How we do pain assessment: Critical-Care Pain Observation Tool


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What is the Critical-Care Pain Observation Tool (CPOT)?

The CPOT is a behavioural assement pain scale. The CPOT includes evaluation of four different behaviours (facial expressions, body movements, muscle tension, and compliance with the ventilator for mechanically ventilated patients or vocalisation for non-intubated patients) rated on a scale of zero to two with a total score ranging from 0 to 8. The CPOT is feasible, easy to complete, and simple to understand. The full itemised CPOT, descriptions of behaviours and directives for use are available here.

When should we use CPOT?

The gold standard for the evaluation of pain is still patient self-report. When this is not possible, due to sedation, intubation/mechanical ventilation or delirium, the CPOT should be used. In my unit we have chosen CPOT due to a clinical governance group consensus that the supporting literature for ICU behavioural pain scales demonstrates that CPOT has been validated in patient groups that are most similar to our ICU case-mix.

Why do we need another assessment tool?

The addition of a pain assessment tool specifically validated in both mechanically ventilated and delirious ICU patients, allows us to deliver more objectively targeted pain relief and achieve a greater balance between sedation and analgesia. It also allows us to more reproducibly assess the efficacy of our pain relief interventions, both pharmacological and non-pharmacological. Currently available options for pain assessment of the non-speaking or delirious patient are highly subjective and therefore difficult to reproduce from one clinician to the next. It is difficult to determine whether this predisposes patients to excessive or inadequate analgesia.

In combination with our use of the Richmond Agitation-Sedation Scale (RASS) to set targets for sedation choice, CAM-ICU Delirium assessment to screen for the presence of delirium, and the careful selection of sedative and analgesic agents (see ICUdelirium.org protocol for example), we are aiming to reduce the rate of ICU associated delirium and potentially reduce the number of days patients require mechanical ventilation. These practices align with the recommendations made in the Society for Critical Care Medicine Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit.

How can you quickly and easily calculate the CPOT?

In my ICU we have a CPOT calculation and assessment guide in our clinical information system. There is also a great website that provides a huge number of medical scoring calculators, MDCalc. They also have a free App. The MDCalc CPOT calculator is available here.

Watch the video below for an overview and examples of the CPOT assessment

Where can I find more resources for best practice in ICU sedation, pain and delirium management?