Behavioral Pain Assessment Phase II, in the Pediatric Cardiac Intensive Care Unit
Corey Anderson BSN Rn, Amelia Beaver BSN Rn, Chad Pickering BSN Rn, Katie Gibson
BSN Rn, Heather Smith BSN Rn, Patrycja Mahdavi BSN Rn
Children’s Healthcare of Atlanta
Background
Accurate assessment of pain “is the first step toward pain management and is extremely
important in pediatric settings, especially in [intensive care units]” (1). The gold standard for
pain assessment is self-report; however, the preverbal infant population is unable to
quantify their pain, which places them “at risk for inconsistent identification of pain and
inadequate pain relief” (2). Instead of pain self-report, the healthcare team uses behavioral
pain assessment tools which rely on physiological and behavioral indicators to quantify
pain. The CICU used FLACC, CRIES, and OPS tools.
Purpose
Paired observations for pain assessment to determine the reliability of the behavioral pain
assessment tools currently used, if the Comfort revised scale is a better pain scoring tool
for this patient population, by using ANOVA models, and the construct validity of the
Comfort revised scale.
Methods/Sample
The investigator nurses will collect pain scores, each using the CRIES, FLACC, OPS, and
Comfort Revised Scale during independent simultaneous assessments with bedside nurses
assigned to the patient on one occasion. Inclusion Criteria: 0-24 months and a
cardiology/cardiothoracic surgery patient. Exclusion Criteria: Presence of genetic
abnormality, on a methadone/ativan wean, use of nurse controlled analgesia or
neuromuscular blockade.
Results
Results for Interrater Reliability
ICC¹
(95% CI)
Scale
Rater
FLACC
CRIES
OPS
Comfort
Chad
0.840
(0.567 – 0.947)
0.970
(0.908 – 0.990)
1.0
--
1.0
--
Katie
1.0
--
0.980
(0.941 – 0.993)
0.970
(0.912 –
0.990)
0.950
(0.856 –
0.983)
Heather
1.0
--
1.0
--
1.0
--
1.0
--
¹For an ICC = 1, 95% confidence intervals could not be calculated.
Conclusions
All three raters had perfect or nearly perfect agreement with the gold standard (Corey);
these raters may now be used interchangeably for Phase II of the study. Due to high
volumes, Phase II of the study could not be completed prior to the IRB deadline. The
decision was made to abort the study and resubmit at a future time as it is important to
ensure that the pain scales used are being used are reliable and being documented
correctly as pain medication administration is based on the use of observational pain scales
in the CICU.
References/Acknowledgements
1. Van Dijk, M., Peters, W.B., Van Deventer, P., & Tibboel, D. (2005). The COMFORT
behavior scale: A tool for assessing pain and sedation in infants. American Journal
of Nursing, 105(1), 33-36.
2. Manworren, R.C.B., Hynan, L.S. (2003).Clinical validation of FLACC: Preverbal
patient pain scale. Pediatric Nursing, 29(2), 140-146.
Special thanks to Dudley Moore Foundation, Dr. Nikhil Chanani, Jeryl Huckaby, RRT, MS,
CCRC, Lisa Pugsley, RN (MSN), and Dr. Linda Riley