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A systematic review of observational pain assessment instruments for use with nonverbal intubated critically ill adult patients in the emergency department: an assessment of their suitability and psychometric properties

Varndell, W., Fry, M., and Elliott, D.
AIM AND OBJECTIVE: To examine the psychometric properties and suitability of the available observational pain instruments for potential use with nonverbal critically ill adult patients in the emergency department.

BACKGROUND: In the emergency department, assessing pain in critically ill patients is challenging, especially those unable to communicate the presence of pain. Critically ill patients are commonly unable to verbally communicate pain due to altered oral communication (e.g. endotracheal intubation) and/or diminished consciousness (e.g. sedation, delirium), placing them at great risk of inadequate pain management. Over half of intensive care critically ill intubated patients experience moderate-to-severe pain whilst intubated and mechanically ventilated.

DESIGN: Systematic review.

DATA SOURCES: The CINAHL, EMBASE, MEDLINE, ProQuest databases, and the Cochrane Library and the National Institute of Clinical Excellence were also searched from their date of inception to April 2016, with no language restrictions applied.

REVIEW METHOD: Studies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published classification of psychometric tests for consistency of interpretation.

RESULTS: Twenty-six studies evaluating five observational pain assessment instruments that had been used with critically ill intubated patients were identified. All five instruments included behavioural indicators, with two including physiologic indicators. All five instruments have undergone validity and reliability testing involving nonverbal critically ill intubated patients, three were examined for feasibility, and one instrument underwent sensitivity and specificity testing. None have been tested within the emergency department with nonverbal critically ill intubated adult patients.

CONCLUSION: The use of an appropriate and valid observational pain assessment instrument is fundamental to detecting and optimising pain management in nonverbal critically ill intubated patients in the emergency department. Of the observational pain assessment instruments reviewed, the Critical-Care Pain Observation Tool was identified as most appropriate for testing in a prospective trial in an emergency department setting.
J Clin Nurs
Publication year:
Symptom status:
Physical state
Adults (18-65)
Codes for special purposes
Factors influencing health status and contact with health services
PRO / non-PRO:
Non-patient Reported Outcome
Type of measurement instrument:
6 - Clinical rating scales
7 - Observations
BPS - Behavioural Pain Scale
CCPOT - Critical-Care Pain Observation Tool
FLACC - Faces, Legs, Activity, Cry and Consolability Scale
NVPS - Nonverbal Pain Scale
PAINAD - Pain Assessment in Advanced Dementia Scale