Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report.

Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm. The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended. When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles. To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.

Respuesta a: Sobre la ubicuidad del coeficiente alfa en los estudios de validación / Response to: About the ubiquity of the alpha coefficient in the validation studies

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Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients / Validación psicométrica de la Escala de Conductas Indicadoras de Dolor para la medición de dolor en pacientes críticos, no comunicativos y sometidos a ventilación mecánica

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. Procedure: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-_ coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p < 0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-_ value of 0.85 (95%CI 0.81-0.88). Cronbach-_ coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients

OBJETIVO: Evaluar las propiedades psicométricas de la Escala de Conductas Indicadoras de Dolor (ESCID), aplicada a una muestra amplia de pacientes críticos de patología médica y posquirúrgica. DISEÑO: Estudio multicéntrico, observacional, prospectivo de validación de una escala como instrumento de medida. Ámbito: Veinte Unidades de Cuidados Intensivos de 14 hospitales del Sistema Nacional de Salud español. PARTICIPANTES: Doscientos ochenta y seis pacientes críticos adultos, sometidos a ventilación mecánica, sin capacidad de comunicación, de patología médica y posquirúrgica. Intervención: Se midió el nivel de dolor de los pacientes por 2 observadores de manera simultánea y utilizando dos escalas: ESCID y la Behavoiral Pain Scale. El dolor fue medido antes, durante y después de la aplicación de dos procedimientos dolorosos (movilización y aspiración endotraqueal) y un procedimiento no doloroso. Variables de interés: La fiabilidad de ESCID se midió mediante la consistencia interna determinada con el coeficiente alfa de Cronbach. Se midió la concordancia inter- e intraobservadores. Se determinó la correlación entre las escalas ESCID y Behavoiral Pain Scale mediante el coeficiente de Spearman. RESULTADOS: Se realizaron 4.386 observaciones de dolor en 286 pacientes (62% patología médica y 38% posquirúrgica). Se evidencia una alta correlación entre ESCID y Behavoiral Pain Scale(r = 0,94-0,99; p < 0,001) así como una alta concordancia inter- e intraobservador. La escala ESCID presenta buena consistencia interna, con un valor de α-Cronbach de 0,85 (IC 95% 0,81-0,88). Los 5 dominios de ESCID presentan alta consistencia interna con α-Cronbach: musculatura facial 0,87 (IC 95% 0,84-0,89), tranquilidad 0,84 (IC 95% 0,81-0,87), tono muscular 0,80 (IC 95% 0,75-0,84), adaptación a ventilación mecánica 0,70 (IC 95% 0,63-0,75) y confortabilidad 0,85 (IC 95% 0,81-0,88). CONCLUSIÓN: ESCID es válida y fiable para medir el dolor en pacientes críticos médicos y posquirúrgicos, no comunicativos y sometidos a ventilación mecánica

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients.

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. PROCEDURE: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.