Mélanie Bérubé

Psychometric analysis of subjective sedation scales in critically ill adults.

Objective:To describe and analyze the development and psychometric properties of subjective sedation scales developed for critically ill adult patients. Data Sources:PubMed, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, ISI Web of Science, and the International Pharmaceutical Abstracts. Study Selection:English-only publications through December 2012 with at least 30 patients older than 18 years, which included the key words of adult, critically ill, subjective sedation scale, sedation scale, validity, and reliability. Data Extraction:Two independent reviewers evaluated the psychometric properties using a standardized sedation scale psychometric scoring system. Data Synthesis:Among the 19,000+ citations extracted for the 2013 Society of Critical Care Medicine’s Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium and from December 2010 to 2012, 36 articles were identified compassing 11 sedation scales. The scale development process, psychometric properties, feasibility, and implementation of sedation scales were analyzed using a 0–20 scoring system. Two scales demonstrated scores indicating “very good” published psychometric properties: Richmond Agitation-Sedation Scale (19.5) and the Sedation-Agitation Scale (19). Scores with “moderate” properties include the Vancouver Interaction and Calmness Scale (14.3), Adaptation to the Intensive Care Environment (13.7), Ramsay Sedation Scale (13.2), Minnesota Sedation Assessment Tool (13), and the Nursing Instrument for the Communication of Sedation (12.8). Scales with “low” properties included the Motor Activity Assessment Scale (11.5) and the Sedation Intensive Care Score (10.5). The New Sheffield Sedation Scale (8.5) and the Observer’s Assessment of Alertness/Sedation Scale (3.7) demonstrated “very low” published properties. Conclusions:Based on the current literature, and using a predetermined psychometric scoring system, the Richmond Agitation-Sedation Scale and the Sedation-Agitation Scale are the most valid and reliable subjective sedation scales for use in critically ill adult patients.

Acute to chronic pain transition in extremity trauma: A narrative review for future preventive interventions (part 2)

BACKGROUND The first part of this series of 2 articles revealed that chronic pain is an important issue post extremity trauma (ET) involving permanent biological transformations. Interventions aimed at preventing chronic pain in ET patients are therefore required. OBJECTIVE To conduct a comprehensive analysis of literature on risk and protective factors for chronic pain post-ET to guide the development of relevant preventive interventions. METHODS A narrative review of the literature was undertaken. Databases were searched to identify studies on chronic pain prognostic factors in ET patients. RESULTS Demographic, injury-related and psychological factors were shown to either contribute to or limit acute to chronic pain transition. High-intensity acute pain hasconsistently been identified as an important chronic pain risk factor. Other significant documented risk factors include: female gender, older age, less than college education, lower limb injury, symptoms of anxiety and depression and pain catastrophizing. Pain self-efficacy and pain acceptance have been shown to protect individuals against chronic pain. CONCLUSIONS This narrative review highlights factors placing ET patients at higher risk of chronic pain or protecting them against this problem. Determining how these factors could be addressed in preventive interventions is the next step before undertaking their development.

The effect of tailored Web-based interventions on pain in adults: a systematic review protocol

BackgroundInformation technologies can facilitate the implementation of health interventions, especially in the case of widespread conditions such as pain. Tailored Web-based interventions have been recognized for health behavior change among diverse populations. However, none of the systematic reviews looking at Web-based interventions for pain management has specifically addressed the contribution of tailoring.MethodsThe aims of this systematic review are to assess the effect of tailored Web-based pain management interventions on pain intensity and physical and psychological functions. Randomized controlled trials including adults suffering from any type of pain and involving Web-based interventions for pain management, using at least one of the three tailoring strategies (personalization, feedback, or adaptation), will be considered. The following types of comparisons will be carried out: tailored Web-based intervention with (1) usual care (passive control group), (2) face-to-face intervention, and (3) standardized Web-based intervention. The primary outcome will be pain intensity measured using a self-report measure such as the numeric rating scale (e.g., 0–10) or visual analog scale (e.g., 0–100). Secondary outcomes will include pain interference with activities and psychological well-being. A systematic review of English and French articles using MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library will be conducted from January 2000 to December 2015. Eligibility assessment will be performed independently in an unblinded standardized manner by two reviewers. Extracted data will include the following: sample size, demographics, dropout rate, number and type of study groups, type of pain, inclusion and exclusion criteria, study setting, type of Web-based intervention, tailoring strategy, comparator, type of pain intensity measure, pain-related disability and psychological well-being outcomes, and times of measurement. Disagreements between reviewers at the full-text level will be resolved by consulting a third reviewer, a senior researcher.DiscussionThis systematic review is the first one looking at the specific ingredients and effects of tailored and Web-based interventions for pain management. Results of this systematic review could contribute to a better understanding of the mechanisms by which Web-based interventions could be helpful for people facing pain problems.Systematic review registrationPROSPERO CRD42015027669

Delirium Assessment Tools for Use in Critically Ill Adults: A Psychometric Analysis and Systematic Review

Background Delirium is highly prevalent in critically ill patients. Its detection with valid tools is crucial. Objective To analyze the development and psychometric properties of delirium assessment tools for critically ill adults. Methods Databases were searched to identify relevant studies. Inclusion criteria were English language, publication before January 2015, 30 or more patients, and patient population of critically ill adults (>18 years old). Search terms were delirium, scales, critically ill patients, adult, validity, and reliability. Thirty‐six manuscripts were identified, encompassing 5 delirium assessment tools (Confusion Assessment Method for the Intensive Care Unit (CAM‐ICU), Cognitive Test for Delirium, Delirium Detection Score, Intensive Care Delirium Screening Checklist (ICDSC), and Nursing Delirium Screening Scale). Two independent reviewers analyzed the psychometric properties of these tools by using a standardized scoring system (range, 0‐20) to assess the tool development process, reliability, validity, feasibility, and implementation of each tool. Results Psychometric properties were very good for the CAM‐ICU (19.6) and the ICDSC (19.2), moderate for the Nursing Delirium Screening Scale (13.6), low for the Delirium Detection Score (11.2), and very low for the Cognitive Test for Delirium (8.2). Conclusions The results indicate that the CAM‐ICU and the ICDSC are the most valid and reliable delirium assessment tools for critically ill adults. Additional studies are needed to further validate these tools in critically ill patients with neurological disorders and those at various levels of sedation or consciousness.

Development and Acceptability Assessment of a Self-Management Intervention to Prevent Acute to Chronic Pain Transition after Major Lower Extremity Trauma

Abstract: Purpose: Transition from acute to chronic pain often occurs after major lower extremity trauma. Chronic pain has been found to negatively affect daily functioning, including the capacity to work and quality of life. Empirical data and an acceptability assessment were used to develop a self‐management intervention aimed at preventing acute to chronic pain transition after major lower extremity trauma (i.e., iPACT‐E‐Trauma). Methods: Evidence from previous studies on preventive self‐management interventions, combined with a biopsychosocial conceptual framework and clinical knowledge, helped define the key features of the preliminary version. Then a mixed‐methods design was used to assess the acceptability of iPACT‐E‐Trauma by clinicians and patients. Results: The key features of the preliminary version of iPACT‐E‐Trauma were assessed as acceptable to very acceptable by clinicians and patients. After clinician assessment, intervention activities were simplified and session duration was reduced. Patient acceptability assessment of iPACT‐E‐Trauma led to the tailoring of key intervention features, based on determinants such as pain intensity and the implementation of self‐management behaviors between intervention sessions. Web‐based sessions were also developed to facilitate iPACT‐E‐Trauma delivery. Conclusion: This study outlines the process involved in the development of an intervention to prevent chronic pain in patients with lower extremity trauma. Relevant information is provided to nurses and interdisciplinary teams on a self‐management intervention to prevent the transition from acute to chronic pain in the trauma population.

Content validation of behaviours and autonomic responses for the assessment of pain in critically ill adults with a brain injury.

BACKGROUND The evidence shows that brain-injured patients express behaviours that are related to their level of consciousness (LOC), and different from other patients in the intensive care unit (ICU). Therefore, existing behavioural scales should be revised to enhance their content and validity for use in these patients. OBJECTIVES The aim was to evaluate the content relevance of behaviours and autonomic responses for pain assessment of brain-injured ICU patients from the perspective of critical care clinicians. METHODS A total of 77 clinicians from four adult neuroscience ICUs (three from Canada and one from the United States) participated in this descriptive study. A physician/nurse ratio of 21% (13/61) was reached in this quota sample, and three physiotherapists also participated. They completed a content validation questionnaire of 19 items rated on clarity and relevance based on the patients LOC. Item Content Validity Index (I-CVI), and modified kappa (κ*) were calculated. Values higher than 0.78 and 0.75 respectively were considered excellent. RESULTS Regardless of the patients LOC, brow lowering, grimacing, and trying to reach the pain site were rated as the most relevant behaviours by clinicians, with excellent values of I-CVI>0.78 and κ*>0.75. Eyes tightly closed, moaning and verbal complaints of pain also obtained excellent values in altered LOC and conscious patients. Eye weeping obtained excellent values only in conscious patients. Other items showed fair (0.40-0.59) to good (0.60-0.74) values, while blinking and coughing showed poor values (<0.40) at various LOC. CONCLUSIONS Facial expressions, movements towards the pain site, and vocalisation of pain were the most relevant pain-related behaviours rated by critical care clinicians. The relevance of some behaviours (e.g., moaning and verbal complaints of pain) varied across LOCs, thereby calling forth adaptations of behavioural pain scales to allow for interpretation in the context of a patients LOC and ability to express specific behaviours.

Incidence and Risk Factors of Long-term Opioid Use in Elderly Trauma Patients

Objective: Evaluate the incidence and risk factors of opioid use 1 year after injury in elderly trauma patients. Background: The current epidemic of prescription opioid misuse and overdose observed in North America generally concerns young patients. Little is known on long-term opioid use among the elderly trauma population. Methods: In a retrospective observational multicenter cohort study conducted on registry data, all patients 65 years and older admitted (hospital stay >2 days) for injury in 57 adult trauma centers in the province of Quebec (Canada) between 2004 and 2014 were included. We searched for filled opioid prescriptions in the year preceding the injury, up to 3 months and 1 year after the injury. Results: In all, 39,833 patients were selected for analysis. Mean age was 79.3 years (±7.7), 69% were women, and 87% of the sample was opioid-naive. After the injury, 38% of the patients filled an opioid prescription within 3 months and 10.9% [95% confidence interval (CI) 10.6%–11.2%] filled an opioid prescription 1 year after trauma: 6.8% (95% CI 6.5%–7.1%) were opioid-naïve and 37.6% (95% CI 36.3%–38.9%) were opioid non-naive patients. Controlling for confounders, patients who filled 2 or more opioid prescriptions before the injury and those who filled an opioid prescription within 3 months after the injury were, respectively, 11.4 and 3 times more likely to use opioids 1 year after the injury compared with those who did not fill opioid prescriptions. Conclusions: These results highlight that elderly trauma patients are at risk of long-term opioid use, especially if they had preinjury or early postinjury opioid consumption.