Critical Care Medicine: May 2016 - Volume
44 - Issue 5 - p 943–947
Kanji, S
Objectives: The 2013 clinical practice
guidelines for the management of pain, agitation, and delirium in adult
patients in the ICU suggest that pain be routinely assessed using a validated
pain assessment tool. Currently available tools have only been evaluated in
nondelirious critically ill patients, yet delirium can affect as many as 80% of
ICU patients. The validated pain assessment tool adopted by our institution is
the Critical Care Pain Observation Tool, and the objective of this study was to
investigate the validity of this tool in patients with evidence of delirium.
Design: Prospective cohort study. Setting: Two ICUs within a Canadian tertiary
healthcare center. Patients: Forty consecutive adult patients deemed delirious
on the day of enrollment using the Confusion Assessment Method for ICU.
Measurements and Main Results: Serial Critical Care Pain Observation Tool
assessments were conducted simultaneously by study personnel and objective
nurses at baseline and after nonpainful and painful stimuli. Subjective
opinions about pain and objective physical variables (including mean arterial
pressure, heart rate, respiratory rate, and oxygen saturation) were collected
at the same time points. Discriminant validity was described using paired t
tests, whereas internal consistency was described using the Cronbach α
statistic. Responsiveness of the Critical Care Pain Observation Tool was
measured by effect size, and reliability was described as the agreement between
raters. Comparisons between the Critical Care Pain Observation Tool and the
subjective assessments and objective measurements were based on positive and
negative percent agreement. Critical Care Pain Observation Tool demonstrated
excellent discriminant validity as evidenced by a highly statistically and
clinically significant change in mean Critical Care Pain Observation Tool
scores between baseline and painful procedures (mean difference, 3.13 ± 1.56; p
< 0.001; Cohen D, 2.0). Interrater agreement was also excellent (κ >
0.6), and scores between raters were highly correlated (r = 0.957). The
Critical Care Pain Observation Tool possessed a high level of internal
consistency (overall Cronbach α, 0.778). Percent agreement was found to be
greater between the Critical Care Pain Observation Tool and the nurse’s
subjective opinion of the presence or absence of pain when compared with that
between the Critical Care Pain Observation Tool and physiologic variables
(80.5% vs 67.5%, respectively). Conclusions: The Critical Care Pain Observation
Tool is a valid pain assessment tool in noncomatose, delirious adult ICU
patients who are unable to reliably self-report the presence or absence of
pain.
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