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.
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.


METHODS
Systematic review.


METHODS
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.


METHODS
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.


CONCLUSIONS
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.
Prince of Wales Hospital Emergency Department, Randwick, NSW, Australia.|Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.
Wayne
http://orcid.org/0000-0002-4752-9679
W
Varndell
Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.
Margaret
M
Fry
Faculty of Health, University of Technology Sydney, Broadway, NSW, Australia.
Doug
http://orcid.org/0000-0002-6081-5442
D
Elliott
D000328:Adult; D016638:Critical Illness; D004636:Emergency Service, Hospital; D006801:Humans; D010146:Pain / Q000175:diagnosis*; D010147:Pain Measurement; D011594:Psychometrics; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
critical care; emergency department; pain; pain assessment; pain rating scales