.729 for the Sensory, Affective, and Evaluative subscales, respectively. For the entire pain quality scale, the Cronbach's alpha was 0.835. Regarding convergent validity, a moderate correlation was observed between the ratings on the pain intensity scale and the Faces Pain Scale-Revised (Spearman's rho = 0.711). Patients for whom pain was a problem reported higher pain intensity (Mann Whitney U = 41.50, P = 0.032) and more pain quality descriptors (Mann Whitney U = 45.50, P = 0.020) and painful body areas (Mann-Whitney U = 25.50, P = 0.001) than those for whom it was not (Mann-Whitney U, P < 0.05). In terms of feasibility, completing the tool may require a considerable time commitment and assistance from a clinician or parent, especially if the patient is experiencing pain and provides detailed pain location and quality information by completing the APPT. Conclusions: This study suggests that the APPT is valid for the multidimensional assessment of pain in children and adolescents with OI, but feasibility needs to be enhanced.

Family Members' Experiences with Observing Pain Behaviors Using the Critical-Care Pain Observation Tool

BACKGROUND

Current guidelines support family members' participation in care, but little is known regarding their potential contribution to pain assessment using validated behavioral pain scales.

AIMS

This study aimed to describe family members' observations of pain behaviors with the Critical-Care Pain Observation Tool and their evaluation of the tool and its use, and to understand their experience and perceptions of their potential role in pain management in the intensive care unit.

DESIGN

A mixed methods cross-sectional explanatory design was used.

SETTING

A medical-surgical intensive care unit in Canada.

PARTICIPANTS/SUBJECTS

Family members were eligible if they had a loved one admitted in the intensive care unit who was unable to self-report.

METHODS

Family members identified pain behaviors using the Critical-Care Pain Observation Tool after a brief training, completed a self-administered questionnaire, and participated in a follow-up individual interview regarding their experience and perceived potential role in pain management when their loved one is unable to self-report.

RESULTS

Ten family members participated. A 15-minute training appeared sufficient for family members to be comfortable with observing pain behaviors included in the Critical-Care Pain Observation Tool. The tool allowed them to confirm their observations of pain behaviors, to focus more on the patient, and to advocate for better pain management.

CONCLUSIONS

Future research is needed to explore the views of more family members and to compare their Critical-Care Pain Observation Tool scores to the ones of nurses' for interrater reliability testing.

Does Hand Massage Have Sustained Effects on Pain Intensity and Pain-Related Interference in the Cardiac Surgery Critically Ill? A Randomized Controlled Trial

BACKGROUND

Despite the promising short-term pain relief effect of massage, little is known regarding its sustained effects on pain intensity and pain-related interference with functioning.

AIMS

To evaluate the sustained effect of hand massage on the pain intensity and pain-related interference with functioning of cardiac surgery patients.

DESIGN

A randomized controlled trial.

SETTINGS

A medical-surgical intensive care unit in Canada.

PARTICIPANTS/SUBJECTS

Adult patients undergoing cardiac surgery and at low risk for postoperative complications were eligible.

METHODS

In the intensive care unit, patients were randomly assigned to either 20-minute hand massage, hand holding, or rest. Pain intensity and pain-related interference with functioning were assessed on the second postoperative day.

RESULTS

A total of 60 patients were randomly allocated and 46 completed data collection on the second postoperative day. Although no significant differences were identified across groups, the hand massage group reported a maximum pain intensity (median 5.75, range: 2-10) that was lower than the hand-holding (median 6.50, range: 1-10) and standard care groups (median 6.25, range: 0-10). The hand massage group could reach 0 pain intensity throughout a 24-hour period (median 0, range: 0-7), contrary to the hand-holding (median 2, range: 0-5) and standard care groups (median 2, range: 0-4.5). A trend for statistical significance was noted for dichotomized ratings on pain interference with walking (p = .176) and sleep (p = .050).

CONCLUSIONS

Hand massage could help patients experience longer periods without pain and lower levels of maximum pain intensity. When coupled with recovery activities, hand massage could reduce pain-related interference with functioning.

Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit

CONTEXT

Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited.

OBJECTIVES

The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors.

METHODS

Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS≤8), altered consciousness (9≤GCS≤12), or conscious (13≤GCS≤15).

RESULTS

A sample of 147 patients participated (65 conscious, 56 altered consciousness, and 26 unconscious). Active behaviors (e.g., face expressions and body movements) were more frequent in conscious patients. High-percentage interrater agreement (80%-98%) was obtained for most behaviors. The total number of active behaviors was significantly higher during turning and other nociceptive procedures compared with rest (Wilcoxon = 9.873, P < 0.001) and soft touch (Wilcoxon = 9.486, P < 0.001) regardless of levels of consciousness. The strongest predictors of pain intensity (n = 33) were grimace, mouth opening, orbit tightening, eye weeping, and eyes tightly closed; these behaviors were moderately correlated with self-reported pain intensity (Spearman rho = 0.47).

CONCLUSION

These findings may guide the revision of existing pain scales to make their content more suited for this population.

Family members’ perceptions of pain behaviors and pain management of adult patients unable to self-report in the intensive care unit: A qualitative descriptive study

Background

Current guidelines suggest that family members be consulted in the pain assessment process of patients unable to self-report. However, little is known regarding family members’ perceptions of their loved one’s pain behaviors and pain management.

Aims

This qualitative descriptive study aimed to describe family members’ perceptions of pain behaviors and pain management in critically ill hospitalized patients admitted to an intensive care unit and unable to self-report.

Methods

A qualitative descriptive design was used. This study was conducted in a medical–surgical intensive care unit in Canada. Family members of nonverbal adult patients participated in a semistructured interview regarding their perceptions of pain behaviors and pain management in the intensive care unit.

Results

Ten family members with a nonverbal loved one admitted to the intensive care unit participated. Family members agreed on the presence of pain in the intensive care unit and reported being proactive and applying nonpharmacological interventions to help palliate pain of their loved one. Although family members identified behavioral indicators such as grimace, limb movement, and verbal complaints to assess pain in their loved one, the majority were unsure of their ability to detect pain.

Conclusions

Family members have intimate knowledge of their loved one and could be invited to share their perceptions of their loved one’s pain when they feel confident to do so.

Nurses' Perception of a Tailored Web-Based Intervention for the Self-Management of Pain After Cardiac Surgery

Background

Cardiac surgeries rank among the most frequent surgical procedures and present a risk of chronic postsurgical pain (CPSP). A continuum approach is required to prevent the development of CPSP. As a first step, a tailored web-based intervention was developed and successfully tested to tackle pain management during hospitalization. Before proceeding to further development, preliminary acceptability of the intervention including the postdischarge phase must be evaluated.

Purpose

The purpose of this study was to examine nurses’ perception of a tailored Web-based intervention for pain management in the early recovery phase. The objectives were to evaluate intervention’s acceptability and to identify ways to enhance its acceptability.

Methods

A parallel mixed methods approach was used to assess the acceptability of the intervention in the early recovery phase (first month after surgery).

Results

In total, 249 participants completed the online survey and 10 participants were individually interviewed. Overall, the intervention was rated as acceptable. No difference was found in acceptability ratings by demographics. The intervention was rated as appropriate to very much appropriate by 79% of participants. Although nurses seemingly would recommend it to their patients, they did not perceive that their patients would be as highly willing to use it. Interviews highlighted several strengths of the intervention, such as postoperative pain awareness, customization of content, and flexible dosage and schedule. However, the main weakness was related to patient adherence. Opting for a hybrid format and integrating individual preferences could enhance the coaching experience.

Conclusion

The innovative intervention was judged as acceptable for pain management in the early recovery phase. Considering that the intervention has demonstrated positive effects on the pain experience in the first week after cardiac surgery, it seems logical to explore its potential impact after discharge on the transition to CPSP.

Validation of Two Pain Assessment Tools Using a Standardized Nociceptive Stimulation in Critically Ill Adults

CONTEXT

The Behavioral Pain Scale (BPS) or the Critical-Care Pain Observation Tool (CPOT) are recommended in practice guidelines for pain assessment in critically ill adults unable to self-report. However, their use in another language requires cultural adaptation and validation testing.

OBJECTIVES

Cross-cultural adaptation of the CPOT and BPS English versions into Brazilian Portuguese, and their validation by comparing behavioral scores during rest, standardized nociceptive stimulation by pressure algometry (SNSPA), and turning were completed. In addition, we explored clinical variables that could predict the CPOT and BPS scores.

METHODS

A prospective cohort study was conducted with 168 medical-surgical critically ill adults unable to self-report in the intensive care unit. Two nurses were trained to use the CPOT and BPS Brazilian Portuguese versions at the following assessments: 1) baseline at rest, 2) after SNSPA with a pressure of 14 kgf/cm², 3) during turning, and 4) 15 minutes after turning.

RESULTS

Inter-rater reliability of nurses' CPOT and BPS scores was supported by high weighted kappa >0.7. Discriminative validation was supported with higher CPOT and BPS scores during SNSPA or turning in comparison to baseline (P < 0.001). The Glasgow Coma Scale score was the only variable that predicted CPOT and BPS scores with explained variance of 44.5% and 55.2%, respectively.

CONCLUSION

The use of the Brazilian CPOT and BPS versions showed good reliability and validity in critically ill adults unable to self-report. A standardized procedure, the SNSPA, was used for the first time in the validation process of these tools and helped us improve the validation process.

Validation of The Critical-care Pain Observation Tool (CPOT) for the detection of oral-pharyngeal pain in critically ill adults

OBJECTIVE

Mechanically ventilated patients experience pain at rest and during daily care procedures. Our objective was to test the reliability and validity of the Critical-Care Pain Observation Tool (CPOT) to detect oral-pharyngeal pain in intubated and tracheostomised adults during routine oral care procedures.

MATERIALS AND METHODS

Two trained research team members independently observed patients during two non-painful (rest and gentle touch) and three potentially painful (oral suctioning, tooth brushing, and swabbing with a sponge toothette) procedures. Conscious patients were asked if they experienced pain during each procedure (yes/no) and to rate their pain intensity on a 0 to 10 numeric rating scale.

RESULTS

A total of 98 patients, primarily intubated (92.9%) and male (63.3%) participated. Criterion validation was supported by patient self-report of pain during tooth brushing (AUC=.80; P<0.5) and oral suction (AUC=.72; P<0.3) but not for oral swabbing (AUC=.68; P=0.16). Discriminative validation was demonstrated for all oral care procedures compared to rest (P<.001). Intra-class correlation coefficients between raters ranged from .78 to .91 (P<.001) for total CPOT scores, indicating excellent inter-rater reliability.

CONCLUSIONS

The CPOT is reliable and valid for the detection of oral-pharyngeal pain during oral care procedures indicated as painful by critically ill adults.