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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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7-9. For each of the 3 testing periods. • CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness. RN. RN. during a nociceptive procedure (positioning).aacnjournals. the tool could be used to assess the effect of various measures for the management of pain. Puntillo.4-12 Pain assessment is the first step in proper pain relief. MPs. CA 92656. Chantal Viens.aacnjournals. especially for patients who cannot communicate verbally. Quebec City.VALIDATION OF THE CRITICAL-CARE PAIN OBSERVATION TOOL IN ADULT PATIENTS By Céline Gélinas. • METHODS A total of 105 cardiac surgery patients in the intensive care unit. Faculty of Nursing. RN. San Francisco. No. Montreal. Use of these instruments in critical care practice is restricted because of the limitations of the studies. University of California. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. patients were evaluated by using the Critical-Care Pain Observation Tool at rest. P 420 sedative agents. 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated. Following surgery. Limitations include small sample sizes (<40 patients).org by guest on December 2. all 105 were evaluated after extubation. • RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. For criterion validity. From School of Nursing. e-mail.12 In the absence of a patient’s self-report. critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. RN. CV. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation. observable behavioral and physiological indicators become important indices for the assessment of pain. Volume 15.13. Interrater reliability was supported by moderate to high weighted κ coefficients. an important goal in patients’ care. and Department of Physiological Nursing. (949) 362-2049. contact The InnoVision Group. DNSc. Kathleen A. recruited in a cardiology health center in Quebec. significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool.13. including the use of To purchase electronic or print reprints. PhD. • BACKGROUND Little research has been conducted to validate pain assessment tools in critical care. 4 Downloaded from ajcc. Laval University. • OBJECTIVE To validate the Critical-Care Pain Observation Tool. July AMERICAN JOURNAL OF CRITICAL CARE. for a total of 9 assessments. Phone. Lise Fillion. mechanical ventilation. Aliso Viejo.15-17 Preliminary research18-20 has been conducted to validate instruments that include behavioral and/or physiological indicators. 101 Columbia. 2006.14 Several pain scales have been used to document self-reporting of pain in intubated patients. and Martine Fortier. MF). McGill University. Although critical care clinicians strive to obtain each patient’s self-report of pain. many factors compromise patients’ ability to communicate verbally.18-20 lack of validation in intubated http://ajcc. fax. (800) 809-2273 or (949) 362-2050 (ext 532). Quebec (CG).15:420-427) ain is an important stressor for many patients in critical care. PhD. 2011 . participated in the study. Canada. (American Journal of Critical Care. and changes in the level of consciousness. Therefore.1-3 and it is not unusual for the intensity of the pain to be described as moderate to severe. Calif (KP). Quebec (LF. and 20 minutes after the procedure. PhD.

hemorrhage.aacnjournals. brow lowering. had an ejection fraction less than 0. The CPOT. statistical analysis of the observations rather than of the sample of patients). patients were taught how to use the pain intensity descriptive scale. had a dependence on alcohol or drugs. touching or rubbing the pain site.aacnjournals.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). were in the ICU after surgery. seeking attention through movements Pulling tube. At this time. body movements and muscle rigidity). orbit tightening. sobbing Total. rigid Very tense or rigid Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing. understood French.Table 1 Description of the Critical-Care Pain Observation Tool Indicator Facial expression Description No muscular tension observed Presence of frowning. trying to climb out of bed Score Relaxed. Sample. Instruments Method Design. 4 Downloaded from ajcc. sobbing 0 1 2 0 1 2 OR Vocalization (extubated patients) Talking in normal tone or no sound Critical-Care Pain Observation Tool. and Ethics A repeated measures design was chosen for this quantitative study. Patients were excluded if they had been admitted for a heart transplant or thoracic aortal aneurysm repair. muscle tension. This study was approved by the human research committee of the health center.25. Recruitment was done the day before the surgery. received medical treatment for chronic pain. striking at staff. has 4 sections. or had complications after surgery (eg. July 2006. each with different behavioral categories: facial expression. the study was explained to eligible patients. 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. No. and use of dependent observations (ie. 18 use of a subjective scale (eg. death). Canada. and were able to hear and to see. delirium. developed in French. inability to complete them Compliance with the ventilator (intubated patients) Alarms not activated. and informed consent was obtained. Patients were considered for inclusion if http://ajcc. had been admitted for cardiac surgery. A convenience sample of 105 cardiac surgery patients in the intensive care unit (ICU) at a cardiology health center in Quebec. attempting to sit up. alarms frequently activated Relaxed Tense. moderate. moaning Crying out. 2011 . and compliance with the ventilator for intubated patients or vocalization for extubated patients (Table 1). received neuromuscular blockers following surgery. range 0 1 2 0-8 patients. moaning Crying out. slight. not following commands. they were 18 years or older. had preexisting psychiatric or neurological problems. by guest on December 2.18 confusion in the definition of behaviors (eg. easy ventilation Alarms stop spontaneously Asynchrony: blocking ventilation. body movements. 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. Behavioral and physiological indicators are important indices for assessment of pain in patients unable to self-report. Volume 15. moving limbs/ thrashing. cautious movements. and extreme intensity of behaviors). was recruited for the study. Items in each section are 421 AMERICAN JOURNAL OF CRITICAL CARE.

Volume 15.23 Content validity of the CPOT was established with 4 physicians and 13 critical care nurses.G. The instrument has good sensitivity and specificity for assessing delirium in critically ill patients. each including 3 assessments for a total of 9 pain assessments (T1-T9) with the CPOT. The CPOT was developed as follows. This standardization of procedures was based on the work of Puntillo et al. Positioning represented a previously confirmed nociceptive procedure. T1 was done with the patient at rest. A previously validated pain intensity descriptive scale (0 = none. July 2006. 3. 20 minutes after the positioning procedure. with a sedation score of 5 or 6 on the Ramsay Scale).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. rest. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was used to assess delirium. This scale has been used in previous studies18. The second testing period (assessments T4-T6) was 3 hours after the first testing period. were completed during each patient’s early postoperative course (Figure 1). Finally. Abbreviations: P. 4 http://ajcc. For each patient. For each of the 3 testing periods. or 4 on the Ramsay Scale.aacnjournals. were calculated. Second. assessments T4-T6). endotracheal suctioning often was performed at the same time as positioning. The positioning procedure at T8 sometimes occurred with ambulation and/or respiratory exercises. scored from 0 to 2.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. During this time. All indicators had indices of 0. Confusion Assessment Method for the Intensive Care Unit. 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. 3 = severe.9 On the basis of the patient’s needs. approximately 5 hours after the second testing period. 2 = a little. Upon completion of the CPOT during the second testing period (ie. with a possible total score ranging from 0 to 8. which were part of the postoperative care protocol. 1 = mild. the Ramsay Scale28 was used to assess the level of sedation.00.) and a critical care nurse (G. the patient was still intubated but conscious. Patients were considered conscious if they had a score of 2. 3 = moderately. patients’ inattention was verified by assessing their capacity to concentrate on the pain intensity descriptive scale used in our study. REC. 2 = moderate. T2 was completed a few minutes after T1 during positioning of the patient.N. patients were evaluated with the CPOT for 1 minute at rest both before and after positioning and for the duration of the positioning procedure. T3 was done at recovery.aacnjournals. approximately 2 hours after the end of surgery. by guest on December 2. First. the third testing period (assessments T7T9) was after the patient was extubated.88 to 1. positioning procedure. Procedure Three testing periods. No.26. Content validity indices greater than Downloaded from ajcc. which are the proportion of participants who answered 3 or 4 on the Likert scale. Content validity indices. recovery (20 minutes after the positioning procedure). Some items and their operational definitions were derived from previously described instruments for pain assessment. 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.80 were sufficiently satisfactory24 to consider including all these indicators in the CPOT. and 4 = very much). 2011 . Pain Intensity Descriptive Scale. the f irst 3 assessments (T1-T3) were done while the patient was intubated and still unconscious (ie.25 in acute and critical care. 4 = unbearable) was used. R.) evaluated the patients.9 One of us (C.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.

For each patient. * Levels of acceptability for interrater reliability scores from Landis and Koch.7 mg/h). 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). July 2006. the gold standard measure of pain. No.41-0. and 117 (89%) agreed to participate in the study. at T7. and 1 because of extubation right after surgery.29 To test validity of the CPOT. Interrater reliability was examined. Finally. assessments T7T9) after completion of the CPOT. Anesthesia was similar for all patients.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.00 P ≤ . the extubated patients used the pain intensity descriptive scale to grade their pain. 8 patients were excluded because of postoperative complications (hemorrhage. 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 ≤ .org AMERICAN JOURNAL OF CRITICAL CARE. death). Volume 15.61-0. Reasons for refusal were as follows: anxious about the surgery (n = 9 patients). During the course of the study. Spearman correlations31 were calculated between the A total of 131 patients were approached for consent the day before surgery. and bad experience with research (n = 1).20 0. Ill). The final sample size was 105 patients enrolled during a 3-month period. 2011 . SD 39. Three patients were excluded because of delirium.aacnjournals. this medication was tapered off and stopped 1 to 3 hours after the patient’s arrival in the ICU. Data Analysis extubated patients’ self-reports of pain intensity (ordinal descriptive scale) and the CPOT scores (assessments T7-T9). and all were receiving continuous infusions of propofol after surgery (mean dose 85. Table 3 gives the demographic characteristics of the patients.01 Abbreviation: CPOT. Before the third testing period.5 of SPSS for Windows (SPSS Inc.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. 4 423 Downloaded from ajcc. the CPOT) of a phenomenon (ie. patients were evaluated by using the CAM-ICU to determine the presence of delirium. Critical-Care Pain Observation Tool. Also. Results Characteristics of the Sample Statistical analyses were completed by using version 11. the CPOT) and the gold standard measure of pain (ie. 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. T4 with T5.4 mg/h.aacnjournals.30 question. During the third testing period (ie. and T7 with T8). Thus. the patient’s self-report) Extubated patients (T7-T9): In this study. 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 0-0.40 0. Criterion validity was examined by measuring the relationship between the CPOT scores and the patients’ selfreports.80 0. Weighted κ coefficients were calculated for all assessments (T1T9). Chicago. all patients were receiving propofol during http://ajcc. not interested (n = 3). 3 because their surgery was canceled.21-0. undecided (n = 1).org by guest on December 2. 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.81-1. delirium. Descriptive statistics were computed for all variables. discriminant validity 31 was examined by performing paired t tests between assessments with the CPOT taken at rest and during positioning (T1 with T2.60 0. we determined criterion and discriminant validity (Table 2).

79 0. in this testing period. Moreover. all 105 patients were assessed after they were extubated.0 0.52 0.7 µg/h (SD 21.aacnjournals. 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 0.89 1.21 3. The mean dosage of fentanyl decreased from 73.0 Variable Age.62 0.85 0.83 0.87 SD 1.69 2.aacnjournals.71 Together. 2011 . patients (n = 4) received an intravenous bolus of fentanyl before positioning.31 1.67 1. The sample sizes for interrater reliability differed for each time. The remaining 6 patients were extubated before the completion of this testing period.1) at the third testing period. Second Testing Period. assessments T1-T3). reflecting the times when both were present.38 1. *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 Downloaded from ajcc. No. Rarely. CPOT scores were higher during the positioning procedure (T2) than during rest (T1) or recovery (T3.G. 4 http://ajcc.23 1.55 2. the principal investigator and the critical care nurse (C.7 µg/h (SD 31. Conscious intubated T5 T8 T2 Conscious extubated Unconscious intubated Value 60 83 22 (8) 3. (%) of patients Male Female Type of cardiac surgery.36 0. Finally. Again.03 1. Third Testing Period.35 0. CPOT scores were higher during the positioning procedure (T5) than during rest (T4) or recovery (T6).0 1. 424 AMERICAN JOURNAL OF CRITICAL CARE. Volume 15. July 2006. a criterion for testing during this period. Interrater Reliability Figure 2 Mean scores and standard deviations of the CriticalCare Pain Observation Tool for the 3 testing periods (N = 105 patients).70 0. For assessments T4 to T6.87 1. The CPOT scores were similar to those of the 2 previous testing periods (Figure 2).5 0. patients had the highest scores on the CPOT (Figure 2). data were collected on 99 of the awake 105 intubated by guest on December 2. Table 4 Weighted κ coefficients for each assessment from T1 to T9* Assessment T1 T2 T3 T4 T5 T6 T7 T8 T9 No. All patients also were receiving continuous infusions of fentanyl when they were admitted to the ICU from surgery.0 Mean score (79) (21) 2.Table 3 Description of the study sample (n = 105)* 4.5 2.5 1.85 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.42 0. of patients 12 12 14 29 33 33 34 33 34 Weighted κ coefficient 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.N. No. data were collected on 33 of the 105 intubated patients who were unconscious. and G. No.04 First Testing Period.77 0. mean (SD) Sex. for assessments T7 to T9.) completed the CPOT at all 9 assessments and were blinded to each other’s scores.38 1.88 0.5 3. Figure 2). The scores can range from 0 to 8.8) at the first testing period to 50.63 0. For assessments T1 to T3.

CPOT scores were significantly higher during positioning than during the rest periods. These results 425 AMERICAN JOURNAL OF CRITICAL CARE.78 3. and results cannot be generalized to other ICU nurses. 5 patients at T4. CPOT scores were higher during painful procedures.07 0. present (n = 54) No. Such results emphasize that pain behaviors are observable even if a patient cannot report pain. and then awake and extubated. Our results support the criterion validity of the CPOT because the indicators were tested against the most valid measurement of pain.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. and 6 at T6 were unable to give their self-reports of pain by nodding their heads. Alpha is adjusted to 0. Discussion Our f indings validated the CPOT.74 when they compared behavioral pain scores between pairs of evaluators. Table 6 gives the results of the paired t tests.71) and recovery at T9 (1. 4 Downloaded from ajcc. 95) (1. Weighted κ coefficients were moderate to high at all assessments (Table 4). Interrater reliability was high for most assessments and moderate at T4. 2 at T5.65 2. During the third testing period (ie. the higher a patient’s selfreport of pain was. Mean CPOT scores according to patients’ selfreports of the presence or absence of pain during the second testing period (ie. Criterion Validity CPOT scores were associated with patients’ self-reports of pain. When patients were intubated during the second testing period. conscious and intubated. Moreover. Payen et al19 obtained a weighted κ coefficient of 0.88 F 11. however. 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.01) than during rest at T7 (1.83† 22. *Because of intermittent drowsiness postoperatively. assessments T4-T6) and the analysis of variance are presented in Table 5. present (n = 79) No. the higher was the patient’s score on the CPOT.89† ANOVA df (1. Discriminant Validity At the 3 testing periods. †P ≤ . that is. July 2006. which was developed specifically to assess pain in ICU patients.49. assessments T7-T9). CPOT scores differed significantly between those who reported pain and those who did not.aacnjournals. 92) (1.19 In our study. 91) Abbreviation: ANOVA. and 1 physician participated in that study. Payen et al19 also found higher behavioral scores during positioning than at rest in unconscious critically ill patients. 1 physical therapist. A total of 46 nurses and nurse’s aides.59.40 (P ≤ . http://ajcc. analysis of variance. Volume 15. 0.40 0.85 1. At each assessment in this testing period.01 because 3 comparisons were made on the same subjects.001.31 0.001) at T7 to T9 showed that the patients’ selfreported pain intensity scores were moderately correlated with the CPOT scores. lending support to its validity.40). absent (n = 41) Yes. and T6) Assessment T4 T5 T6 Patients’ self-reports of pain: pain present or absent* Yes.62 Discriminant validity was supported by the finding that CPOT scores were higher during positioning than at rest in the 3 testing periods. No. absent (n = 18) Yes. CPOT scores were significantly higher for intubated patients reporting pain than for those who had no pain.32 in which self-reports of pain of patients in a postanesthesia care unit were moderately related to pain behaviors. Our study.90 1.18† 38. by guest on December 2. present (n = 53) No. which is a limitation to the examination of interrater reliability. the patients’ self-reports. Spearman correlations of 0. These results are consistent with those of previous studies18. only 2 evaluators used the instrument. when patients were extubated during the third testing period. and 0. 2011 .11 2.38 0. absent (n = 39) Scores Mean 1.49 SD 1. mean pain intensity scores were significantly higher during the positioning procedure at T8 (2.

18 of them who did not report pain had high CPOT scores (mean 2. a period when intermittent drowsiness can be expected. Experts recommend we assume that unconscious patients have pain.34 recommend that these patients be treated the same way as conscious patients when the patients are exposed to sources of pain. This result may have occurred because the patients were highly sedated while unconscious and may have been experiencing the residual effects of anesthesia. understand. This finding suggests that behaviors observed by using the CPOT may be an indicator of more than pain. cardiac surgery patients are a relatively healthy ICU group and may not represent most ICU patients. 2011 . Those patients might have had more time to recuperate from the residual effects of anesthesia than our patients did.19 Once extubated. the endotracheal tube may have caused coughing during the positioning procedure. In the study by Ferguson et al.07* -15. Interestingly.17 This pressure may cause stretching of the sternal incision. Perhaps for these patients the positioning was a distressful or an uncomfortable experience1. Until there is evidence to the contrary. The presence of the endotracheal tube as a potential source of pain6. postoperative drowsiness led to missing data for some patients. when conscious intubated patients were positioned during assessment T5. leading to higher CPOT scores in the absence of reported pain. 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. in a study by Lawrence. experts recommend that healthcare providers assume that unconscious patients may have pain. Limitations This study was not without limitations. July 2006. especially if behavioral responses to noxious stimuli occur. The experts33.11. More raters should be used in tests of interrater reliability in subsequent evaluations of the CPOT. tioned.5 patients’ self-reports of pain after coronary artery bypass graft surgery were collected more than 8 hours after the end of surgery. and T7) and during the procedure (T2.01* -12. Whether a behavioral response to a noxious procedure is accompanied by perception of pain in an unconscious patient is unknown. In light of this finding. patients seemed to have higher CPOT scores when they were conscious and intubated than they did when they were unconscious or extubated. especially if behavioral responses to a known noxious stimulus occur. Finally. Third. who are AMERICAN JOURNAL OF CRITICAL CARE. The occurrence of the same inability to communicate in the patients in our study is not surprising. perhaps the CPOT can be used to assess pain in other populations of critical care patients.aacnjournals.5. Previous studies7-9.20 in which intubated patients provided self-reports of pain were conducted in periods varying from 12 to 72 hours after the end of surgery.36 for cardiac surgery patients. In our study.Table 6 Differences in scores on the Critical-Care Pain Observation Tool measured at rest before the procedure (T1. Second. they could have experienced less severe pain than they did when they were intubated. data were collected by only 2 persons. No.12. SD 0. may demonstrate pain behaviors in response to a nociceptive procedure. and 9 (21%) of 43 patients were unable to communicate their self-report of pain because of drowsiness. whatever their levels of consciousness. in addition to the sternal incision. First. Indeed. 4 http://ajcc. Also.35 formerly unconscious patients revealed that they could hear. T4.96* df 32 98 104 *P < . Moreover. and respond emotionally to what was being said while they were unconscious. of patients 33 99 105 t -9.aacnjournals.90). and T8) Assessments T1-T2 T4-T5 T7-T8 No. However. data could be collected for only 33 of the 105 patients while the patients were unconscious. which does not occur in nonsurgical Downloaded from ajcc. Further research is warranted to determine the sensitivity and specificity of the CPOT as a measure of pain. mechanical ventilation modes provided a positive inspiratory pressure to allow distribution of oxygen throughout the lungs. and which can be painful to some patients. Alpha is adjusted to 0. Behaviors observed by using the CPOT may indicate more than by guest on December 2.37 rather than a painful one. Data collection in this study was completed in the 8 hours after surgery. Volume 15. This hypothesis requires confirmation in future studies. T5. suggest that patients.001.01 because 3 comparisons were made on the same subjects.8 may help to explain these findings.

7. Assessment of patients’ experience of discomforts during respirator therapy. 24. Canada. Crit Care Med. Focus Crit Care. 1997. July 2006. Philadelphia. Potgieter PD. Prog Cardiovasc Nurs. Paquin M-J. Francis J. data were obtained from patients at different levels of consciousness. Fernsler J. Kaiser KS. thanks to Celeste Johnston. 3rd ed. Am J Crit Care. 1974. 1992. Christoph SB. Ambuel B. Springhorn HE. Hamill-Ruth RJ. Broste SK. 15. 16-20. Crit Care Med. 1990. Wu AW. et al.17:95-109. 3. 2001. Fillion L.10:238-251.1:165-167. 1995. et al. Assessing distress in pediatric intensive care environments: the COMFORT Scale. Quebec. Marx CM. 34. Controlled sedation with alphaxalone-alphadolone. Perception of pain in the persistent vegetative state [letter]? Eur J Pain. Blumer JL. Am J Crit Care. Conclusions The CPOT had acceptable reliability and validity in this sample of cardiac surgery ICU patients. Pharmacotherapy. 2nd ed. Lenz ER.33:159-174. Bucknall T. Despite these limitations. 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Valdix SW. Nye P. Health Measurement Scales: A Practical Guide to Their Development and Use. http://ajcc. Puntillo KA. NY: Oxford University Press Inc. Weiss JS. Norman GR. Fontaine DK.much sicker.10:3-11. 1997. for their helpful comments on this article. and use of validated measures of pain could aid in the evaluation of multidisciplinary pain management techniques for nonverbal critically ill patients.29:1370-1379. Biometrics. Future research should be conducted to determine if CPOT scores can be used to differentiate pain from other conditions. Pain assessment in critical care: what have we learnt from research? Intensive Crit Care Nurs. Bergbom-Engberg I. Stannard D. New York.34:557-562. and opioid administration. 2003. Bosson JL. 32.18:966-968.15:14-34.10:252-259. Pain. Gilroy D. The research was performed at the Faculty of Nursing. Behavior responses and self-reported pain in postoperative patients. Hungler BP. et al. 21. Streiner DL. the critical care nurse who contributed to data collection. Fillion L. Krenzischek DA. 37. the relationship between intubated patients’ self-reports of pain and behavioral indicators was explored for the second time. Second. 26. Kehrle K. 1977. Pa: FA Davis Co. 33. Appropriate pain assessment is an important part of quality care for critically ill patients. Morris AB. et al. Margolin R. Pa: Lippincott. ACKNOWLEDGMENTS Special thanks to Gaëlle Napert. 1994.2:1214. 30. Choinière M. 1996. 1990. Bernard GR. Crit Care Med.