9/25/2013

Eve Broughton MSN, RN, ACNS-BC, Pain-C, CNRN

Larry Hoth BSN, RN, CCRN
Bernadette Montano MS, RN
Mary Doyle, PhD, RN, CPHQ
Veterans Health Administration SAVAHCS

ConflictofInterestDisclosure
ConflictsofInterestforALLlistedcontributors.
None

EveL.Broughton
LawrenceHoth
BernadetteMontano
MaryDoyle

Aconflictofinterestisaparticularfinancialornonfinancialcircumstancethatmight
compromise,orappeartocompromise,professionaljudgment.Anythingthatfitsthis
shouldbeincluded.Examplesareowningstockinacompanywhoseproductisbeing
evaluated,beingaconsultantoremployeeofacompanywhoseproductisbeing
evaluated,etc.

TakeninpartfromOnBeingaScientist:ResponsibleConductinResearch.National
AcademiesPress.1995.

Objectives

1. The Road Traveled

2. Roadblocks and Detours

3. The Open Road

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TheRoadTraveled2010to2013
Brainstormed
Literature search
A lot of reading
Developing the
PICO
Determining the
tools
Writing the proposal
Submitting to the
IRB
Hitting a road block;
a detour; .and
finally Data
Collection
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LiteratureReview
Wehavenowrunthesearches3times,onceeachyearsincethe
start.
Datacoverstimeframefrom1997 2013.
Confirmedthoughts
Painisastressor,
PainundertreatedovertimecanaffectlongtermQOL.
ICUpatientsonD/CfromICU,reportedpainasundertreatedwhenthey
wereintubated.

Manyscaleshavebeendevelopedtoassesstheunconscious
childandadultpatient.
Threetoolsfloattothetopwhenitcomestoassessmentofthe
unconsciousintubatedadultICUpatient.
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FindingsofInterest
BehaviorToolsareconsideredthebestalternativewhenpatients
areunconscious.
Physiologicmonitors/indicatorsshouldnotbeusedasaprimary
indicatorofpain(althoughmoreresearchisnowbeingdonein
thisarea)
ASPMN:supportsuseofeithertheBehaviorpainscale(BPS)or
CriticalCarePainObservationTool(CPOT)inunconscious
patients,ventilatedornotventilated.(2006)
Faces,Legs,Arms,CryandConsolabilityScale(FLACC),BPSand
CPOTallhavereliabilityandvaliditydatatosupport(somebetter
thanothers.)AllhavebeentestedinanICUsettinginunconscious
ventilatedpatients.
CPOTcanbeusedinbothconsciousandunconsciouspatients
ventilatedornot;isan8pointscale.
BPSisa12pointscale(BPSmayhavesomeinterrelaterreliability
concerns.)
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2010QuestionsRaised:TheBeginning
WhydidtheFLACCbecomeatoolforAdultsinourVA?
Implementedinoraround2001
AreourRNspleasedwiththeFLACC,dotheyfeelitaccurately
assessestheunconsciousICUpatient?Canweprovidealarger
studyforreliability,validity,andinterraterreliabilitytesting?
ShouldwelookattheNVPS?Why?WhyNot?
CanweidentifyatoolthatourICUnursesfindeasytouse,
provideconsistencyinassessment?
Isthereonetoolwhichnursesfeelpositivelyimprovespatient
outcomes?Onetoolthatthenursesfeelthatdemonstratesthat
theirinterventionspositivelyimprovepatientoutcomes (i.e.that
lowerspainscores) ?
Howcanourstudyimproveuponwhatwehavelearned?Canwe
changepractice?Doweneedtochangepractice?
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Assessment
Tools
VAS
NRS
BPS
CPOT
FLACC
Comfort
NVPS
PAIN
PBAT
BPRS
CCPRS
PAIN
Algorithm
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FLACC
Meets

BPS

And
The
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Payen, J.F, Bru, O., Boaaon, J., Lagrasta, A., Novel, E., Deschaux, I., et.al. (2001). Assessing pain
in critically ill sedated patients by using a behavioral pain scale. Critical Care Medicine,
29(12), 2258-2263.

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Critical Care Pain Observation Tool (CPOT)

Gelinas, C., Fillion, L., Puntillo, K.A., Viens, C. & Fortier, M., (2006). Validation of the Critical-Care

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Pain Observation Tool in adult patients. American Journal of Critical Care, 15(4), 420-427

OriginalPICO
P: Population:ICUpatientsattheSAVAHCS
ventilatedand/orpossibleunresponsive
I: Intervention:PainAssessmentusinganalternate
scale
C:Comparison:CurrentstandardofCaretheFLACC

(Face,Legs,Arms,Cry,Consolability)
O: Outcomes:Toidentifythebesttoolforassessing
ICUpatientswhoareeitherunresponsiveor
ventilated.
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RoadBlock(SpinningourWheels)andaDetour
EBP vs Research: either way
we needed to go to the IRB.
Changing the PICO as
we determine what we were
really looking at.
IRB/mentor felt it was
research.
Intervention and Help of
our Mentor
The IRB who determined it
was an EBP
The Blessing with
Forward motion
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PICO
P:Population:ICUpatientsattheSAVAHCSventilated
and/orpossibleunresponsive
I:Intervention:PainAssessmentusinganalternatescale
C:Comparison:CurrentstandardofCaretheFLACC(Face,
Legs,Arms,Cry,Consolability)
O:Outcomes:Toidentifythebestliked/easytousetoolfor
assessingpaininICUpatientswhoareventilatedand
unresponsive.

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TheSlowMeanderingRoad:
MethodsandDatacollection

SoYouthinkyouknowhowtogetdata??!!
Developedasurvey,frontbackwithall3toolsonit.
SAVAHCSICUisbusy,wealwayshavesomeoneona
ventilator.Butnotafterwestartedthesurvey.We
hadacoupleofdaysofnovents.Noproblem,just
multipleitout.Wellbedonein3or5weeks.HaHa..
TheMethodsandDataCollection:Asrealitysetin.

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Findings
35weeksturnedintoalmost8months!
Thegoalwastoobtain100completedpairedsurveys
totalusingobservationswiththebedsidenurseand
EPBteamnurse
Ofthe100pairs,therewere4extrapairsofforms;a
totalof27pairsthatcouldnotbeuseddueto
incompletion,incorrectinformation,ormissingforms
duetooutofsequencenumbering.
Totalof77pairsor154individualsurveyswereusable
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Findings
ICUNURSEtoolpreference
results:

CPOT 54or70%
BPS 15or20%
FLACC 4or5%
Reportednopreference 4

EPBTeamnursetool
preferenceresults:

CPOT 64or83%
BPS 6or8%
FLACC 3or4%
Nopreference 2
SelectedbothCPOT&BPS 2

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Findings
MostcommonreasonfortoolpreferencesbytheICU
nurseswere:
CPOT:65%listedreasonsmoredetailed/descriptive;
accurate;appropriate;moreoptions
BPS:themajorityofcommentsrelatedtothe
behavioraldescriptionandpainassessmentspecific
toaventilatorpatient
FLACC:easeofuse;mostapplicable
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Findings

Mostcommonreasonsfortoolpreferencebytheteam
nurses:
CPOT:50%selectedthetoolbecausemore
descriptive/choices/options
19% moreparametersforventilators

BPS listedreasonsmoreaccurate,concise,
appropriateforsedation/wakefulness
FLACC easytouse;familiarity;identifyingpain
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DataAnalysis
(GottoloveStatisticalData)

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DataAnalysis
LookingatcomparisonofTeamRNsvsICURNs
FirstpasswasexcitingwithExcelsoftware
Correlationsof.58to.67
BUT
Gavedatatoourstatistician
SpearmanAnalysisshowsnocorrelationbetweenRNgroups
So,anoldproverb,experienceiswhatyougetwhenyoudont
getwhatyouwant.

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DataAnalysis

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DataAnalysis

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Conclusions
TheCPOTwasthetoolbestlikedbybothICUstaff
andtheEBPteam
TheCPOTwasbycommentstheeasiesttooltouse
forassessingpaininICUpatientswhoareventilated
andunresponsive.
StatisticalDatadoesnotsupportthenurses
preferenceasanybetterthantheFLACC
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Limitations
EducationandbuyintoandfromtheICUstaffcould
havebeenimproved
Template/Toolhaderrors
Timelinessofdatacollectiongotawayfromtheteam
andmayhaveaffectedtheoutcomes
Couldhaveopenedthefocusofthepatient
populationabitbroader.
Didnotreachgoalofsurveysduetoincomplete
forms

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TheOpenRoad
PresentedtotheICUnurses January2013
PresentedattheSpring2013SAVAHCSEBP
Conference
AmericanSocietyofPainManagementNurses
(ASPMN)October2013(submittedandhereweare)
AmericanAssociationofCriticalCareNurses
(AACN)May2014 and/ortheSocietyofCritical
CareMedicine(SCCM)
Publish
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Whatisnextonthisroad?
GoodQuestion
PICIS/CriticalCareManager/ICUElectronicDocumentation
SoftwareistobeinstalledatSAVAHCS.CPOTisthe
assessmenttoolwearelookingat theRNspreferit itisan
optionwithBPS,VASandFLACCinPainAssessment.
ANCCalsohasmadethechangetoCPOTorBPSasanational
GuidelineforICUpainassessment.
Oh!ThatmeansaSAVAHCSpolicychangeasthecurrent
standardis010scale
MaymeanaVHAaddanalternateoptionforICUpatientsVA
wide.
CanwedoalargerprojectwithotherVAs,weknowwehave
interest.
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Bibliography

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Bibliography(cont.)
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CreditsandThanks

TheSAVAHCSEBPCommittee
NurseExecutivesoldandnew
TheTucsonLibrarystaff
TheICUmanagersandstaff
Dr.Ringenbergwhounderstandsthedifference
betweenEBPandresearch
Dr.MaryDoyle
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Questions

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