The Psychometric Properties of the Visual Analogue Scale Applied by an Observer to Assess Procedural Pain in Infants and Young Children: An Observational Study.

PURPOSE: The Visual Analogue Scale applied by an observer (VASobs) is widely used to quantify pain but the evidence to support validity is poor. The aim of this study was to evaluate the psychometric and practical properties of the VASobs used to assess procedural pain in infants and young children. DESIGN AND METHODS: In an observational study, 26 clinicians applied the VASobs independently to video segments of 100 children aged six to 42 months undergoing a procedure to generate pain and distress scores. Each video segment was scored by four randomly selected reviewers. RESULTS: Reliability for pain scores was poor to fair (ICC 0.35 to 0.55) but higher for distress scores (ICC 0.6 to 0.89). At a cut-off score of 3, sensitivity and specificity were 84.7% and 95.0%, respectively for pain and 91.5% and 77.5% respectively for distress. Linear mixed modelling confirmed responsiveness. An increase in pain scores (regression slope 4.95) and distress scores (regression slope 5.52) across phases (baseline to procedure) was seen for painful procedures. The correlation between VASobs pain and FLACC scores was good (r = 0.74) and correlations between VASobs distress and FLACC scores were excellent (r = 0.89). CONCLUSION: VASobs was easily applied and preferred by clinicians. Despite evidence of sensitivity and responsiveness to pain, the reliability results were poor, and this scale cannot be recommended for use. PRACTICE IMPLICATIONS: The results of this study prevent recommending the VASobs for assessing procedural pain in infants and young children for clinical or research purposes.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS).

PROBLEM: Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use. ELIGIBILITY CRITERIA: Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included. SAMPLE: Twenty-eight studies (8 psychometric and 20 RCTs) were included. RESULTS: Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS. CONCLUSIONS: It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children. IMPLICATIONS: Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

The Psychometric Properties of the FLACC Scale Used to Assess Procedural Pain.

The Face, Legs, Activity, Cry, and Consolability (FLACC) scale is one of the most commonly and widely used behavioral observation pain scales. The aim of this study was to test the psychometric and practical properties of the FLACC scale to quantify procedural pain in infants and young children. Twenty-six clinicians independently applied the FLACC scale to segments of video collected from 100 children aged 6 to 42 months undergoing a procedure. Video segments were scored by 4 reviewers. Inter- and intrarater reliability coefficients were high (.92 and .87, respectively). Linear mixed modeling confirmed scale responsiveness (differences in difference between FLACC scores across phases for painful versus nonpainful procedures was 4.2, 95% confidence interval = 3.67-4.81). Sensitivity and specificity were 94.9% and 73.5%, respectively, at a cutoff of 2. However, the mean difference across phases for children with baseline scores >3 was much lower than for children with scores <3, P = .0001. Correlations between FLACC and Visual Analog Scale observer pain and distress were good (r = .74 and r = .89, respectively). This study supports the reliability and sensitivity of the FLACC scale for procedural pain assessment. However, the circumstances of procedures interfered with application of the scale and the findings question the capacity of the scale to differentiate between pain- and nonpain-related distress. PERSPECTIVE: This article provides evidence that the FLACC scale is reliable and sensitive to pain for procedural pain assessment. Concerns remain about specificity and scale design. Identification of a scale valid for this purpose is needed to provide a platform for improved procedural pain management in infants and young children.

The Psychometric Properties of the MBPS Scale Used to Assess Procedural Pain.

The Modified Behavioral Pain Scale (MBPS) was designed to assess procedural pain in infants and is considered valid for assessing immunization pain. The aim of this study was to assess the practical and psychometric properties of the MBPS when applied to other commonly performed procedures. Twenty-six clinicians independently applied the MBPS scale to segments of video collected from 100 infants and children aged 6 to 42 months undergoing 1 of 4 procedures in the emergency department. Positive correlation between MBPS and Visual Analogue Scale observer applied (VASobs) pain (r = .74) was shown and inter- and intrarater reliability coefficients were high (.87 and .89, respectively). Construct validity was shown by scale responsiveness to painful stimuli (4.6 times increase in scores across phases) and the capacity of the scale to distinguish between painful versus nonpainful procedures (P < .001). However, mean baseline scores for procedures were not 0 (likely a function of item descriptors for a "0" score) and the mean difference increased across phases for children with baseline scores >3, which was much lower than for children with scores <3 (P = .0001). Finally, 28% of scores changed after the second viewing of a video segment. The MBPS appears reliable and sensitive to procedural pain when applied by clinicians. Results question the capacity of the scale to differentiate between pain- and nonpain-related distress, the feasibility of this scale, and the appropriateness of item descriptors for medical procedures. PERSPECTIVE: This article presents the psychometric and practical properties of the MBPS applied to assess procedural pain. Identification of a suitable scale for this purpose will support improved pain management in infants and young children who undergo painful procedures.

Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6-42 months.

INTRODUCTION: Infants and children are frequently exposed to painful medical procedures such as immunisation, blood sampling and intravenous access. Over 40 scales for pain assessment are available, many designed for neonatal or postoperative pain. What is not well understood is how well these scales perform when used to assess procedural pain in infants and children. AIM: The aim of this study was to test the psychometric and practical properties of the Face, Legs, Activity, Cry and Consolability (FLACC) scale, the Modified Behavioural Pain Scale (MBPS) and the Visual Analogue Scale (VAS) observer pain scale to quantify procedural pain intensity in infants and children aged from 6-42 months to determine their suitability for clinical and research purposes. METHODS AND ANALYSIS: A prospective observational non-interventional study conducted at a single centre. The psychometric and practical performance of the FLACC scale, MBPS and the VAS observer pain scale and VAS observer distress scale used to assess children experiencing procedural pain will be assessed. Infants and young children aged 6-42 months undergoing one of four painful and/or distressing procedures were recruited and the procedure digitally video recorded. Clinicians and psychologists will be recruited to independently apply the scales to these video recordings to establish intrarater and inter-rater reliability, convergent validity responsiveness and specificity. Pain score distributions will be presented descriptively; reliability will be assessed using the intraclass correlation coefficient and Bland-Altman plots. Spearman correlations will be used to assess convergence and linear mixed modelling to explore the responsiveness of the scales to pain and their capacity to distinguish between pain and distress. ETHICS AND DISSEMINATION: Ethical approval was provided by the Royal Children's Hospital Human Research Ethics Committee, approval number 35220B. The findings of this study will be disseminated via peer-reviewed journals and presented at international conferences.

Systematic review of the Face, Legs, Activity, Cry and Consolability scale for assessing pain in infants and children: is it reliable, valid, and feasible for use?

The Face, Legs, Activity, Cry and Consolability (FLACC) scale is one of the most widely used behavioural observation pain scales. However, the psychometrics of the scale have not been adequately summarised and evaluated to provide clear recommendations regarding its use. The aim of this study was to rigorously evaluate the reliability, validity, feasibility, and utility of the scale for clinical and research purposes and provide recommendations regarding appropriate use of the scale. Databases searched were MEDLINE, CINAHL, Embase, PsycINFO (using the Ovid, PubMed, and Ebscohost platforms), The Cochrane Database of Systematic reviews and Cochrane Controlled Trials, and Google Scholar. Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the FLACC scale applied to children (birth to 18 years) and randomised controlled trials (RCT) using the FLACC scale to measure a study outcome in infants and children. Data extraction included study design, population demographics, and psychometric data. Analysis involved in this study are quality assessment of the psychometric evaluation studies and the RCTs using the COSMIN checklist and the Jadad scale, respectively, and narrative synthesis of all results. Twenty-five psychometric evaluations studies and 52 RCTs were included. The study population, circumstances, and quality of the studies varied greatly. Sufficient data addressing postoperative pain assessment in infants and children exist. Some positive data support the psychometrics of the scale used to assess postoperative pain in children with cognitive impairment. Limited and conflicting data addressing procedural pain assessment exist. Content validity and scale feasibility have had limited psychometric evaluation. There are insufficient data to support the FLACC scale for use in all circumstances and populations to which is currently applied.

Poor agreement in application of the Australasian Triage Scale to paediatric emergency department presentations.

BACKGROUND: The Australasian Triage Scale (ATS) is used in Australian emergency departments (ED) to describe patient priority on arrival. This study aimed to determine the level of inter-rater consistency with which the scale is applied to paediatric presentations. Additionally, it sought to document the level of certainty with which nurses apply the scale. METHOD: An anonymous survey of emergency nurses responsible for paediatric triage decisions using written patient profiles. RESULTS: The level of agreement between nurses applying the ATS to paediatric presentations can be described as poor and appears lower than the consistency with which it is applied to adult presentations. CONCLUSION: Inconsistent allocation of ATS category implies variable patient waiting times, which may have detrimental effects on patient condition. Hence, efforts must be made to address the inconsistency that exists in paediatric triage decision-making.

Who is responsible for pediatric triage decisions in Australian emergency departments: a description of the educational and experiential preparation of general and pediatric emergency nurses.

BACKGROUND: Pediatric presentations to the emergency department (ED) account for approximately one third of ED presentations. Triage is the process employed by the ED to prioritize presenting patients, including children, on the basis of clinical urgency. This role is undertaken by emergency nurses, and a range of recommendations are available regarding the level of experience and education required by the nurse responsible for pediatric triage decisions. However, little is known about the actual education and experience of nurses undertaking pediatric triage. OBJECTIVES: To describe the level of experiential and educational preparation of emergency nurses responsible for pediatric triage decisions in pediatric and adult and pediatric population EDs. METHODS: An anonymous survey of emergency nurses responsible for pediatric triage decisions in a number of specialist and mixed EDs was conducted. RESULTS: Education and experience varies widely among nurses responsible for pediatric triage decisions. Many nurses practicing pediatric triage do not meet recognized guidelines for the levels of education and experience required to undertake pediatric triage. Nurses practicing in mixed population EDs were less likely to meet the recommended educational requirements than pediatric emergency nurses and yet reported no difference in their level of confidence in undertaking pediatric triage. CONCLUSIONS: Educationalists and managers must make a commitment to pediatric triage preparation for nurses in EDs providing pediatric services. In particular, emphasis must be placed on providing pediatric continuing education for nurses practicing in mixed population EDs. However, it is also essential that the impact of education and experience on patient outcomes be investigated before an attempt is made to influence the preparation of nurses for triage.