Validation of the Critical-Care Pain Observation Tool in Adult Patients

Céline Gélinas, Lise Fillion, Kathleen A. Puntillo, Chantal Viens and Martine Fortier
Am J Crit Care 2006;15:420-427
© 2006 American Association of Critical-Care Nurses Published online Personal use only. For copyright permission information:

Subscription Information Information for authors Submit a manuscript Email alerts

AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2006 by AACN. All rights reserved.

Downloaded from by guest on December 2, 2011

1-3 and it is not unusual for the intensity of the pain to be described as moderate to severe. McGill University. an important goal in patients’ care. Faculty of Nursing. recruited in a cardiology health center in Quebec. (949) 362-2049.7-9. PhD. especially for patients who cannot communicate verbally. From School of Nursing. Volume 15. Canada. patients were evaluated by using the Critical-Care Pain Observation Tool at by guest on December 2. during a nociceptive procedure (positioning). critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain.aacnjournals. Calif (KP). Quebec City.4-12 Pain assessment is the first step in proper pain relief. for a total of 9 assessments. P 420 sedative agents. University of California. AMERICAN JOURNAL OF CRITICAL CARE. observable behavioral and physiological indicators become important indices for the assessment of pain. participated in the study. 4 Downloaded from ajcc. all 105 were evaluated after extubation. 101 Columbia.aacnjournals. DNSc. • METHODS A total of 105 cardiac surgery patients in the intensive care unit. MF). and 20 minutes after the procedure. Chantal Viens. Quebec (CG). Following surgery. including the use of To purchase electronic or print reprints. mechanical ventilation. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. No.15-17 Preliminary research18-20 has been conducted to validate instruments that include behavioral and/or physiological Limitations include small sample sizes (<40 patients). Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation.13. and Department of Physiological Nursing. fax. CV. July 2006. MPs.18-20 lack of validation in intubated http://ajcc. For each of the 3 testing periods. (800) 809-2273 or (949) 362-2050 (ext 532). RN.13.12 In the absence of a patient’s self-report. e-mail. contact The InnoVision Group. and Martine Fortier. Aliso Viejo. RN. • OBJECTIVE To validate the Critical-Care Pain Observation Tool. 2006. • CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness. RN. Use of these instruments in critical care practice is restricted because of the limitations of the studies. Therefore. For criterion validity. Laval University. Kathleen A. Although critical care clinicians strive to obtain each patient’s self-report of pain.15:420-427) ain is an important stressor for many patients in critical care. San Francisco.14 Several pain scales have been used to document self-reporting of pain in intubated patients. Montreal. • RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Lise Fillion. and changes in the level of consciousness. PhD. PhD. 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated. reprints@aacn. RN. significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. many factors compromise patients’ ability to communicate verbally.VALIDATION OF THE CRITICAL-CARE PAIN OBSERVATION TOOL IN ADULT PATIENTS By Céline Gélinas. Puntillo. Quebec (LF. CA 92656. • BACKGROUND Little research has been conducted to validate pain assessment tools in critical care. the tool could be used to assess the effect of various measures for the management of pain. 2011 . Interrater reliability was supported by moderate to high weighted κ coefficients. (American Journal of Critical Care.

slight. has 4 sections. body movements and muscle rigidity). striking at staff. alarms frequently activated Relaxed Tense. range 0 1 2 0-8 patients.18 confusion in the definition of behaviors (eg. they were 18 years or older. Patients were excluded if they had been admitted for a heart transplant or thoracic aortal aneurysm repair. and levator contraction All of the above facial movements plus eyelid tightly closed Does not move at all (does not necessarily mean absence of pain) Slow. received neuromuscular blockers following surgery. or had complications after surgery (eg. were in the ICU after surgery. understood French.Table 1 Description of the Critical-Care Pain Observation Tool Indicator Facial expression Description No muscular tension observed Presence of frowning. moving limbs/ thrashing. body movements. July 2006. and use of dependent observations (ie. brow by guest on December Critical-Care Pain Observation Tool. patients were taught how to use the pain intensity descriptive scale. Volume 15. absence. Recruitment was done the day before the surgery. death). had been admitted for cardiac surgery. and were able to hear and to see. and Ethics A repeated measures design was chosen for this quantitative study. Canada. the study was explained to eligible patients. attempting to sit up. moderate.25. easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation.aacnjournals. delirium. and extreme intensity of behaviors). moaning Crying out. 2011 . The CPOT. A convenience sample of 105 cardiac surgery patients in the intensive care unit (ICU) at a cardiology health center in Quebec. moaning Crying out. neutral Tense Grimacing Absence of movements Protection Restlessness 0 1 2 0 1 2 Body movements Muscle tension No resistance to passive movements Evaluation by passive flexion and Resistance to passive movements extension of upper extremities Strong resistance to passive movements. Instruments Method Design. and compliance with the ventilator for intubated patients or vocalization for extubated patients (Table 1). received medical treatment for chronic pain. Patients were considered for inclusion if http://ajcc. had a dependence on alcohol or drugs. and informed consent was obtained. rigid Very tense or rigid Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing. had an ejection fraction less than 0. This study was approved by the human research committee of the health center. was recruited for the study. Sample. each with different behavioral categories: facial expression. touching or rubbing the pain site. sobbing 0 1 2 0 1 2 OR Vocalization (extubated patients) Talking in normal tone or no sound Sighing. statistical analysis of the observations rather than of the sample of patients). muscle tension. inability to complete them Compliance with the ventilator (intubated patients) Alarms not activated. cautious movements. orbit tightening. had preexisting psychiatric or neurological problems.aacnjournals. At this time. seeking attention through movements Pulling tube. 18 use of a subjective scale (eg. developed in French.19 The aim of our study was to examine the reliability and validity of a newly developed instrument for pain assessment: the Critical-Care Pain Observation Tool (CPOT). trying to climb out of bed Score Relaxed. No. hemorrhage. Items in each section are 421 AMERICAN JOURNAL OF CRITICAL CARE. Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report. 4 Downloaded from ajcc. not following commands. sobbing Total.

4 = unbearable) was used. were completed during each patient’s early postoperative course (Figure 1). Volume 15. 2 = moderate. 3 = severe.25 in acute and critical care. or 4 on the Ramsay Scale. recovery (20 minutes after the positioning procedure). REC.) and a critical care nurse (G. Content validity indices greater than 0. 3.9 On the basis of the patient’s needs.88 to 1. each including 3 assessments for a total of 9 pain assessments (T1-T9) with the CPOT. patients were evaluated with the CPOT for 1 minute at rest both before and after positioning and for the duration of the positioning procedure. assessments T4-T6). with a sedation score of 5 or 6 on the Ramsay Scale). the patient was still intubated but conscious. which are the proportion of participants who answered 3 or 4 on the Likert scale.aacnjournals. Upon completion of the CPOT during the second testing period (ie. Procedure Three testing periods.00. No. T2 was completed a few minutes after T1 during positioning of the patient. Positioning represented a previously confirmed nociceptive procedure.9 One of us ( by guest on December 2.80 were sufficiently satisfactory24 to consider including all these indicators in the CPOT. All indicators had indices of 0. During this time. patients’ inattention was verified by assessing their capacity to concentrate on the pain intensity descriptive scale used in our study. 2011 . Content validity indices. First. The CPOT was developed as follows. T3 was done at recovery.G. The instrument has good sensitivity and specificity for assessing delirium in critically ill patients.aacnjournals. the third testing period (assessments T7T9) was after the patient was extubated. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to assess delirium. were calculated. with a possible total score ranging from 0 to 8. This standardization of procedures was based on the work of Puntillo et al. Second.18-21 In addition. intubated patients communicated the presence or absence of pain by nodding their heads (yes or no) to the 422 AMERICAN JOURNAL OF CRITICAL CARE. Confusion Assessment Method for the Intensive Care Unit. R. Pain Intensity Descriptive Scale.Intensive care unit First testing period Unconscious intubated patients Consent day before surgery Operating room T1 R T2 P T3 REC T4 R T5 P T6 REC T7 R T8 P T9 REC Second testing period Third testing period Conscious intubated Conscious extubated patients patients Figure 1 Illustration of the time of consent and the 3 testing periods.27 Two modifications were made in the CAM-ICU to adapt it to the sedation scale used in our study and to facilitate assessment of patients’ inattention. 1 = mild. For each patient. 3 = moderately. which were part of the postoperative care protocol. Finally. approximately 2 hours after the end of surgery. Finally.26. positioning procedure.23 Content validity of the CPOT was established with 4 physicians and 13 critical care nurses. 4 http://ajcc. 20 minutes after the positioning procedure. the f irst 3 assessments (T1-T3) were done while the patient was intubated and still unconscious (ie. T1 was done with the patient at rest. and 4 = very much). The positioning procedure at T8 sometimes occurred with ambulation and/or respiratory exercises. Abbreviations: P. the Ramsay Scale28 was used to assess the level of sedation. The second testing period (assessments T4-T6) was 3 hours after the first testing period. rest. pain indicators were described by using findings from a chart review of the medical files of 52 critically ill patients22 and from 9 focus groups with 48 critical care nurses and interviews of 12 physicians. approximately 5 hours after the second testing period.) evaluated the patients. scored from 0 to 2. endotracheal suctioning often was performed at the same time as positioning. Patients were considered conscious if they had a score of 2. For each of the 3 testing periods. The physicians and nurses completed a questionnaire on the relevance of the inclusion of these indicators in the CPOT by using a Likert scale (1 = not at all. Some items and their operational definitions were derived from previously described instruments for pain assessment.N. This scale has been used in previous studies18. A previously validated pain intensity descriptive scale (0 = none. 2 = a little. July Downloaded from ajcc.

Table 2 Description of reliability and validity methods examined in this study Psychometric property Interrater reliability Description Interrater reliability is the consistency with which 2 raters agree on their measurement/observation (ie. and 1 because of extubation right after surgery. discriminant validity 31 was examined by performing paired t tests between assessments with the CPOT taken at rest and during positioning (T1 with T2. Do you have pain? This procedure was selected because many intubated patients during this phase of their recovery were unable to use the pain intensity descriptive scale.00 P ≤ . the CPOT) of a phenomenon (ie.01 Abbreviation: by guest on December 2. we determined criterion and discriminant validity (Table 2). Three patients were excluded because of delirium. During the third testing period (ie. Analysis of variance was used to examine the differences between the intubated patients’ self-reports of pain (yes or no) and the CPOT scores (assessments T4-T6). and all were receiving continuous infusions of propofol after surgery (mean dose 85. 3 because their surgery was canceled. No. Also. For each patient. T4 with T5. 8 patients were excluded because of postoperative complications (hemorrhage. death). and T7 with T8).7 mg/h). yes/no and pain intensity Spearman correlation were used as the gold standard self-report measures Discriminant validity refers to evidence that instruments measuring 2 different constructs should not correlate In this study. Before the third testing period. and 117 (89%) agreed to participate in the study. Critical-Care Pain Observation Tool. 2011 . the CPOT) and the gold standard measure of pain (ie. at T7. patients were evaluated by using the CAM-ICU to determine the presence of delirium.5 of SPSS for Windows (SPSS Inc. 4 423 Downloaded from ajcc. Thus.40 0.30 question.41-0. July 2006. the patient’s self-report) Extubated patients (T7-T9): In this study. Reasons for refusal were as follows: anxious about the surgery (n = 9 patients). Ill). pain) Two raters assessed the patients in this study: the principal investigator and 1 critical care nurse Coefficient or analysis κ coefficient (proportion of responses in which the 2 raters agreed) Level of acceptability* <0 0-0.81-1. Results Characteristics of the Sample Statistical analyses were completed by using version 11. the extubated patients used the pain intensity descriptive scale to grade their pain. * Levels of acceptability for interrater reliability scores from Landis and Koch. undecided (n = 1). The final sample size was 105 patients enrolled during a 3-month period. During the course of the study. not interested (n = 3).61-0. Table 3 gives the demographic characteristics of the AMERICAN JOURNAL OF CRITICAL CARE.29 To test validity of the CPOT.20 0. we examined whether the CPOT could be used to discriminate between pain during positioning and lack of pain at rest Rest time compared with positioning for all three testing periods: paired t test Discriminant validity P ≤ . Finally. the gold standard measure of pain. Spearman correlations31 were calculated between the A total of 131 patients were approached for consent the day before surgery. Anesthesia was similar for all patients. all patients were receiving propofol during http://ajcc. Criterion validity was examined by measuring the relationship between the CPOT scores and the patients’ selfreports.21-0. Weighted κ coefficients were calculated for all assessments (T1T9). and bad experience with research (n = 1). assessments T7T9) after completion of the CPOT. Chicago. this medication was tapered off and stopped 1 to 3 hours after the patient’s arrival in the ICU. Volume 15.80 0. SD 39. delirium. Interrater reliability was examined.aacnjournals. Data Analysis extubated patients’ self-reports of pain intensity (ordinal descriptive scale) and the CPOT scores (assessments T7-T9).4 mg/h.01 Poor Slight Fair Moderate Substantial Almost perfect Criterion validity Criterion validity refers to the relationship Intubated patients (T4-T6): analysis of variance between the instrument (ie. Descriptive statistics were computed for all variables.60 0.aacnjournals.

For assessments T1 to T3. 424 AMERICAN JOURNAL OF CRITICAL CARE.aacnjournals. *Assessments made by using the Critical-Care Pain Observation Tool were independently completed by the principal investigator and the critical care nurse when both were present.0 Mean score (79) (21) 2. Table 4 Weighted κ coefficients for each assessment from T1 to T9* Assessment T1 T2 T3 T4 T5 T6 T7 T8 T9 No. 4 http://ajcc. Finally.) completed the CPOT at all 9 assessments and were blinded to each other’s scores. Conscious intubated T5 T8 T2 Conscious extubated Unconscious intubated Value 60 83 22 (8) 3. data were collected on 99 of the awake 105 intubated patients.83 0.79 0.71 Together.87 1.5 1. CPOT scores were higher during the positioning procedure (T2) than during rest (T1) or recovery (T3.21 3.5 2.23 1. patients (n = 4) received an intravenous bolus of fentanyl before positioning.38 1. 2011 .85 0. The mean dosage of fentanyl decreased from 73.38 1.0 Rest T4 T7 T1 83 (79) 11 (10) 9 (9) 2 (2) T6 T9 T3 Procedure Time Recovery the first testing period (ie. Volume 15. the principal investigator and the critical care nurse (C. The CPOT scores were similar to those of the 2 previous testing periods (Figure 2). reflecting the times when both were present. Figure 2). For assessments T4 to T6.77 0. assessments T1-T3). all 105 patients were assessed after they were extubated. patients had the highest scores on the CPOT (Figure 2). mean (SD) Sex. data were collected on 33 of the 105 intubated patients who were unconscious. Second Testing Period.04 First Testing Period.67 1. Moreover.89 1. of patients 12 12 14 29 33 33 34 33 34 Weighted κ coefficient 0.0 1. Sample at the 3 Testing Periods Testing period 1 Unconscious intubated patients (n = 33) 2 Conscious intubated patients (n = 99) 3 Conscious extubated patients (n = 105) Assessment T1 Rest T2 Procedure T3 Recovery T4 Rest T5 Procedure T6 Recovery T7 Rest T8 Procedure T9 Recovery Mean 0. Interrater Reliability Figure 2 Mean scores and standard deviations of the CriticalCare Pain Observation Tool for the 3 testing periods (N = 105 patients). Again.55 by guest on December 2.42 0. of patients (%) Coronary artery bypass graft Valvular repair or replacement Coronary artery bypass graft and valvular surgery Interauricular/interventricular communication repair *All patients had sternal incisions.N. a criterion for testing during this period. (%) of patients Male Female Type of cardiac surgery. The sample sizes for interrater reliability differed for each time.52 0.35 0.36 0.69 2.7 µg/h (SD 31.5 3. Rarely.0 0.G. for assessments T7 to T9. No. Third Testing Period.70 0.88 0.aacnjournals. CPOT scores were higher during the positioning procedure (T5) than during rest (T4) or recovery (T6). in this testing period.5 0.8) at the first testing period to 50.Table 3 Description of the study sample (n = 105)* 4.62 0. and G. No. July Downloaded from ajcc.03 1.85 0.1) at the third testing period.0 Variable Age.31 1. The remaining 6 patients were extubated before the completion of this testing period. The scores can range from 0 to 8.63 0. All patients also were receiving continuous infusions of fentanyl when they were admitted to the ICU from surgery.87 SD 1. No.7 µg/h (SD 21.

Weighted κ coefficients were moderate to high at all assessments (Table 4).11 2.78 3.62 0. and then awake and extubated.01) than during rest at T7 (1.07 0. 5 patients at by guest on December 2. July 2006.65 2. and T6) Assessment T4 T5 T6 Patients’ self-reports of pain: pain present or absent* Yes. the patients’ self-reports. analysis of variance. †P ≤ .49 SD 1.83† 22.18† 38. is the first to document differences in pain behavior scores according to levels of activity during different states of consciousness and intubation: unconscious and intubated. when patients were extubated during the third testing period. CPOT scores were significantly higher for intubated patients reporting pain than for those who had no pain. Our results support the criterion validity of the CPOT because the indicators were tested against the most valid measurement of pain.59. 2 at T5. CPOT scores differed significantly between those who reported pain and those who did not.40 (P ≤ . T5. Criterion Validity CPOT scores were associated with patients’ self-reports of pain. These results 425 AMERICAN JOURNAL OF CRITICAL CARE.71) and recovery at T9 (1.001) at T7 to T9 showed that the patients’ selfreported pain intensity scores were moderately correlated with the CPOT scores. Discriminant Validity At the 3 testing periods. CPOT scores were higher during painful procedures. No. During the third testing period (ie. *Because of intermittent drowsiness postoperatively. Discussion Our f indings validated the CPOT.01 because 3 comparisons were made on the same subjects.38 0. that is.40). Our study. These results are consistent with those of previous studies18. assessments T7-T9). only 2 evaluators used the instrument. the higher a patient’s selfreport of pain was. http://ajcc. Payen et al19 obtained a weighted κ coefficient of 0. lending support to its validity.90 1.19 In our study.Table 5 Differences in scores on the Critical-Care Pain Observation Tool according to patients’ self-reports of pain in the second testing period (T4. the higher was the patient’s score on the CPOT.88 F 11. Volume 15. Spearman correlations of 0.74 when they compared behavioral pain scores between pairs of evaluators. 2011 . Moreover. absent (n = 18) Yes.40 0. Payen et al19 also found higher behavioral scores during positioning than at rest in unconscious critically ill patients. absent (n = 39) Scores Mean 1. When patients were intubated during the second testing period.001. Interrater reliability was high for most assessments and moderate at T4. 95) (1. which is a limitation to the examination of interrater reliability.49.85 1. and 6 at T6 were unable to give their self-reports of pain by nodding their heads. Table 6 gives the results of the paired t tests. however.32 in which self-reports of pain of patients in a postanesthesia care unit were moderately related to pain behaviors. A total of 46 nurses and nurse’s aides. assessments T4-T6) and the analysis of variance are presented in Table 5. mean pain intensity scores were significantly higher during the positioning procedure at T8 (2. 0. At each assessment in this testing period.aacnjournals. and 1 physician participated in that study. 1 physical therapist. absent (n = 41) Discriminant validity was supported by the finding that CPOT scores were higher during positioning than at rest in the 3 testing periods. conscious and intubated.aacnjournals. and 0. Mean CPOT scores according to patients’ selfreports of the presence or absence of pain during the second testing period (ie. present (n = 54) No. 91) Abbreviation: ANOVA. which was developed specifically to assess pain in ICU patients. and results cannot be generalized to other ICU nurses. CPOT scores were significantly higher during positioning than during the rest periods. Such results emphasize that pain behaviors are observable even if a patient cannot report pain. 4 Downloaded from ajcc.31 0.89† ANOVA df (1. present (n = 79) No. present (n = 53) No. Alpha is adjusted to 0. 92) (1.

Moreover.01 because 3 comparisons were made on the same subjects. No. especially if behavioral responses to noxious stimuli occur. mechanical ventilation modes provided a positive inspiratory pressure to allow distribution of oxygen throughout the lungs.07* -15. In our study.8 may help to explain these findings. and T8) Assessments T1-T2 T4-T5 T7-T8 No. who are AMERICAN JOURNAL OF CRITICAL CARE. More raters should be used in tests of interrater reliability in subsequent evaluations of the CPOT.5.aacnjournals. Interestingly. leading to higher CPOT scores in the absence of reported pain. in addition to the sternal incision. This finding suggests that behaviors observed by using the CPOT may be an indicator of more than pain. The occurrence of the same inability to communicate in the patients in our study is not surprising. 4 http://ajcc. postoperative drowsiness led to missing data for some patients. which does not occur in nonsurgical patients.17 This pressure may cause stretching of the sternal incision. Experts recommend we assume that unconscious patients have pain. In the study by Ferguson et al.19 Once extubated. perhaps the CPOT can be used to assess pain in other populations of critical care patients. Second. Perhaps for these patients the positioning was a distressful or an uncomfortable experience1. and 9 (21%) of 43 patients were unable to communicate their self-report of pain because of drowsiness. data could be collected for only 33 of the 105 patients while the patients were unconscious.37 rather than a painful one. cardiac surgery patients are a relatively healthy ICU group and may not represent most ICU patients.96* df 32 98 104 *P < . However. Data collection in this study was completed in the 8 hours after surgery. Behaviors observed by using the CPOT may indicate more than pain. The experts33. they could have experienced less severe pain than they did when they were intubated. Indeed. understand.90). Whether a behavioral response to a noxious procedure is accompanied by perception of pain in an unconscious patient is unknown. Also. In light of this finding. SD 0.34 recommend that these patients be treated the same way as conscious patients when the patients are exposed to sources of pain. Finally. especially if behavioral responses to a known noxious stimulus occur. suggest that patients. Third. Those patients might have had more time to recuperate from the residual effects of anesthesia than our patients did. whatever their levels of consciousness.36 for cardiac surgery patients. July 2006.35 formerly unconscious patients revealed that they could hear. experts recommend that healthcare providers assume that unconscious patients may have pain. and T7) and during the procedure (T2.Table 6 Differences in scores on the Critical-Care Pain Observation Tool measured at rest before the procedure (T1. patients seemed to have higher CPOT scores when they were conscious and intubated than they did when they were unconscious or extubated.12. First. The presence of the endotracheal tube as a potential source of pain6. Alpha is adjusted to 0. in a study by Lawrence. and respond emotionally to what was being said while they were unconscious. tioned. of patients 33 99 105 t -9. may demonstrate pain behaviors in response to a nociceptive procedure. T5. data were collected by only 2 persons. This result may have occurred because the patients were highly sedated while unconscious and may have been experiencing the residual effects of anesthesia. 18 of them who did not report pain had high CPOT scores (mean 2. Limitations This study was not without limitations. when conscious intubated patients were positioned during assessment T5.5 patients’ self-reports of pain after coronary artery bypass graft surgery were collected more than 8 hours after the end of surgery. T4.001. and which can be painful to some patients. Volume 15.01* -12. a period when intermittent drowsiness can be expected. Further research is warranted to determine the sensitivity and specificity of the CPOT as a measure of pain. Previous studies7-9. Until there is evidence to the Downloaded from ajcc.20 in which intubated patients provided self-reports of pain were conducted in periods varying from 12 to 72 hours after the end of surgery. the endotracheal tube may have caused coughing during the positioning procedure. 65 conscious intubated patients had endotracheal suctioning while they were being posi426 We also found that CPOT scores were similarly low for both unconscious and conscious extubated patients.aacnjournals. This hypothesis requires confirmation in future studies.9.11. 2011 .org by guest on December 2.

32.3:116-122. reliable. receiver operating characteristic curve analysis could be performed to examine the specificity and the sensitivity of the CPOT as a measure of pain. 3. Puntillo KA. 4. 21. data were obtained from patients at different levels of consciousness. Strickland OL. Inouye SK. 1994. Fortier M. 24. 20. REFERENCES 1. Soeken KL. Lawrence M. by guest on December 2. Payen JF. Bucknall T.24:1953-1961. Gleeson S. the relationship between intubated patients’ self-reports of pain and behavioral indicators was explored for the second time. Gilroy D. Canada. 26. Choinière M. No. the statistician who reviewed the analyses. Ferguson J.15:52-59.15:14-34. Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. 9. Gélinas C. Viens C. critical care patients’ self-reports of pain. Fortier M.3:11-16. the tool needs to be further validated in different populations of critically ill patients. Crit Care Nurs Clin North Am. Second. Patients’ experiences of postoperative respirator treatment: influence of anaesthetic and pain treatment regimens.34:557-562. Quebec City.40:143-152.17:95-109. Am J Crit Care. et al. Future research should be conducted to determine if CPOT scores can be used to differentiate pain from other conditions. and use of validated measures of pain could aid in the evaluation of multidisciplinary pain management techniques for nonverbal critically ill patients. 2001. 28. JAMA. 1994. Quebec. Potgieter PD. Lewis KS. 19. 1992. et al. Valdix SW. This study was supported by a nursing fellowship research grant from the Heart and Stroke Foundation of Canada and a doctorate research grant from the Fondation de Recherche en Sciences Infirmières du Québec. Hallenberg B. Am J Crit Care. Stannard D. Pain experiences of traumatically injured patients in a critical care setting.19:154-162.286:2703-2710. Assessment and management of pain in the critically ill trauma patient.much sicker.33:159-174. 1977. However. 1991.25:1159-1166. RN. July 2006. Pain.aacnjournals. 29. 2003. Bernard GR. 30. 2001. Am J Crit Care. Haljamäe H. Philadelphia.10:238-251. Puntillo KA. Miaskowski C. Crit Care Med. Crit Care Nurs Clin North Am. 2011 . 23. Kaiser KS. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Webb MR. Gift AG. et al.18:966-968. Dimensions of procedural pain and its analgesic management in critically ill surgical patients. Focus Crit Care. Finally. Kwekkeboom KL. Nurs Res.9:91-95. Heart Lung. Bru O. Mateo OM.10:252-259.43:31-36. 2001. 1990. 1987. Polit DF. Simpson B. 3rd ed. Nye P. Puntillo KA. J Post Anesth Nurs. Pain experiences of intensive care unit patients. for their helpful comments on this article. Philadelphia. Perception of pain in the persistent vegetative state [letter]? Eur J Pain. Lenz ER. Fillion L. Perspect Infirm. Blumer JL. Marohn L. J Pediatr Psychol. 12. and opioid administration.26:1065-1072. Broste SK. Crit Care Clin. Laval University. Kehrle K. and Denise Li. 1992. Finally. 1991. 35. Am J Crit Care. Hungler BP. Patients’ perceptions and responses to procedural pain: results from Thunder Project II. 13. Puntillo KA. NY: Oxford University Press Inc. J Adv Nurs. A pilot study to assess the relationship between behavioral manifestations and self-report of pain in postanaesthesia care unit patients. Desbiens NA. Biometrics. 6th ed.15:592-599. The problem of pain in the critically ill patient. Wilson VS.16:267-273. 11. 2003.10:3-11. Identification of stressors related to patients’ psychologic responses to the surgical intensive care unit. Behavior responses and self-reported pain in postoperative patients. 37. First. The measurement of observer agreement for categorical data. Herr KA. Quebbeman EJ. Springhorn HE. Bergbom-Engberg I. Crit Care Med. Hamlett KW. 1990. RN. thanks to Celeste Johnston. Assessment of patients’ experience of discomforts during respirator therapy. 18. Waltz CF. Pain assessment in critical care: what have we learnt from research? Intensive Crit Care Nurs. Crit Care Med. pain relief and accuracy of their recall after cardiac surgery. Wu AW.15:35-53. the critical care nurse who contributed to data collection. 1989. Koch GG. Crit Care Med. Special thanks to Drs Jean Bussières and Mathieu Simon for their valuable collaboration in the conception and the conduction of this study. Measurement in Nursing Research. Patients’ recollection of intensive care unit experience. 2nd ed. Ely EW. 15. 1992. Ramsay M. 22. Pain: its mediators and associated morbidity in critically ill cardiovascular surgical patients. 25. Pa: FA Davis Co. 1990. Nursing Research: Principles and Methods.29:2258-2263. Girard N. 10. 2001. Marx CM. Perception of pain in the persistent vegetative state [letter]? Eur J Pain. ACKNOWLEDGMENTS Special thanks to Gaëlle Napert. 16. 1999. The unconscious experience. 7. Analysis of pain management in critically ill patients. Turner JS. The research was performed at the Faculty of Nursing.7:15-21.1:167. Bushnell MC. Assessing pain in critically ill sedated patients by using a behavioral pain scale. 34. Evaluation of pain in the critically ill patient.13:181-194. 2005. Patient perceptions of the mechanical ventilation experience. Pa: Lippincott. 2004. 2. 2001. thanks to all the patients who participated in this study. Thanks to all intensive care unit nurses and physicians for their support and collaboration in the performance of this study.1:165-167. Volume 15. Puntillo KA. Health Measurement Scales: A Practical Guide to Their Development and Use. 2001. Acta Anaesthesiol Scand. Rondeau J. and to François Harel. Fontaine DK. Relationship between behavioral and physiological indicators of pain. Br Med J. 1999.19:526-533. http://ajcc. Puntillo KA. Heart Lung.aacnjournals.29:1370-1379. 1997. 27. Crit Care Nurs Q. Also. Klein M. Gélinas C. Summer 1995. 4 427 Downloaded from ajcc. 1990. 1995. 1974. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. Fillion L. Francis J. Puntillo KA. Landis AMERICAN JOURNAL OF CRITICAL CARE. Stanik-Hutt J. Despite these limitations. Bergbom-Engberg I. 1996. Pain assessment and management in critically ill intubated patients: a retrospective study. Assessment of pain in the critically ill. Crit Care Med.17:1068-1072. 1997. 5.2:1214. Am J Crit Care. 1997. Also. Paquin M-J. 6. This further testing could substantiate the CPOT as a valid. Controlled sedation with alphaxalone-alphadolone. Briggs SJ. 33. Melzack R. Viens C. Prog Cardiovasc Nurs. 8. 36. Norman GR. Ely EW. Whipple JK. and useful tool for measuring pain in critically ill patients who are unable to self-report. et al. 1988. DEd. Bosson JL. Morris AB. Krenzischek DA. Future research on the effectiveness of the CPOT as a nonverbal measure of pain in other sicker ICU patients is warranted. Crit Care Med. Margolin R. Goodwin R. Savege T. Shannon K. et al. Les indicateurs de douleur en soins critiques [Pain indicators in critical care]. 22. 17. Puntillo KA. J Post Anesth Nurs. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). 1995.4:227-232. Weiss JS. Pharmacotherapy. Streiner DL. Haljamäe H.13:126-135. 1994. Fernsler J. Assessing distress in pediatric intensive care environments: the COMFORT Scale. development of the CPOT was based on previous research of others as well as on descriptive data from 2 preliminary studies that led to selection of the behavioral indicators. White C.2:656-659. 16-20. Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Aus- tralian intensive care unit. New York. 14. Appropriate pain assessment is an important part of quality care for critically ill patients. Kennedy MG. 31. this study was innovative in several aspects. Ambuel B. Christoph SB. Hamill-Ruth RJ. Gries ML. et al. 1997. Conclusions The CPOT had acceptable reliability and validity in this sample of cardiac surgery ICU patients.