How Painful Could It Be? The Challenge of Measuring Pain in the Intensive Care Unit

“Of pain you could wish only one thing: that it should stop. Nothing in the world was so bad as physical pain.” George Orwell, 1984 Pain is defined as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”1 In the intensive care unit (ICU), pain is common, but it is more difficult to assess than in acute care patients because of the frequent inability of critically ill patients to verbally describe their pain. However, the inability to self-report pain does not mean it is absent. In fact, the majority of critically ill patients do experience or recall pain,2 and even 3 months afterward consider it a significant source of stress during their ICU stay.3 Importantly, poorly treated pain in the ICU may negatively affect ICU outcomes. Acute pain can lead to derangements in cardiac and respiratory physiology, possibly prolonging hospital length of stay and worsening functional recovery.4 In addition, high levels of acute pain in perioperative patients increase the risk of developing chronic pain, limitations in functional status, poor global recovery, and lower health-adjusted quality of life 6 months later.5 Adverse psychologic outcomes, including symptoms of depression and posttraumatic stress disorder, are associated with acute stress, which may occur with untreated or undertreated pain.6 Fortunately, systematic pain assessments at the ICU bedside combined with analgesic administration titrated to a validated assessment scale can decrease the incidence of pain and associated complications.7,8 Thus, published clinical practice guidelines strongly recommend that pain be routinely monitored in all adult ICU patients using a validated behavioral pain assessment tool for patients who are unable to self-report.3 Given this seemingly straightforward recommendation, would not all ICUs, particularly academic institutions from which the overwhelming majority of pain-related research is generated, systematically assess and treat pain? In this issue of Anesthesia & Analgesia, van der Woude et al.9 report the results of a national survey among adult ICUs in the Netherlands describing nursing attitudes toward pain assessment. The nearly 80% response rate (84 of 108) included a cross-section of both teaching and nonteaching institutions. Whether van der Woude et al.’s sample was representative of its target population is difficult to know. In this case, survey questionnaires were sent to each ICU’s nurse manager, who was then asked, “to discuss the questionnaire with both the ICU nursing staff and attending physicians to make sure that answers would reflect actual behavior and awareness pertaining to pain assessment in the ICU.” To address the challenge of variability in ICU size, the authors weighted the survey results by the number of nurses in each ICU. Although weighting the survey in this way imperfectly addresses potential biases, Van der Woude et al.’s results are, however, thought provoking. In patients unable to self-report, only 1 of 5 (19%) of the responding ICUs used a structural, behaviorally based pain assessment tool. Of these, the critical care pain observation tool and the Behavioral Pain Score (BPS), the 2 scales recommended by the Society of Critical Care Medicine’s 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit,3 were used in only 9 (11%) ICUs, whereas another 7 (8%) used other tools. As the authors themselves note, this low usage of behavioral pain scales is also contrary to a Dutch national guideline.a Even more intriguing, respondents almost universally believed (82 of 84, 98%) that the subjective pain assessment of the bedside nurse was the most accurate at rating the intensity of a patient’s pain even when a behavioral assessment was used. Although this study did not seek out reasons for such a nursing preference, one possibility is that subjective criteria such as body movements and facial expressions not addressed in behavioral scores (tearing or weeping, facial flushing, brow furrowing, reaching or grabbing at invasive lines or tubes, and/or vital signs) are also being incorporated into decisions regarding pain intensity and the subsequent prescription for analgesia. Such a possibility is supported by 2010 German guidelines, which state that for ventilated patients, in addition to the BPS, “subjective criteria such as movement and facial expressions and physiologic parameters such as blood pressure, heart and respiratory rate, lacrimation and sweating, and the changes in these parameters after analgesic therapy” should be used (grade A recommendation).10 These opinions were consistent across institutions, whether teaching or nonteaching. The authors conclude that Dutch ICU nurses consider themselves the best judges of a patient’s pain intensity even when they are able to self-report and that this belief could be contributing to the low acceptance rates for behaviorally based pain assessments. Indeed, over one-third (36%) of respondent ICUs indicated that even when patients are able to self-report, nurses considered their assessment to be superior. Importantly, however, respondents indicated that pain assessment was of great importance, suggesting that underutilization of structured pain assessments was not because of lack of caring. The Dutch are not alone in their nonuse of behavioral pain assessment tools. National surveys involving European and Canadian ICUs have reported approximately 30% utilization rates of behavioral pain assessments in patients who are heavily sedated, mechanically ventilated, or otherwise unable to report.11,12 These disappointing results suggest that patient care can be improved. The implementation of regular, standardized assessments of pain intensity as a cornerstone of a larger protocol, which incorporates standardized assessments for agitation and delirium, can improve the quality of analgesia provided to the patient and may improve morbidity.13,14 Why then have ICU caregivers not adopted this practice? Although international societies have dedicated tremendous resources to formation of evidence-based guidelines, such interventions by themselves may not bring about behavior change. Possible reasons for not adopting behavioral pain scales include the lack of knowledge, skepticism regarding the evidence or benefit, a nonintuitive result (how could a recipe be better than a human for assessing pain?), family reluctance (what if the family wants pain medications but the behavioral scale recommends against it?), or the perception that benefits observed in studies are not generalizable to local practice. Perhaps, health care providers, given enough exposure to ICU clinical practice over time, have developed a healthy skepticism regarding the strength of evidence and consider themselves “late adopters.” Indeed, a number of therapies, which were initially reported to be beneficial and were swiftly incorporated into clinical practice guidelines, failed to live up to that early promise in subsequent and more definitive trials. Activated protein C, tight glycemic control, and moderate-dose steroids in septic shock are just a few.15–17 Such skepticism may lead health care providers to conclude that it is not necessary to make a change or suffer from optimism bias (the tendency to respond to the possibility of a negative outcome with, “that doesn’t (won’t) happen to me” or “that doesn’t happen at my hospital”). At the authors’ institution, behavioral pain assessments are performed by the ICU bedside nurse at least once per shift as part of a clinical guideline incorporating assessments for pain, agitation, and delirium. The results of these assessments and any related treatment is discussed as part of a “plan of the day” checklist on multidisciplinary rounds, which take place every morning and most afternoons. As needed analgesic medications are prescribed for nurses to administer within prescribed parameters, and discussion between nursing and ICU physicians to resolve disagreements regarding assessment and treatment of pain in patients unable to self-report is encouraged. For ICUs seeking to improve performance on evidence-based strategies such as BPS, “plan-do-study-act” cycles are recommended by the Institute for Healthcare Improvement as a “top down” tool for accelerating improvement.b With respect to “bottom-up” strategies, according to Prochaska et al.’s18 stages of change, the individual provider must first undergo “precontemplation” before changing their behavior. For example, a heavy smoker previously unaware of the adverse health effects of smoking will not stop just because he or she has been given information about the negative health effects. What both plan-do-study-act cycles and individual provider perceptions have in common is that the first step to improvement is to identify and raise awareness of the problem. With respect to the perceptions of bedside clinicians regarding pain assessment and treatment in the critically ill, we are thankful that van der Woude et al. have taken this first step. DISCLOSURES Name: Kee Hang Kevin Luk, MD, MS. Contribution: This author prepared the manuscript. Attestation: Kee Hang Kevin Luk approved the final manuscript. Conflicts of Interest: The author declares no conflicts of interest. Name: Aaron M. Joffe, DO. Contribution: This author prepared the manuscript. Attestation: Aaron M. Joffe approved the final manuscript and is the archival author. Conflicts of Interest: Aaron M. Joffe is a member of the Society of Critical Care Medicine’s task force on pain, analgesia, and delirium. This manuscript was handled by: Avery Tung, MD.

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