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
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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.

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RN. and 20 minutes after the procedure. • OBJECTIVE To validate the Critical-Care Pain Observation Tool. 2006.1-3 and it is not unusual for the intensity of the pain to be described as moderate to severe. Laval University.12 In the absence of a patient’s self-report. contact The InnoVision Group. participated in the study. DNSc. CV. critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain.15-17 Preliminary research18-20 has been conducted to validate instruments that include behavioral and/or physiological indicators. Calif (KP). • CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness. Although critical care clinicians strive to obtain each patient’s self-report of pain.4-12 Pain assessment is the first step in proper pain relief. Phone. Quebec (LF. • RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. (949) 362-2049. PhD. observable behavioral and physiological indicators become important indices for the assessment of pain. PhD. PhD. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. fax. including the use of To purchase electronic or print reprints. Therefore. No. Use of these instruments in critical care practice is restricted because of the limitations of the studies. and changes in the level of consciousness. Chantal Viens. Quebec (CG). Kathleen A. • BACKGROUND Little research has been conducted to validate pain assessment tools in critical care. reprints@aacn. From School of Nursing. For each of the 3 testing periods.15:420-427) ain is an important stressor for many patients in critical care.aacnjournals. for a total of 9 assessments. CA 92656. an important goal in patients’ care. July 2006. 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated. and Martine Fortier. by guest on December 2. patients were evaluated by using the Critical-Care Pain Observation Tool at rest. Quebec City. e-mail. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation.13.18-20 lack of validation in intubated http://ajcc. McGill University. P 420 sedative agents. 2011 . many factors compromise patients’ ability to communicate verbally. Canada.13. • METHODS A total of 105 cardiac surgery patients in the intensive care unit. University of California. (800) 809-2273 or (949) 362-2050 (ext 532). mechanical ventilation.7-9. (American Journal of Critical Care. all 105 were evaluated after extubation. and Department of Physiological Nursing. Following surgery. recruited in a cardiology health center in Quebec. 101 AMERICAN JOURNAL OF CRITICAL CARE. the tool could be used to assess the effect of various measures for the management of pain.14 Several pain scales have been used to document self-reporting of pain in intubated patients.aacnjournals. Volume 15.VALIDATION OF THE CRITICAL-CARE PAIN OBSERVATION TOOL IN ADULT PATIENTS By Céline Gélinas. San Francisco. RN. Interrater reliability was supported by moderate to high weighted κ coefficients. MPs. Lise Fillion. MF). Limitations include small sample sizes (<40 patients). especially for patients who cannot communicate verbally. Aliso Viejo. 4 Downloaded from ajcc. during a nociceptive procedure (positioning). RN. For criterion validity. Faculty of Nursing. significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Montreal.

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

the third testing period (assessments T7T9) was after the patient was extubated. Content validity indices. scored from 0 to 2. Procedure Three testing periods. 3 = severe. 2011 . R. Confusion Assessment Method for the Intensive Care Unit. were calculated. 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.) and a critical care nurse (G.aacnjournals.9 One of us (C. Second. were completed during each patient’s early postoperative course (Figure 1). with a sedation score of 5 or 6 on the Ramsay Scale).00. This scale has been used in previous studies18. For each of the 3 testing periods. Positioning represented a previously confirmed nociceptive procedure. The positioning procedure at T8 sometimes occurred with ambulation and/or respiratory exercises.23 Content validity of the CPOT was established with 4 physicians and 13 critical care nurses. Upon completion of the CPOT during the second testing period (ie. patients were evaluated with the CPOT for 1 minute at rest both before and after positioning and for the duration of the positioning procedure.N. 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. the Ramsay Scale28 was used to assess the level of sedation. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to assess delirium. Content validity indices greater than 0.26.18-21 In addition. 4 = unbearable) was used. positioning procedure.80 were sufficiently satisfactory24 to consider including all these indicators in the by guest on December 2. Patients were considered conscious if they had a score of 2. Finally.aacnjournals. Pain Intensity Descriptive Scale. 2 = moderate. rest. T1 was done with the patient at rest. The CPOT was developed as follows. endotracheal suctioning often was performed at the same time as positioning. 20 minutes after the positioning procedure. with a possible total score ranging from 0 to 8.9 On the basis of the patient’s needs. Finally. 1 = mild. intubated patients communicated the presence or absence of pain by nodding their heads (yes or no) to the 422 AMERICAN JOURNAL OF CRITICAL CARE. the patient was still intubated but conscious. No. patients’ inattention was verified by assessing their capacity to concentrate on the pain intensity descriptive scale used in our study. recovery (20 minutes after the positioning procedure). First.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. This standardization of procedures was based on the work of Puntillo et al. The second testing period (assessments T4-T6) was 3 hours after the first testing period. or 4 on the Ramsay Scale. 4 http://ajcc. 3 = moderately. The instrument has good sensitivity and specificity for assessing delirium in critically ill patients. and 4 = very much). T2 was completed a few minutes after T1 during positioning of the patient.) evaluated the patients.88 to 1. 2 = a little. For each patient. July 2006. assessments T4-T6). the f irst 3 assessments (T1-T3) were done while the patient was intubated and still unconscious (ie. All indicators had indices of Downloaded from ajcc. approximately 2 hours after the end of surgery. Abbreviations: P. During this time. Volume 15. each including 3 assessments for a total of 9 pain assessments (T1-T9) with the CPOT. which are the proportion of participants who answered 3 or 4 on the Likert scale.25 in acute and critical care. T3 was done at recovery. 3. REC. approximately 5 hours after the second testing period.G.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. which were part of the postoperative care protocol. A previously validated pain intensity descriptive scale (0 = none. Some items and their operational definitions were derived from previously described instruments for pain assessment.

3 because their surgery was canceled. Critical-Care Pain Observation Tool. the gold standard measure of pain. 4 423 Downloaded from ajcc. Chicago.61-0. 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 0-0.5 of SPSS for Windows (SPSS Inc. the patient’s self-report) Extubated patients (T7-T9): In this study. all patients were receiving propofol during http://ajcc. Data Analysis extubated patients’ self-reports of pain intensity (ordinal descriptive scale) and the CPOT scores (assessments T7-T9). 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. The final sample size was 105 patients enrolled during a 3-month period. undecided (n = 1). Three patients were excluded because of delirium. and T7 with T8).21-0. T4 with T5. 8 patients were excluded because of postoperative complications (hemorrhage. 2011 .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. we determined criterion and discriminant validity (Table 2).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.4 mg/h.7 mg/h). the CPOT) and the gold standard measure of pain (ie.30 question. this medication was tapered off and stopped 1 to 3 hours after the patient’s arrival in the ICU. During the third testing period (ie. and all were receiving continuous infusions of propofol after surgery (mean dose 85. For each patient. the CPOT) of a phenomenon (ie.29 To test validity of the CPOT. Ill). Interrater reliability was examined. Results Characteristics of the Sample Statistical analyses were completed by using version 11. and 117 (89%) agreed to participate in the study. Spearman correlations31 were calculated between the A total of 131 patients were approached for consent the day before surgery. not interested (n = 3) by guest on December 2. * Levels of acceptability for interrater reliability scores from Landis and Koch. 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). No. Thus. the extubated patients used the pain intensity descriptive scale to grade their pain. at T7. SD AMERICAN JOURNAL OF CRITICAL CARE.00 P ≤ . discriminant validity 31 was examined by performing paired t tests between assessments with the CPOT taken at rest and during positioning (T1 with T2. delirium. July 2006.aacnjournals.01 Abbreviation: CPOT. During the course of the study. death). 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. Reasons for refusal were as follows: anxious about the surgery (n = 9 patients).40 0. Volume 15.80 0. Criterion validity was examined by measuring the relationship between the CPOT scores and the patients’ selfreports. and 1 because of extubation right after surgery. Finally. Descriptive statistics were computed for all variables. assessments T7T9) after completion of the CPOT. Weighted κ coefficients were calculated for all assessments (T1T9). Before the third testing period.41-0.20 0. and bad experience with research (n = 1).60 0. patients were evaluated by using the CAM-ICU to determine the presence of delirium. 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 ≤ . Anesthesia was similar for all patients.aacnjournals. Also. Table 3 gives the demographic characteristics of the patients.

(%) of patients Male Female Type of cardiac surgery.0 Mean score (79) (21) 2.71 Together. Second Testing Period. The CPOT scores were similar to those of the 2 previous testing periods (Figure 2).Table 3 Description of the study sample (n = 105)* 4.85 0. 2011 . mean (SD) Downloaded from ajcc. No. Moreover. Interrater Reliability Figure 2 Mean scores and standard deviations of the CriticalCare Pain Observation Tool for the 3 testing periods (N = 105 patients).aacnjournals. The remaining 6 patients were extubated before the completion of this testing period. Volume 15. The scores can range from 0 to 8.77 0. for assessments T7 to T9. The sample sizes for interrater reliability differed for each time. 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 0.38 1.1) at the third testing period. all 105 patients were assessed after they were extubated.04 First Testing Period. Rarely.63 0.23 1.5 2.79 0.52 0.aacnjournals. Finally. assessments T1-T3).N.) completed the CPOT at all 9 assessments and were blinded to each other’s scores. by guest on December 2.70 0.69 2. a criterion for testing during this period.0 1. Table 4 Weighted κ coefficients for each assessment from T1 to T9* Assessment T1 T2 T3 T4 T5 T6 T7 T8 T9 No.36 0.0 Rest T4 T7 T1 83 (79) 11 (10) 9 (9) 2 (2) T6 T9 T3 Procedure Time Recovery the first testing period (ie. CPOT scores were higher during the positioning procedure (T5) than during rest (T4) or recovery (T6). reflecting the times when both were present. of patients 12 12 14 29 33 33 34 33 34 Weighted κ coefficient 0.83 0. No. 4 http://ajcc. All patients also were receiving continuous infusions of fentanyl when they were admitted to the ICU from surgery.0 Variable Age.67 1.62 0.55 2. in this testing period.5 3. CPOT scores were higher during the positioning procedure (T2) than during rest (T1) or recovery (T3.35 0. For assessments T4 to T6.38 1.87 SD 1. For assessments T1 to T3. 424 AMERICAN JOURNAL OF CRITICAL CARE.7 µg/h (SD 31. and G. patients (n = 4) received an intravenous bolus of fentanyl before positioning. July 2006. data were collected on 33 of the 105 intubated patients who were unconscious. the principal investigator and the critical care nurse (C.5 1. patients had the highest scores on the CPOT (Figure 2).G. Third Testing Period. Figure 2).42 0.89 1.31 1. No.8) at the first testing period to 50.85 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. The mean dosage of fentanyl decreased from 73. data were collected on 99 of the awake 105 intubated patients.87 1.03 1.0 0. *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.21 3.88 0.7 µg/h (SD 21.5 0. Conscious intubated T5 T8 T2 Conscious extubated Unconscious intubated Value 60 83 22 (8) 3.

Weighted κ coefficients were moderate to high at all assessments (Table 4). Discussion Our f indings validated the CPOT. assessments T4-T6) and the analysis of variance are presented in Table 5.83† 22. †P ≤ . and 0. CPOT scores differed significantly between those who reported pain and those who did not.40 (P ≤ .org by guest on December 2. which is a limitation to the examination of interrater reliability. 95) (1.38 0. Moreover.aacnjournals.aacnjournals. present (n = 79) No.40 0.49 SD 1. Discriminant Validity At the 3 testing periods.01) than during rest at T7 (1. the patients’ self-reports.90 1. Table 6 gives the results of the paired t tests. A total of 46 nurses and nurse’s aides. Spearman correlations of 0. Volume 15.74 when they compared behavioral pain scores between pairs of evaluators. CPOT scores were higher during painful procedures. analysis of variance. 5 patients at T4. http://ajcc. Such results emphasize that pain behaviors are observable even if a patient cannot report pain. Interrater reliability was high for most assessments and moderate at T4. and then awake and extubated.31 0. 2011 .07 0. and T6) Assessment T4 T5 T6 Patients’ self-reports of pain: pain present or absent* Yes. Our study. No. CPOT scores were significantly higher during positioning than during the rest periods.001) at T7 to T9 showed that the patients’ selfreported pain intensity scores were moderately correlated with the CPOT scores.89† ANOVA df (1. During the third testing period (ie. present (n = 53) No. Criterion Validity CPOT scores were associated with patients’ self-reports of pain. only 2 evaluators used the instrument. Payen et al19 obtained a weighted κ coefficient of 0. When patients were intubated during the second testing period. Payen et al19 also found higher behavioral scores during positioning than at rest in unconscious critically ill patients.19 In our study. 4 Downloaded from ajcc. present (n = 54) No. the higher a patient’s selfreport of pain was. CPOT scores were significantly higher for intubated patients reporting pain than for those who had no pain.59.71) and recovery at T9 (1. Mean CPOT scores according to patients’ selfreports of the presence or absence of pain during the second testing period (ie.01 because 3 comparisons were made on the same subjects.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. 0. conscious and intubated. assessments T7-T9).org Discriminant validity was supported by the finding that CPOT scores were higher during positioning than at rest in the 3 testing periods.65 2. These results 425 AMERICAN JOURNAL OF CRITICAL CARE. These results are consistent with those of previous studies18. mean pain intensity scores were significantly higher during the positioning procedure at T8 (2. and 6 at T6 were unable to give their self-reports of pain by nodding their heads. however. Our results support the criterion validity of the CPOT because the indicators were tested against the most valid measurement of pain.85 1. absent (n = 39) Scores Mean 1.49. that is. 92) (1. *Because of intermittent drowsiness postoperatively. Alpha is adjusted to 0. 2 at T5.78 3.001. absent (n = 41) Yes. July 2006. lending support to its validity. and 1 physician participated in that study.88 F 11. 91) Abbreviation: ANOVA. which was developed specifically to assess pain in ICU patients. and results cannot be generalized to other ICU nurses. when patients were extubated during the third testing period. absent (n = 18) Yes.32 in which self-reports of pain of patients in a postanesthesia care unit were moderately related to pain behaviors. 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.11 2.18† 38. T5.40). the higher was the patient’s score on the CPOT. At each assessment in this testing period. 1 physical therapist.62 0.

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. The occurrence of the same inability to communicate in the patients in our study is not surprising. Volume 15.19 Once extubated. No. In the study by Ferguson et al. leading to higher CPOT scores in the absence of reported pain. T4. Also. However. postoperative drowsiness led to missing data for some patients. Previous studies7-9. and 9 (21%) of 43 patients were unable to communicate their self-report of pain because of drowsiness. they could have experienced less severe pain than they did when they were intubated. This finding suggests that behaviors observed by using the CPOT may be an indicator of more than pain. Third. Moreover. In our study. Second. SD 0. perhaps the CPOT can be used to assess pain in other populations of critical care patients. experts recommend that healthcare providers assume that unconscious patients may have pain. of patients 33 99 105 t -9. 4 http://ajcc. Limitations This study was not without limitations. Interestingly. Alpha is adjusted to 0. Indeed. patients seemed to have higher CPOT scores when they were conscious and intubated than they did when they were unconscious or extubated. and which can be painful to some patients. Data collection in this study was completed in the 8 hours after surgery. especially if behavioral responses to a known noxious stimulus occur. Experts recommend we assume that unconscious patients have pain. Until there is evidence to the contrary. suggest that patients. tioned.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. which does not occur in nonsurgical patients.9. Further research is warranted to determine the sensitivity and specificity of the CPOT as a measure of pain.aacnjournals. in a study by Lawrence.8 may help to explain these findings.01* -12. First.34 recommend that these patients be treated the same way as conscious patients when the patients are exposed to sources of Downloaded from ajcc.Table 6 Differences in scores on the Critical-Care Pain Observation Tool measured at rest before the procedure (T1. This hypothesis requires confirmation in future studies.36 for cardiac surgery patients.01 because 3 comparisons were made on the same subjects.aacnjournals.001. whatever their levels of consciousness. T5.90). in addition to the sternal incision. understand.96* df 32 98 104 *P < . cardiac surgery patients are a relatively healthy ICU group and may not represent most ICU patients.12. July 2006. and T8) Assessments T1-T2 T4-T5 T7-T8 No. This result may have occurred because the patients were highly sedated while unconscious and may have been experiencing the residual effects of anesthesia. Finally. Those patients might have had more time to recuperate from the residual effects of anesthesia than our patients did. data could be collected for only 33 of the 105 patients while the patients were unconscious. 2011 . may demonstrate pain behaviors in response to a nociceptive procedure. Whether a behavioral response to a noxious procedure is accompanied by perception of pain in an unconscious patient is unknown.37 rather than a painful one.35 formerly unconscious patients revealed that they could hear.11. Behaviors observed by using the CPOT may indicate more than pain. and T7) and during the procedure (T2.5 patients’ self-reports of pain after coronary artery bypass graft surgery were collected more than 8 hours after the end of surgery. the endotracheal tube may have caused coughing during the positioning procedure. In light of this finding. Perhaps for these patients the positioning was a distressful or an uncomfortable experience1. The presence of the endotracheal tube as a potential source of pain6. 18 of them who did not report pain had high CPOT scores (mean 2. data were collected by only 2 persons. More raters should be used in tests of interrater reliability in subsequent evaluations of the CPOT. when conscious intubated patients were positioned during assessment T5.07* -15.17 This pressure may cause stretching of the sternal incision. and respond emotionally to what was being said while they were unconscious. mechanical ventilation modes provided a positive inspiratory pressure to allow distribution of oxygen throughout the lungs. especially if behavioral responses to noxious stimuli occur. a period when intermittent drowsiness can be expected.5. who are AMERICAN JOURNAL OF CRITICAL CARE. The by guest on December 2.

Valdix SW. the statistician who reviewed the analyses.much sicker. Streiner DL. Am J Crit Care.1:165-167. 33. 20. Blumer JL. Fortier M. 11. Savege T. Pain and satisfaction with pain control in seriously ill hospitalized adults: findings from the SUPPORT research investigations. Marx CM. 1988. receiver operating characteristic curve analysis could be performed to examine the specificity and the sensitivity of the CPOT as a measure of pain. Bernard GR. 15. Bucknall T. Simpson B. Nursing Research: Principles and Methods. 1992.15:14-34. 23.29:1370-1379.33:159-174. 16-20. Potgieter PD. Perception of pain in the persistent vegetative state [letter]? Eur J Pain. Hallenberg B. 2001. 2011 . NY: Oxford University Press Inc. Whipple JK. Am J Crit by guest on December 2. Measurement in Nursing Research. 2004. 1996. 1992. RN. Inouye SK. First. et al. J Post Anesth Nurs.9:91-95. 37. Prog Cardiovasc Nurs. Gélinas C. Puntillo KA. Gift AG. Puntillo KA. Finally. Philadelphia. Melzack R. Heart Lung. JAMA. 36. A pilot study to assess the relationship between behavioral manifestations and self-report of pain in postanaesthesia care unit patients. 2001. Assessment and management of pain in the critically ill trauma patient. Haljamäe H. 13. Patients’ perceptions and responses to procedural pain: results from Thunder Project II. 2003. 1999. 18. 19. Rondeau J. 24. Viens C. 1990. 1995. 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. Biometrics. Gilroy D. Kehrle K. 2001. the critical care nurse who contributed to data collection. Gries ML. Crit Care Nurs Clin North Am. Ramsay M. 1994. Laval University. Bergbom-Engberg I. Ely EW. Turner JS. 7. 2001. 28. Heart Lung. Puntillo KA. 1991. Soeken KL. Behavior responses and self-reported pain in postoperative patients.17:95-109. Polit DF. Finally. New York. 4 427 Downloaded from ajcc. 6.7:15-21. Canada. Hungler BP.25:1159-1166. Broste SK. Assessment of pain in the critically ill. Puntillo KA. for their helpful comments on this article. Perception of pain in the persistent vegetative state [letter]? Eur J Pain.16:267-273. 29. The problem of pain in the critically ill patient. Girard N. Pa: FA Davis Co. the relationship between intubated patients’ self-reports of pain and behavioral indicators was explored for the second time. Future research on the effectiveness of the CPOT as a nonverbal measure of pain in other sicker ICU patients is warranted. 25. White C. Also. Delirium in mechanically ventilated patients: validity and reliability of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Lewis KS. 1990. Mateo OM. Acta Anaesthesiol Scand. 4. Patients’ experiences of postoperative respirator treatment: influence of anaesthetic and pain treatment regimens. Gélinas C. 1999. J Post Anesth Nurs. July 2006. Choinière M. Haljamäe H. Les indicateurs de douleur en soins critiques [Pain indicators in critical care]. 2nd ed. Am J Crit Care. et al. Fontaine DK. Ambuel B. Puntillo KA.10:252-259. and use of validated measures of pain could aid in the evaluation of multidisciplinary pain management techniques for nonverbal critically ill patients. Crit Care Med. Wilson VS. Thanks to all intensive care unit nurses and physicians for their support and collaboration in the performance of this study. 1987. Gleeson S. Goodwin R. 2001. 35. ACKNOWLEDGMENTS Special thanks to Gaëlle Napert. 1990. Dimensions of pain and analgesic administration associated with coronary artery bypass grafting in an Aus- tralian intensive care unit. 1977. Crit Care Med. et al.17:1068-1072. Francis J. Lenz ER. Landis RJ.aacnjournals. Conclusions The CPOT had acceptable reliability and validity in this sample of cardiac surgery ICU patients. 17. 1997. Pain experiences of traumatically injured patients in a critical care setting. Kaiser KS. 21. Norman GR. Crit Care AMERICAN JOURNAL OF CRITICAL CARE. Kwekkeboom KL. Hamill-Ruth RJ. Krenzischek DA. 22. Health Measurement Scales: A Practical Guide to Their Development and Use. The research was performed at the Faculty of Nursing. Fillion L. Pain. 1989. Second. Herr KA. 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. Also. Quebec. Nurs Res. Assessing pain in critically ill sedated patients by using a behavioral pain scale. Controlled sedation with alphaxalone-alphadolone. Koch GG.15:52-59. Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. Webb MR. Klein M. Strickland OL. Morris AB. data were obtained from patients at different levels of consciousness.19:526-533.1:167. Bushnell MC. Pain experiences of intensive care unit patients. Assessment of patients’ experience of discomforts during respirator therapy. 2003. and useful tool for measuring pain in critically ill patients who are unable to self-report. 10. Crit Care Med. 2001. 2.34:557-562.10:238-251. No. Puntillo KA. Bergbom-Engberg I. Stanik-Hutt J. This further testing could substantiate the CPOT as a valid. and to François Harel. this study was innovative in several aspects. Evaluation of pain in the critically ill patient. 12. 8. Viens C. Weiss JS. 1994. 31. and opioid administration. Quebec City.4:227-232. et al. RN.aacnjournals. 1995. Despite these limitations. Volume 15. Crit Care Med. et al. reliable.3:116-122. Summer 1995. 9. 14. thanks to Celeste Johnston. 1991. Hamlett KW. DEd. Future research should be conducted to determine if CPOT scores can be used to differentiate pain from other conditions. 22. Ferguson J. 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