A review of compliance with pain assessments within a UK ICU

Literature review

The literature review was conducted using Liverpool John Moores University's Discover More search tool, which was used to search a range of academic journals relevant to pain assessment in the intensive care unit (ICU). The search included articles from Intensive Critical Care Nursing and the American Journal of Critical Care. Alongside these, government documents and guidance from NICE, the Intensive Care Society (ICS) and the Department of Health were explored.

Barr et al (2013) set out recommendations and guidelines for best practice in managing pain, agitation and delirium. These include daily sedation breaks for patients who are ventilated in critical care and promoting sleep by optimising the environment for this.

Pain assessment is useful in identifying why a patient is distressed when delirium and agitation have been excluded (Faculty of Intensive Care Medicine (FICM) and ICS, 2015). Adequate pain assessment and management have significant consequences for physical and psychological health, which can include patients being at a higher risk of respiratory and cardiovascular events, in addition to anxiety and depression (Schug and Goddard, 2014).

Regular assessment and management of pain improve clinical outcomes including a reduced length of stay, less use of analgesia and shorter mechanical ventilation time (Malchow and Black, 2008; Sacco and LaRiccia, 2016). However, Whitehouse et al (2014) identified that 50–65% of patients recalled severe pain, with 15% unhappy with how their pain was managed.

This demonstrates that significant improvements are needed to the assessment and management of pain. As well as a reduction in length of stay, adequate pain control can promote quality of sleep and ventilator compliance, and reduce oxygen demand and the risk of atelectasis (Whitehouse et al, 2014; Ehieli et al, 2017). However, providing too much analgesia can delay weaning from the ventilator, make assessment of neurological status difficult and lead to cardiovascular instability (Barr et al, 2013). This shows the importance of accurate assessment in achieving the best outcomes for patients.

The FICM and ICS (2015) suggest pain should be assessed regularly and appropriate analgesia provided as required, with Barr et al (2013) suggesting regular pain assessments are made frequently and carried out at least four times per shift and more often if required. This is consistent with guidance in paediatrics, with guidelines from the Royal Children's Hospital Melbourne (RCHM) (2012) recommending a minimum baseline of 4-hourly assessments for all ventilated patients. In view of documentation from the RCHM (2012), it was appropriate to use a minimum 4-hourly assessment for the purpose of this audit.

NHS Quality Improvement Scotland (2004), in a best practice statement, suggested that pain should be assessed as regularly as other vital signs, because pain levels change frequently. This statement focuses on postoperative pain, where pain might be expected to fluctuate more than in medical patients.

Research by Malchow and Black (2008) and Rose et al (2011) has highlighted that documentation of pain assessment is poor in ICUs. With regards to recording pain assessments, a lack of documentation within clinical areas could suggest pain assessments are not being completed, which begs the question of whether patients' pain is managed effectively. This has implications for the care a patient receives and their experience while in hospital.

The American Society of Anesthesiologists Task Force on Acute Pain Management (2012) highlighted the importance of using a pain-assessment tool that is appropriate to the patient's cognitive ability to ensure a correct response that is tailored to the patient, individualised care, a patient-centred approach, effective analgesia regimens and better outcomes.

Examples of assessment tools are the Critical Care Pain Observation Tool (CCPOT) and the visual analogue scale (VAS), both of which have been recognised as gold standards in pain assessment (Gélinas et al, 2006; Barr et al, 2013; Whitehouse et al, 2014). Barr et al (2013) recommended that regular assessments should be conducted with a validated pain-assessment tool, with the Faculty of Pain Medicine (2015) reinforcing the need for the assessment tool to be standardised to ensure the reliability and validity of assessments (Schofield, 2018). Recommendations include treating pain within 30 minutes then reassessing to identify the effectiveness of interventions (RCHM, 2012; Barr et al, 2013). However, it may be felt that pain should be treated as soon as possible once nursing staff are aware pain is present. De Andrés et al (undated) supported frequent assessments before and after analgesia is given to assess how effective it is, with a reduction in assessment frequency indicated if the intensity of pain becomes lower (Herr et al, 2011).

Rationale for clinical audit

A clinical audit was conducted in a UK ICU to elucidate if there were any areas for service improvement in relation to the assessment and documentation of patients' pain. The rationale for this is that pain assessments are commonly not documented or performed adequately, and the reasons for this are unclear.

Malchow and Black (2008) and Rose et al (2011) have highlighted that documentation of pain assessment in ICUs is poor. ‘If it's not documented then it's not done’ is a phrase often used in nursing to promote accurate documentation (Andrews and St Aubyn, 2015). The Code (Nursing and Midwifery Council (NMC), 2018) clearly states that records should be kept and be clear and accurate; this is to demonstrate the care delivered as well as to protect nurses from potential litigation (Andrews and St Aubyn, 2015). The Code (NMC, 2018) therefore supports the need for accurate and timely documentation and keeping records of pain assessments.

Professional bodies and research studies have identified the importance of adequate pain control and suggest the use of recommendations proposed by Barr et al (2013) to guide nursing practice (Malchow and Black, 2008). Rose et al (2012) have identified a significant number of nurses who are unaware of published recommendations and guidelines regarding pain-assessment tools, which may be why pain assessments are infrequent and poorly applied. Reasons for this could be related to a lack of education and may be an area for future exploration through research.

The aim of this audit was to gain an initial insight into the assessments of pain within intensive care to identify compliance. Reliable assessment of pain provides the basis for effective pain management (Barr et al, 2013).

Conducting the audit

Pain should be acted on as part of high-quality nursing care, and this benefits patients' physical and psychological health (Malchow and Black, 2008; Sacco and LaRiccia, 2016; Ehieli et al, 2017). The assessment tools used in this ICU are the gold standard CCPOT and VAS (Gélinas et al, 2006; Barr et al, 2013; Whitehouse et al, 2014). The importance of adequately assessing a patient's pain to ensure it is controlled is the rationale for completing this audit. This includes checking whether pain is assessed every 4 hours at a minimum, is managed appropriately and is reassessed regularly to ensure interventions are effective (Barr et al, 2013).

Consent for this audit was gained from the audit lead within the ICU. Patient documentation was reviewed within the clinical area retrospectively over one 24-hour period to include early, late and night shifts plus any admission assessment.

Observation charts in the audited ICU allow for hourly documentation only. For this reason, the audit proforma aims to identify whether pain was assessed and documented within the hour. Table 1 shows the proforma used to collect the data.

The decision to audit pain assessment over a retrospective 24-hour period was to capture an initial snapshot into practices in relation to undertaking pain assessments. It was anticipated that, following this initial insight, more regular audits around pain assessments would follow.

The audit tool was derived by the author in response to the literature. Pain assessments were audited in line with guidance from Barr et al (2013), who suggested pain should be assessed at least four times per shift. As mentioned above, reassessments were audited within an hour as opposed to the recommended 30 minutes because of the documentation used in the ICU (Barr et al, 2013).

The aim of this audit was to gain an initial insight into the assessment of pain within an ICU to identify where improvements to practice could be made.

Findings and analysis

Pain assessment was documented infrequently and varied between patients, which supports findings in the literature.

The audit was carried out without difficulty or obstruction, and colleagues were supportive and openly provided the data needed. Data had been collected over a 24–hour period to include early, late and night shifts as well as identifying if an admission assessment had been completed. It was clear that the documentation of pain assessment required improvement. Data were collected through identification of the use of the CCPOT or VAS assessment tools, which is clearly identified on the ICU observation charts.

The audit covered 14 patients in total. The second author found that only five (35.71%) patients' documentation had a pain assessment recorded within two hours of admission (Figure 1). This could suggest that documentation of pain is lacking or that pain assessments did not occur because of poor practice or unfamiliarity with gold standard pain-assessment tools. Rose et al (2012) reported that nurses may be unfamiliar with guidelines regarding pain assessment and this could explain why such a low number of patients received an initial assessment. This has an impact on care as there is no baseline pain score to refer to when assessing and reassessing the effects of analgesia.

Pain assessment within the previous six hours was carried out for between two and four patients per shift (a range of 21.4%–42.8%), with compliance on the night shift being twice that on the late shift (Figure 2). The reasons behind this are unclear but it could be that nursing staff find it easier on a night shift to ensure an accurate pain assessment is completed and timely documentation is undertaken. Despite higher compliance on a night shift, assessments at this time did not meet the guidelines or documentation requirements as published by Barr et al (2013) and the Code (NMC, 2018).

No patients had their pain acted upon and reassessed during this initial audit. This was because either the previous pain score was 0 or pain was not assessed at all. This lack of assessment meant staff would not know if analgesia was required so would also be unable to reassess to if it had been effective. Subsequently, this may pose a potential issue during handover. More importantly, it will have effects on patients, such as poor control of pain, prolonged healing, increased stress, a prolonged length of stay in hospital and a need for prolonged ventilation.

Staff are therefore unaware whether a patient needs analgesia and are failing to complete an accurate, complete pain assessment themselves that could prove beneficial to the patient.

The findings of this audit demonstrate that pain assessments do not meet the minimum standards in relation to the frequency, management and reassessment of patients' pain, which correlates with the literature (Malchow and Black, 2008; Rose et al, 2011; Barr et al, 2013). The reasons behind this could include a lack of nurses' knowledge and understanding regarding pain guidelines or gold standard pain-assessment tools, as identified by Rose et al (2012). Both the literature and the results from the audit demonstrate that intensive care has significant areas where work is needed to improve patient experiences and outcomes.

By identifying this lack of compliance with assessments, changes can be implemented to promote the education of nurses and the use of appropriate pain-assessment tools. In turn, this would improve patient experiences by identifying the effectiveness of analgesia and generating effective management regimens to limit patients stress, improve healing and address complications from not assessing pain effectively.

The purpose of assessment is also to identify whether patients are receiving too much or too little analgesia, which may impede recovery. Guidelines from Barr et al (2013) recommend that pain is treated and reassessed at half hourly intervals. It is not possible to identify whether this standard was met because of the format of documentation; this is a limitation of this audit. This is not to say that patients were not assessed by nursing staff; the audit has highlighted that compliance with documentation that nursing staff are expected to complete is poor, and this could be an area of future exploration.

The findings of this audit are consistent with national trends and demonstrate how, despite a wealth of literature being available, pain-assessment compliance is below the standard required of nursing staff.

Recommendations

After this audit was completed, recommendations were made to improve compliance with pain-assessment documentation, which could improve patient care. These include:

Documented assessments are lacking in numerous ICUs, and other units have focused on re-education and the introduction of pain champions to promote the use of pain-assessment tools (Rose et al, 2011). These are intended to provide effective management of pain, with the aims of improving physical and psychological health (Rose et al, 2011). It may be the case that updates are required from the pain team in the trust to reinforce and re-educate nursing staff regarding pain assessment and management. Equally, the involvement of practice educators is pivotal to support staff in practice through applying information from the pain team in the context of critical care. Practice educators can answer questions that may arise from practice and can educate and encourage staff to complete assessments.

It is clear from the audit that there is a need to focus on professional responsibilities with regard to the documentation of these assessments, as well as a need to educate staff on the use of pain-assessment tools. This would not only aim to improve the experience of patients within intensive care but also create roles for staff, which could improve morale (Health Service Executive, 2013).

It should be noted that the findings of this audit are largely indicative of a national trend for pain assessments within intensive care.

Conclusion

The need for appropriate analgesia has been well documented, as it benefits physical and psychological health within intensive care. It is essential not only to ensure adequate analgesia is provided but also to identify when a patient may be receiving too much analgesia. Appropriate analgesia will provide a better experience for patients, reduce ventilator times, encourage weaning and aid sleep (Malchow and Black, 2008; Sacco and LaRiccia, 2016).

Barr et al (2013) have produced guidelines for staff on the assessment of pain, with recommendations for pain-assessment tools. Despite this, pain assessment within ICUs requires improvement (Malchow and Black, 2008; Rose et al, 2011).

KEY POINTS

CPD reflective questions