Objective: To foster best practice in pain management in the critically ill through a comprehensive assessment of current practice, a review of the literature, development of a sedation tool and implementation of a pain, anxiety and sedation protocol. A multidisciplinary critical care pain committee reviewed current pain and sedation management practice within our medical center, community and internationally. To date there has been little agreement regarding a standardized tool with which to assess patients administered sedative-hypnotics and analgesics in the critical care unit. The majority of scales published combine agitation and level of consciousness within the same scale. We developed the Consciousness/Agitation Assessment Tool (CAAT) for the assessment of the critically ill patient. This assessment tool measures the level of consciousness and agitation as separate variables.
Design: A validation study was conducted to determine the interrater reliability of the CAAT tool in comparison to the Modified Ramsay Scale and the Motor Activity Assessment Scale (MAAS). In addition, we measured critical care practitioners compliance to documentation of pain and sedation before and after the implementation of the critical care pain, anxiety and sedation protocol.
Sample: The convenience sample consisted of 1700 patient assessments done in a tertiary care tri-campus 800-bed medical center. The critical care units included two medical-surgical intensive care units, a coronary care unit, and two transitional care units. The patient population included cardiac and vascular surgery, heart, liver pancreas and kidney transplant, neurology and neurosurgery, pulmonary, and general medicine and surgery patients.
Variables: The study was designed to measure interrater reliability of the newly developed consciousness/agitation assessment tool as compared to the Ramsay Scale and the Motor Activity Assessment Scale in the critical care setting.
Methods: Teams of three to five critical care nurses were instructed regarding one of the three scales. They then evaluated and scored each patient simultaneously, independently, and confidentially in the ICU. The same process was then repeated with a different scale either the Ramsay or MAAS. A survey rating the understandability, ease of use and preceived accurateness of each scale was completed by the nurse conducting the assessments.
Results: A total of 1700 patient assessments were recorded. Kappa statistics were used to measure agreement among raters in each session. Separate kappa scores for the consciousness and agitation components of the CAAT were calculated. The CAAT consciousness scale kappa score of 0.773 was significantly higher than the Ramsay scale at 0.505 (p=0.03) and the MAAS at 0.559 (p=0.01). There was no statistical difference between the CAAT agitation scale and the Ramsay and MAAS. The nursing survey demonstrated that the CAAT scale was significantly better than the Ramsay and MAAS in the areas of accuracy (p=0.01, p=0.001), ease of use (p=0.01, p=0.001), and understandability (p=0.04, p=0.02). Staff compliance to documentation of pain and sedation improved in all the critical care units.
Conclusions: The research study demonstrated wide applicability with data from 1700 patient assessments on multi-service ICU patients. Fourty-four critical care nurses (novice to expert) were involved in the research project. The kappa scores for the CAAT consciousness scale showed significantly higher agreement as compared to the Ramsey or MAAS. The kappa scores for the CAAT agitation scale showed no significant difference as compared to the Ramsey or MAAS scale. In addition, the nurse survey results rate the CAAT scale higher in terms of understandability, ease of use, and perceived accurateness. The protocol for the management of pain, anxiety, and sedation in the critically ill was developed and included the CAAT scale, as well as, alternative approaches to pain management (i.e. massage therapy, guided imagery, chaplain service, creative expressive arts).
Innovative Nature: Our sedation research project is unique in its design and number of subjects and researchers, which included 44 critical care nurses and 1700 patient encounters. Because it was carried out on multi-service ICU patients it has wide applicability. To date this study is the largest patient group study of a new sedation assessment tool as seen in the current literature. It sets the stage for further research in validating inter-rater reliability and usability of sedation scales in critical care. The significant difference in accuracy, understandability and ease of use indicate that the CAAT scale will be practical in our critical care areas that use 25% registry and travelers. The most important aspect of this project was the involvement of the critical care staff as researchers, since they are responsible for the evaluation and charting of patient assessment.
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