Effective pain management in the Intensive Care Unit (ICU) is paramount, yet it presents unique challenges, particularly in patients unable to self-report their pain due to sedation and mechanical ventilation. In the UK, as globally, best practice advocates for minimal sedation and prioritising analgesia to mitigate the adverse effects of oversedation and undertreated pain. Despite these recommendations and the availability of validated behavioural pain assessment tools, their consistent implementation across UK critical care units remains inconsistent. This article details a successful quality improvement (QI) project undertaken at Raigmore Hospital, NHS Highland, UK, focusing on the implementation of the Critical-Care Pain Observation Tool (CPOT). This project aimed to enhance pain management through an analgesia-first approach, utilising the CPOT to improve patient outcomes and nursing practice within a busy ICU environment.
The Problem of Pain Management in Critically Ill Patients
Assessing and managing pain in critically ill patients is a complex issue. A significant barrier is the common inability of patients in intensive care to verbally communicate their pain levels, primarily due to the necessary sedation for mechanical ventilation. While clinical guidelines emphasize the importance of validated behavioural pain assessment tools for these patients, their routine use in ICUs, including within the UK’s National Health Service (NHS), is not widespread. Studies have shown a direct correlation between regular pain assessments and reduced sedation requirements in ventilated patients, highlighting the potential benefits of consistent pain monitoring. A local audit in Scotland revealed that a concerningly low 30% of Scottish ICUs were utilizing these validated pain assessment instruments at the time of this project’s inception, underscoring a significant gap in best practice. This QI initiative at Raigmore Hospital sought to address this gap directly within their ICU setting.
Background: Why CPOT Matters in Critical Care
Effective pain assessment and treatment are fundamental to patient comfort and well-being in critical care. While continuous opioid infusions are frequently used in ICUs, they do not always guarantee adequate pain relief. Untreated or poorly managed pain in ICU patients can lead to a cascade of negative consequences, both physiological and psychological. Survivors of critical illness often report long-term issues such as anxiety, depression, sleep disturbances, chronic pain, and even post-traumatic stress disorder, significantly impacting their recovery and overall quality of life even after hospital discharge. Physiologically, pain triggers the release of stress hormones, contributing to tissue damage, inflammation, and immune system compromise. Research consistently demonstrates that many ICU patients experience pain both at rest and during routine nursing and medical procedures. Therefore, effectively addressing and minimizing unrelieved pain is not only a matter of patient comfort but also a crucial aspect of improving patient outcomes and long-term health.
Recognising the importance of this issue, medical societies globally, including within the UK, strongly advocate for the adoption of validated pain assessment tools in ICUs. These tools facilitate earlier identification and treatment of pain in patients who cannot self-report. The Behavioural Pain Scale (BPS) and, crucially, the Critical-Care Pain Observation Tool (CPOT) are among the recommended instruments. However, as highlighted by the Scottish audit, their uptake in UK critical care settings has been slow. The evidence suggests that regular pain assessment leads to more appropriate pain management and, consequently, reduced need for sedation. An analgesia-first approach, facilitated by tools like CPOT, is considered best practice not only for ethical pain management but also to promote earlier patient participation in their care and rehabilitation. The CPOT has been shown to be more robust and discriminative than the BPS, making it the preferred tool for this quality improvement project at Raigmore Hospital.
Methodology: Implementing CPOT at Raigmore Hospital, NHS Highland
To improve pain assessment and management for sedated and mechanically ventilated patients, the ICU team at Raigmore Hospital initiated a quality improvement (QI) project using the established Model for Improvement (MFI). The core aim was to implement the CPOT as a routine pain assessment tool and to promote an analgesia-first strategy. The project commenced on March 20, 2017, with the goal that by June 30, 2017, all eligible patients would receive regular, systematic pain assessments and treatment based on CPOT scores.
The project focused on two key process measures to track progress:
- Reliability of nursing staff in performing and documenting pain assessments every four hours: This measured the consistency of pain monitoring using the CPOT.
- Reliability of nursing staff in treating significant pain (CPOT scores ≥3) with rescue opioid analgesia: This assessed the responsiveness to identified pain based on CPOT scores, prior to escalating sedation.
It was hypothesised that improvements in these processes would lead to positive outcome measures, such as reduced ventilator time and length of stay in the ICU. While outcome data is not detailed in this article due to insufficient data points within the project timeframe, the focus remained on the immediate process improvements. Balancing measures were also identified to monitor for potential unintended consequences of the analgesia-first approach. These included:
- Risk of respiratory depression following opioid bolus administration.
- Risk of unplanned extubation associated with potentially lighter sedation levels.
Measurement and Data Collection
Operational definitions were established to ensure data consistency. CPOT charts for each ventilated patient were reviewed to check for four-hourly pain assessments. Compliance was assessed on an “all-or-nothing” basis; even a single missed assessment categorized a patient as non-compliant. Weekly compliance percentages were calculated. For treatment of pain, the reliability was measured by calculating the percentage of CPOT scores ≥3 that were actively treated with a rescue opioid analgesic bolus. A dedicated tracking sheet was designed for data collection, documenting assessment times, pain scores at rest and during procedures, reassessments post-procedure, opioid treatment for scores ≥3, and sedative bolus administration. The tracking sheet also included a feedback section for staff input.
Figure 1: Driver diagram. CPOT, Critical-Care Pain Observation Tool; ICU, intensive care unit.
Figure 1: Driver diagram illustrating the key areas addressed in the Critical Care Pain Observation Tool (CPOT) implementation project within the Intensive Care Unit (ICU).
Baseline Assessment
Initial testing of the CPOT began with single-patient trials, utilising the Plan-Do-Study-Act (PDSA) cycle of the MFI. These early tests showed 100% compliance with documentation but initially revealed low pain scores. Further testing with single patients confirmed staff understanding of protocols for scores ≥3. Expanding to three patients still showed high compliance with assessment frequency, but highlighted an issue: nurses sometimes relied on their clinical judgment over CPOT scores, and confusion existed regarding bolus administration of remifentanil, due to concerns about rapid administration causing hypotension. Feedback from nurses on the tracking sheets highlighted this confusion around remifentanil bolus administration. These initial PDSA cycles informed the development of educational posters using the Situation-Background-Assessment-Recommendation (SBAR) framework. Posters clarified that CPOT scores ≥3 indicated significant pain requiring treatment and provided guidance on appropriate remifentanil management, advising infusion rate increases per protocol and medical review if maximum doses were reached without adequate effect.
Design and Team
The QI project adopted the MFI and PDSA cycles for iterative testing and refinement. Testing was progressively scaled up from one to three patients, then expanded to all appropriate patients in the seven-bedded ICU. The baseline measurement phase spanned three weeks. Run charts were employed to visualise data trends and track improvements over time, aiding in understanding process variations. The project gained approval from the ICU lead consultant, and a multidisciplinary team was formed, including ICU consultants, pain specialists, pharmacists, physiotherapists, and nurses. Due to time constraints, team meetings were often ad-hoc “huddles.” To further understand the scope of the problem, questionnaires were distributed to nursing staff and ICU consultants, with responses reinforcing the need for improvement. Brainstorming sessions using fishbone diagrams identified potential obstacles, and driver diagrams visualised the project components needed for successful outcomes. Ethical considerations were addressed by emphasising patient narratives to highlight the impact of unassessed pain, reinforcing the project’s importance. Training objectives aimed to educate 75% of nursing staff on CPOT and tracking sheet use by the project launch date. Training methods included point-of-care teaching, presentations, expert speakers, and informational posters. Pain management guidelines and CPOT algorithms were also implemented.
Results: Improved Pain Assessment and Treatment with CPOT
The project conducted multiple PDSA cycles, with key learnings informing adaptations and improvements.
PDSA Cycle 1: Initial observations revealed issues with nighttime documentation and highlighted the impact of workload and staff training gaps. While treatment of scores ≥3 was generally good, instances of nurses prioritising clinical judgement over CPOT scores were noted, as was confusion regarding pain management in patients with epidurals. Corrective actions included peer education, workload awareness, and clarification on treating pain in epidural patients by adjusting epidural infusions or consulting medical staff.
PDSA Cycle 2: Focused on consistent treatment of scores ≥3 and improving assessment frequency. While treatment compliance remained high, assessment frequency initially worsened, with various factors like workload, time constraints, and forgetfulness contributing. Actions taken included annotating run charts to visually link missed assessments with increased pain scores, reinforcing the importance of even minimal pain assessment during busy periods, and using stickers on patient charts to prompt tracking sheet use.
PDSA Cycle 3: Targeted reducing delays in pain assessment. Despite reminders about the brief time needed for CPOT assessment, some delays persisted. However, significant improvement in assessment frequency was observed, possibly influenced by the chart stickers. Treatment of significant pain scores remained at 100% reliability when CPOT was used.
Figure 2: Nursing staff recording CPOT score every 4 hours. CPOT, Critical-Care Pain Observation Tool.
Figure 2: Run chart depicting the improved compliance of nursing staff in recording Critical Care Pain Observation Tool (CPOT) scores every 4 hours within the ICU.
Figure 3: Treatment of CPOT scores ≥3. CPOT, Critical-Care Pain Observation Tool.
Figure 3: Run chart illustrating the enhanced treatment rates of Critical Care Pain Observation Tool (CPOT) scores greater than or equal to 3, indicating effective pain management protocols in the ICU.
Overall Results: Run charts demonstrated significant improvements in both process measures. Figure 2 shows a sustained improvement in four-hourly pain assessments, with data points indicating a shift above the median. Figure 3 indicates consistently high treatment rates for CPOT scores ≥3, with a sustained run of 100% compliance. Balancing measures revealed one minor respiratory depression episode, managed without incident, and two unavoidable unplanned extubations unrelated to the CPOT implementation.
Lessons Learned and Limitations of CPOT Implementation
This QI project successfully improved timely pain assessment and treatment using the CPOT in mechanically ventilated ICU patients at Raigmore Hospital. Four-hourly pain assessments increased to 89%, and treatment of CPOT scores ≥3 reached 100%. Key factors in success included multidisciplinary team engagement, expert leadership, and recognition of the need for organizational change. Nurses reported increased accountability and autonomy in opioid titration and decision-making. The project’s learnings are potentially transferable to other critical care settings in the UK and beyond.
For future implementations, further education is crucial, particularly regarding pain management with specific drugs like remifentanil and epidurals. Other quality considerations include enhancing staff knowledge of analgesic onset times, pre-emptive analgesia for paralysed or deeply sedated patients, and awareness of masked pain signs. Unexpectedly, the project observed potential reductions in sedation needs with improved pain management, with some patients managed effectively with analgesia alone. This may contribute to reduced ICU length of stay, although this was not formally measured in this project. Improved communication and shared decision-making, particularly around sedation interruption, were also noted benefits.
Limitations include the potential lack of generalizability to different ICU settings and the small sample size of 65 patients. However, the PDSA approach provided valuable process improvement data. Limited data on ventilator time and LOS prevented outcome measure analysis within this project timeframe. The CPOT’s exclusion criteria for certain patient groups also reduced the sample size. Common barriers encountered included change fatigue, workload pressures, and staffing constraints. The initial use of a separate tracking sheet may have slowed initial progress, but this was addressed with chart stickers. Sustaining these improvements requires ongoing monitoring, education, and adaptation to emerging evidence. Given the identified practice gaps in pain assessment in UK critical care, the inclusion of pain assessment tools like CPOT as healthcare quality indicators should be considered to ensure consistent standards of care and reduce patient harm.
Conclusion: Enhancing Pain Management in UK Critical Care with CPOT
In conclusion, pain is a common and preventable harm for ICU patients unable to self-report. This QI project demonstrates the successful implementation of the CPOT as a valuable tool for pain assessment and treatment in a UK ICU setting. The project highlights the effectiveness of incremental PDSA cycles in driving practice change. The findings suggest that the implementation of CPOT has led to a tangible improvement in the quality of pain management at Raigmore Hospital ICU and provides a model for other UK ICUs seeking to enhance their pain management strategies.
Acknowledgements
The authors gratefully acknowledge the multidisciplinary team, especially the nursing staff, of the ICU at Raigmore Hospital for their dedicated participation in this quality improvement initiative.
