Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study.

BACKGROUND: Intensive care (ICU) patients' burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity. AIMS: To understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients. METHODS: Consecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n=70). Analysis of 36 qualitative interviews with ICU clinicians (n=12) and burn-injured adults (n=12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model. RESULTS: Overall, there was a significant increase in morphine (P=0.04) and propofol (P=0.04) use and a trend towards increased paracetamol (P=0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA<20% (P=0.06), and significantly increased propofol use for TBSA≥20% (P=0.03). Ventilation time and ICU/hospital length of stay were unchanged. Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant. CONCLUSIONS: Effective pain assessment, management and advocacy are assisted by evidence-based assessment practices.