Authors (including presenting author) :
Mok SC, Leung PW
Affiliation :
Intensive Care Unit, Queen Elizabeth Hospital
Introduction :
Pain has been proved as a significant stressor, yet it is difficult to perform the pain assessment in ventilated critically ill patient. Critical Care Pain Observation Tool (CPOT) is a one of the pain score that can be used to assess both mechanically ventilated and non-intubated ICU patients.
CPOT contains four behavioral domains: (1) facial expression, (2) body movement, (3) muscle tension and (4) compliance with the ventilator (for mechanically ventilated patients) or vocalization (for non-intubated patients). Each domain is scored on scale from 0-2, and the total score can range from 0-8. Our ICU adopted this CPOT as the standard pain assessment tool in our ICU since March 2017 after two months of training. After nine months of implementation of CPOT, we would like to evaluate its use in ICU daily practice.
Objectives :
The purposes of the study are to evaluate 1) the usefulness of the CPOT score as pain assessment tools in ventilated critically ill patient. 2) Nursing perception on the use of this score.
Methodology :
An evaluation questionnaire was designed to include 4 domains of assessment namely (1) the feasibility; (2) clinical relevance; (3) satisfaction and (4) suggestions for the improvement in implementation of CPOT. The questionnaires were distributed to 93 ICU nurses in Queen Elizabeth Hospital.
Result & Outcome :
- A total of 72 ICU nurses returned their completed questionnaire (77.4% participation rate). - Regarding its feasibility and clinical utility, above 90% and 70% rated the CPOT as simple to understand, easy to complete and had charted CPOT at least Q4H respectively. - However, some doubted that the CPOT is useful in the daily practice. The co-exist between CPOT and the Ramsay sedation scale (RASS) and the combined infusion of midazolam and morphine prescribed by doctors were their concerns (9% & 25% respectively). - 29% rated that it is unnecessary to perform pain assessment if patients are sedated and 7% rated that patients’ pain level is better to be based on their experience and clinical judgment. - For clinical relevance of CPOT, 50% staff agreed that CPOT facilitates effective communication of pain assessment findings and provide common language between nurses. - For staff’s satisfaction, more than 62.5% nursing staff feel less satisfaction about the use of CPOT and their main concern is inadequate training. 10% staff highlighted that there is a long time gap between training and implementation of the CPOT so that they had already forgotten how to use the CPOT and found difficulty in scoring the pain. - 14% mentioned that the tool is limited patient selective, and 3% complained that they could not seek help when in needed. - For the suggestion of the use of CPOT, most staff reinforced that they should receive re-training again to strengthen the knowledge about CPOT (42%). And one-to-one bedside education and the creation of clinical support group were highly recommended to provide them with immediate assistances. Computerized reminders and a pocket size card of CPOT scale as guidance were also suggested to enhance the compliance. Conclusion: - CPOT is a simple assessment tool, easy to understand and apply in the ventilated Critically Ill patient. - Major barriers for generalization of the CPOT in ICU include: 1) fail to recognize the importance of pain assessment; 2) inadequate staff training and 3) misconception of CPOT. For better utilization of the tool, training is important to be reinforced through creation of clinical support group. Lastly, separation of the sedation and analgesia titration will improve the utility of the scoring.
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