Carol Thompson

Pain behaviors observed during six common procedures: Results from Thunder Project Ii*

ObjectivePatients frequently display behaviors during procedures that may be pain related. Clinicians often rely on the patient’s demonstration of behaviors as a cue to presence of pain. The purpose of this study was to identify specific pain-related behaviors and factors that predict the degree of behavioral responses during the following procedures: turning, central venous catheter insertion, wound drain removal, wound care, tracheal suctioning, and femoral sheath removal. DesignProspective, descriptive study. SettingMultiple units in 169 hospitals in United States, Canada, England, and Australia. PatientsA total of 5,957 adult patients who underwent one of the six procedures. InterventionsNone. Measurements and Main ResultsA 30-item behavior observation tool was used to note patients’ behaviors before and during a procedure. By comparing behaviors exhibited before and during the procedure as well as behaviors in those with and without procedural pain (as noted on a 0–10 numeric rating scale), we identified specific procedural pain behaviors: grimacing, rigidity, wincing, shutting of eyes, verbalization, moaning, and clenching of fists. On average, there were significantly more behaviors exhibited by patients with vs. without procedural pain (3.5 vs. 1.8 behaviors; t = 38.3, df = 5072.5; 95% confidence interval, 1.6–1.8). Patients with procedural pain were at least three times more likely to have increased behavioral responses than patients without procedural pain. A simultaneous regression model determined that 33% of the variance in amount of pain behaviors exhibited during a procedure was explained by three factors: degree of procedural pain intensity, degree of procedural distress, and undergoing the turning procedure. ConclusionsBecause of the strong relationship between procedural pain and behavioral responses, clinicians can use behavioral responses of verbal and nonverbal patients to plan for, implement, and evaluate analgesic interventions.

Pay for performance in critical care: An executive summary of the position paper by the Society of Critical Care Medicine

Concerns over the rising costs and quality of U.S. healthcare have led to interest in a performance-based approach. In a comparison of healthcare delivery in 191 countries, the United States ranked 37 in performance while expending the highest portion of gross domestic product on healthcare. Reimbursement for healthcare in the United States has been based primarily on quantity rather than quality. A “pay-for-performance” (P4P) approach has been suggested as a method to align incentives so that hospitals and providers are encouraged to deliver highquality care in a more cost-effective and efficient manner. Understanding the strengths and weaknesses of a P4P system is essential for all aspects of the healthcare system. The Society of Critical Care Medicine (SCCM) and other national organizations must understand these changes and become involved in the developmental aspects to support their members. The Pay-For-Performance Task Force was created by the SCCM to address these issues. This paper, a work product of that task force, serves as a brief primer on the current status of the P4P movement in the United States as it relates to critical care services. A fulllength task force report is available to SCCM members at www.sccm.org.

Translating research into practice. Implications of the Thunder Project II.

The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.

Child and Parental Perception of Asthma Control: Using the Childhood Asthma Control Test

This investigation was conducted to determine if children with asthma and their parents had similar perceptions of asthma control. This retrospective chart review looked at the electronic medical records of 45 children with asthma, ages 4-11 years. The records were reviewed to determine age, gender, race, and medication management. The answers to the C-ACT were analyzed to determine if the child’s asthma was well controlled and to find out if the child and their parents had the same perception of the child’s level of asthma control. It revealed that 62% of the subjects had asthma that was not well controlled. When comparing the child’s weighted score to the parent score on the C-ACT using the signed rank test there was a significance of P <.04. Comparing mean difference in the two groups revealed that the children perceive their asthma to be less well controlled than their parents do. Asthma control was not achieved for the majority of subjects in investigation despite appropriate prescribing practices. M...