Impact of implementing the critical-care pain observation tool in the adult intensive care unit : A nonrandomised stepped-wedge trial

Journal article

Alotni, Majid A., Sim, Jenny, Chu, Ginger, Guilhermino, Michelle, Barker, Daniel, Szwec, Stuart and Fernandez, Ritin. (2025). Impact of implementing the critical-care pain observation tool in the adult intensive care unit : A nonrandomised stepped-wedge trial. Australian Critical Care. 38(2), p. Article 101129. https://doi.org/10.1016/j.aucc.2024.09.014
AuthorsAlotni, Majid A., Sim, Jenny, Chu, Ginger, Guilhermino, Michelle, Barker, Daniel, Szwec, Stuart and Fernandez, Ritin
Abstract

Background
Approximately 70% of patients in intensive care units (ICUs) experience untreated pain, often due to severe patient conditions and communication barriers.
Aim: The aim of this study was to implement the Critical-Care Pain Observation Tool (CPOT) to improve pain assessment in patients unable to self-report pain in the ICU.

Method
A stepped-wedge trial was conducted in six adult ICUs in Saudi Arabia between February and June 2022. The sequential transition of ICU clusters occurred in February 2022, from control to intervention, until all ICUs were exposed to the intervention. The primary outcome was the number of pain assessments, whereas the secondary outcomes were reassessments. Other outcomes were length of stay, mechanical ventilation duration, and administered doses of sedatives and analgesic agents. Statistical analyses were performed using the Statistical Analysis Software v9.4.

Results
A total of 725 patients unable to self-report pain were included; 65% (n = 469) were male with an average age of 55 years. Implementing CPOT showed a significant increase in the number of pain assessments (rate ratio: 1.77, 95% confidence interval: 1.45, 2.16, p < 0.001) and reassessments (rate ratio: 13.99, 95% confidence interval: 8.14, 24.02, p < 0.001) between intervention and control conditions. There was no significant effect on the ICU length of stay, mechanical ventilation duration, and the amount of sedation (midazolam, propofol, and ketamine) and analgesia (fentanyl) administered.

Conclusion
The study indicates that the implementation of the CPOT increased the frequency of pain assessment and reassessment. However, the impact on patient outcomes remains inconclusive. Further investigations focussing on CPOT as the primary pain scale are necessary to determine its holistic impact on patient outcomes over the long term.

Trial registration
NCT05488834.

Clinical trial registration number
This study was registered with the U.S. National Library of Medicine (ClinicalTrial.gov, NCT05488834).

Keywordsnurse; pain; ICU; intensive care unit; stepped wedge; CPOT; adult
Year2025
JournalAustralian Critical Care
Journal citation38 (2), p. Article 101129
PublisherElsevier Inc.
ISSN1036-7314
Digital Object Identifier (DOI)https://doi.org/10.1016/j.aucc.2024.09.014
PubMed ID39489653
Scopus EID2-s2.0-85208036210
Open accessPublished as ‘gold’ (paid) open access
Page range1-7
FunderGovernment of Saudi Arabia
Publisher's version
License
File Access Level
Open
Output statusPublished
Publication dates
Online16 Jan 2025
Publication process dates
Accepted22 Sep 2024
Deposited08 May 2025
Additional information

© 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Permalink -

https://acuresearchbank.acu.edu.au/item/91vx9/impact-of-implementing-the-critical-care-pain-observation-tool-in-the-adult-intensive-care-unit-a-nonrandomised-stepped-wedge-trial

Log in to edit

Download files

Publisher's version
OA_Alotni_2025_Impact_of_implementing_the_critical_care.pdf
License: CC BY 4.0
File access level: Open

  • 33
    total views
  • 5
    total downloads
  • 33
    views this month
  • 5
    downloads this month
These values are for the period from 19th October 2020, when this repository was created.

Export as

Related outputs

Preparedness for practice of health professionals in Papua New Guinea : A cross-sectional survey of nurses and community health workers
Kililo, Mary, Dopsie, Julie, Passingan, Sulpain, Kep, Julie, Joseph, Nina, Kitau, Russel, Roroi, Mary, Rossiter, Chris, Sim, Jenny, Brown, Di, Havery, Caroline, Moloney, Ali and Rumsey, Michele. (2024). Preparedness for practice of health professionals in Papua New Guinea : A cross-sectional survey of nurses and community health workers. Pacific Journal of Health. 7(1), pp. 1-25. https://doi.org/10.56031/2576-215X.1063
Pressure injury prevalence in critical care settings : An observational pre-post intervention study
Alshahrani, Bassam, Middleton, Rebekkah, Rolls, Kaye and Sim, Jenny. (2024). Pressure injury prevalence in critical care settings : An observational pre-post intervention study. Nursing Open. 11(2), p. Article e2110. https://doi.org/10.1002/nop2.2110
Air purifiers and acute respiratory infections in residential aged care : A randomized clinical trial
Thottiyil Sultanmuhammed Abdul Khadar, Bismi, Sim, Jenny, McDonald, Vanessa M., McDonagh, Julee, Clapham, Matthew and Mitchell, Brett G.. (2024). Air purifiers and acute respiratory infections in residential aged care : A randomized clinical trial. JAMA Network Open. 7(11), pp. 1-11. https://doi.org/10.1001/jamanetworkopen.2024.43769
The pressure injury prevalence and practice improvements (PIPPI) study : A multiple methods evaluation of pressure injury prevention practices in an acute-care hospital
Sim, Jenny, Wilson, Val and Tuqiri, Karen. (2024). The pressure injury prevalence and practice improvements (PIPPI) study : A multiple methods evaluation of pressure injury prevention practices in an acute-care hospital. International Wound Journal. 21(10), p. Article e70050. https://doi.org/10.1111/iwj.70050
Oral care practices and hospital-acquired pneumonia prevention : A national survey of Australian nurses
Tehan, Peta Ellen, Browne, Katrina, Matterson, Georgia, Cheng, Allen C., Dawson, Sonja, Graves, Nicholas, Johnson, Douglas, Kiernan, Martin, Madhuvu, Auxillia, Marshall, Caroline, McDonagh, Julee, Northcote, Maria, O'Connor, Jayne, Orr, Liz, Rawson, Helen, Russo, Philip, Sim, Jenny, Stewardson, Andrew J., Wallace, Janet, ... Mitchell, Brett G.. (2024). Oral care practices and hospital-acquired pneumonia prevention : A national survey of Australian nurses. Infection, Disease and Health. 29(4), pp. 212-217. https://doi.org/10.1016/j.idh.2024.04.006
Structured interactions between nurses and patients through intentional rounding : A scoping review
Al-Anati, Abdelrahman, Molloy, Luke, Sim, Jenny, Halcomb, Elizabeth and Frost, Shaun. (2024). Structured interactions between nurses and patients through intentional rounding : A scoping review. International Nursing Review. 71(3), pp. 492-503. https://doi.org/10.1111/inr.12984
Malaria vaccine efficacy, safety, and community perception in Africa : a scoping review of recent empirical studies
Chutiyami, Muhammad, Saravanakumar, Priya, Bello, Umar Muhammad, Salihu, Dauda, Adeleye, Khadijat, Kolo, Mustapha Adam, Dawa, Kabiru Kasamu, Hamina, Dathini, Bhandari, Pratibha, Sulaiman, Surajo Kamilu and Sim, Jenny. (2024). Malaria vaccine efficacy, safety, and community perception in Africa : a scoping review of recent empirical studies. Infection: journal of infectious disease. pp. 1-22. https://doi.org/10.1007/s15010-024-02196-y
Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality : A multi-source quantitative study
Al-ghraiybah, Tamer, Lago, Luise, Fernandez, Ritin and Sim, Jenny. (2024). Effects of the nursing practice environment, nurse staffing, patient surveillance and escalation of care on patient mortality : A multi-source quantitative study. International Journal of Nursing Studies. 156, pp. 1-9. https://doi.org/10.1016/j.ijnurstu.2024.104777
The effect of pressure injury prevention care bundles on pressure injuries in hospital patients : A complex intervention systematic review and meta-analysis
Chaboyer, Wendy, Latimer, Sharon, Priyadarshani, Udeshika, Harbeck, Emma, Patton, Declan, Sim, Jenny, Moore, Zena, Deakin, Jodie, Carlini, Joan Julie, Lovegrove, Josephine, Jahandideh, Sepideh and Gillespie, Brigid. (2024). The effect of pressure injury prevention care bundles on pressure injuries in hospital patients : A complex intervention systematic review and meta-analysis. International Journal of Nursing Studies. 155, pp. 1-14. https://doi.org/10.1016/j.ijnurstu.2024.104768
Risk of organism acquisition from prior room occupants : An updated systematic review
Mitchell, Brett G., McDonagh, Julee, Dancer, Stephanie J., Ford, Sindi, Sim, Jenny, Thottiyil Sultanmuhammed Abdul Khadar, Bismi, Russo, Philip L., Maillard, Jean-Yves, Rawson, Helen, Browne, Katrina and Kiernan, Martin. (2023). Risk of organism acquisition from prior room occupants : An updated systematic review. Infection, Disease and Health. 28(4), pp. 290-297. https://doi.org/10.1016/j.idh.2023.06.001
Barriers to nurse-led pain management for adult patients in intensive care units : An integrative review
Alotni, Majid, Guilhermino, Michelle, Duff, Jed and Sim, Jenny. (2023). Barriers to nurse-led pain management for adult patients in intensive care units : An integrative review. Australian Critical Care. 36(5), pp. 855-862. https://doi.org/10.1016/j.aucc.2022.09.002
Healthcare-associated infections in adult intensive care units : A multisource study examining nurses’ safety attitudes, quality of care, missed care, and nurse staffing
Alanazi, Faisal Khalaf, Lapkin, Samuel, Molloy, Luke and Sim, Jenny. (2023). Healthcare-associated infections in adult intensive care units : A multisource study examining nurses’ safety attitudes, quality of care, missed care, and nurse staffing. Intensive and Critical Care Nursing. 78, p. Article 103480. https://doi.org/10.1016/j.iccn.2023.103480
Safety culture, quality of care, missed care, nurse staffing and their impact on pressure injuries : A cross-sectional multi-source study
Alanazi, Faisal Khalaf, Lapkin, Samuel, Molloy, Luke and Sim, Jenny. (2023). Safety culture, quality of care, missed care, nurse staffing and their impact on pressure injuries : A cross-sectional multi-source study. International Journal of Nursing Studies Advances. 5, p. Article 100125. https://doi.org/10.1016/j.ijnsa.2023.100125
The impact of safety culture, quality of care, missed care and nurse staffing on patient falls : A multisource association study
Alanazi, Faisal Khalaf, Lapkin, Samuel, Molloy, Luke and Sim, Jenny. (2023). The impact of safety culture, quality of care, missed care and nurse staffing on patient falls : A multisource association study. Journal of Clinical Nursing. 32(19-20), pp. 7260-7272. https://doi.org/10.1111/jocn.16792
Registered nurses' beliefs about end-of-life care : A mixed method study
Alshammari, Fares, Sim, Jenny, McErlean, Gemma and Lapkin, Samuel. (2023). Registered nurses' beliefs about end-of-life care : A mixed method study. Nursing Open. 10(12), pp. 7796-7810. https://doi.org/10.1002/nop2.2027
Creating respectful workplaces for nurses in regional acute care settings : A quasi-experimental design
Hawkins, Natasha, Jeong, Sarah Yeun-Sim, Smith, Tony, Sim, Jenny and Clapham, Matthew. (2023). Creating respectful workplaces for nurses in regional acute care settings : A quasi-experimental design. Nursing Open. 10(1), pp. 78-89. https://doi.org/10.1002/nop2.1280
Critical care nurses’ knowledge and attitudes toward pressure injury prevention : A pre and post intervention study
Alshahrani, Bassam, Middleton, Rebekkah, Rolls, Kaye and Sim, Jenny. (2023). Critical care nurses’ knowledge and attitudes toward pressure injury prevention : A pre and post intervention study. Intensive and Critical Care Nursing. 79, p. Article 103528. https://doi.org/10.1016/j.iccn.2023.103528
A conflicted tribe under pressure : A qualitative study of negative workplace behaviour in nursing
Hawkins, Natasha, Jeong, Sarah Yeun-Sim, Smith, Tony and Sim, Jenny. (2023). A conflicted tribe under pressure : A qualitative study of negative workplace behaviour in nursing. Journal of Advanced Nursing. 79(2), pp. 711-726. https://doi.org/10.1111/jan.15491
Job satisfaction among small rural hospital nurses : A cross-sectional study
Smith, Sarah, Lapkin, Samuel, Halcomb, Elizabeth and Sim, Jenny. (2023). Job satisfaction among small rural hospital nurses : A cross-sectional study. Journal of Nursing Scholarship. 55(1), pp. 378-387. https://doi.org/10.1111/jnu.12800
Registered nurses' attitudes towards end-of-life care : A sequential explanatory mixed method study
Alshammari, Fares, Sim, Jenny, Lapkin, Samuel and McErlean, Gemma. (2023). Registered nurses' attitudes towards end-of-life care : A sequential explanatory mixed method study. Journal of Clinical Nursing. 32(19-20), pp. 7162-7174. https://doi.org/10.1111/jocn.16787
Bringing it all together : Applying the research process
Sim, Jenny, Harris, Ruth and Minton, Claire. (2023). Bringing it all together : Applying the research process. In Navigating the maze of research : Enhancing nursing and midwifery practice pp. 189-198 Elsevier Australia.
Air purifiers for reducing the incidence of acute respiratory infections in Australian residential aged care facilities : A study protocol for a randomised control trial
Thottiyil Sultanmuhammed Abdul Khadar, Bismi, Sim, Jenny, McDonagh, Julee, McDonald, Vanessa M. and Mitchell, Brett G.. (2023). Air purifiers for reducing the incidence of acute respiratory infections in Australian residential aged care facilities : A study protocol for a randomised control trial. Infection, Disease and Health. 28(3), pp. 239-245. https://doi.org/10.1016/j.idh.2023.05.006
Registered nurses’ knowledge, attitudes and beliefs about end-of-life care in non-specialist palliative care settings : A mixed studies review
Alshammari, Fares, Sim, Jenny, Lapkin, Samuel and Stephens, Moira. (2022). Registered nurses’ knowledge, attitudes and beliefs about end-of-life care in non-specialist palliative care settings : A mixed studies review. Nurse Education in Practice. 59, p. Article 103294. https://doi.org/10.1016/j.nepr.2022.103294
Patients' perspectives of healthcare-associated infection : ‘You don't know what impacts it will have on your life’
Mitchell, B. G., Northcote, M., Rickett, C., Russo, P. L., Amin, M., De Sousa, F., Pearce, K., Sim, J. and Curryer, C.. (2022). Patients' perspectives of healthcare-associated infection : ‘You don't know what impacts it will have on your life’. Journal of Hospital Infection. 126, pp. 93-102. https://doi.org/10.1016/j.jhin.2022.04.014
Development and validation of the World Health Organization disability Assessment Schedule 2.0 (WHODAS 2.0) Indonesian version in stroke survivors
Yuliana, Sri, Muslih, Muhammad, Sim, Jenny, Vidyanti, Amelia Nur, Brahmadhi, Ageng and Tsai, Hsiu Ting. (2022). Development and validation of the World Health Organization disability Assessment Schedule 2.0 (WHODAS 2.0) Indonesian version in stroke survivors. Disability and Rehabilitation. 44(16), pp. 4459-4466. https://doi.org/10.1080/09638288.2021.1900413
Nurses’ perceptions of the practice environment in small rural hospitals
Smith, Sarah, Halcomb, Elizabeth, Sim, Jenny and Lapkin, Samuel. (2021). Nurses’ perceptions of the practice environment in small rural hospitals. Collegian. 28(5), pp. 472-481. https://doi.org/10.1016/j.colegn.2020.11.003
How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study
Cutler, Natalie Ann, Halcomb, Elizabeth, Sim, Jenny, Stephens, Moira and Moxham, Lorna. (2021). How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study. Journal of Clinical Nursing. 30(5-6), pp. 765-772. https://doi.org/10.1111/jocn.15614
Systematic review of pressure injury prevalence in Australian and New Zealand hospitals
Rodgers, Kyrie, Sim, Jenny and Clifton, Ross. (2021). Systematic review of pressure injury prevalence in Australian and New Zealand hospitals. Collegian. 28(3), pp. 310-323. https://doi.org/10.1016/j.colegn.2020.08.012
Integrative review of the experiences of registered nurses who support breastfeeding women
Prokop, Nicole, Meedya, Shahla and Sim, Jenny. (2021). Integrative review of the experiences of registered nurses who support breastfeeding women. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 50(3), pp. 266-274. https://doi.org/10.1016/j.jogn.2021.02.003
Understanding how personhood impacts consumers’ feelings of safety in acute mental health units : A qualitative study
Cutler, Natalie Ann, Sim, Jenny, Halcomb, Elizabeth, Stephens, Moira and Moxham, Lorna. (2021). Understanding how personhood impacts consumers’ feelings of safety in acute mental health units : A qualitative study. International Journal of Mental Health Nursing. 30(2), pp. 479-486. https://doi.org/10.1111/inm.12809
A qualitative descriptive study of new graduate nurses’ experiences supporting breastfeeding women in neonatal settings
Prokop, Nicole, Sim, Jenny and Meedya, Shahla. (2021). A qualitative descriptive study of new graduate nurses’ experiences supporting breastfeeding women in neonatal settings. Nurse Education in Practice. 55, p. Article 103172. https://doi.org/10.1016/j.nepr.2021.103172
Incidence and risk factors for new-onset atrial fibrillation following coronary artery bypass grafting : A systematic review and meta-analysis
Higgs, Megan, Sim, Jenny and Traynor, Victoria. (2020). Incidence and risk factors for new-onset atrial fibrillation following coronary artery bypass grafting : A systematic review and meta-analysis. Intensive and Critical Care Nursing. 60, p. Article 102897. https://doi.org/10.1016/j.iccn.2020.102897
Nursing care left undone, practice environment and perceived quality of care in small rural hospitals
Smith, Sarah, Lapkin, Sam, Sim, Jenny and Halcomb, Elizabeth. (2020). Nursing care left undone, practice environment and perceived quality of care in small rural hospitals. Journal of Nursing Management. 28(8), pp. 2166-2173. https://doi.org/10.1111/jonm.12975
Nurses' influence on consumers' experience of safety in acute mental health units : A qualitative study
Cutler, Natalie Ann, Sim, Jenny, Halcomb, Elizabeth, Moxham, Lorna and Stephens, Moira. (2020). Nurses' influence on consumers' experience of safety in acute mental health units : A qualitative study. Journal of Clinical Nursing. 29(21-22), pp. 4379-4386. https://doi.org/10.1111/jocn.15480
Pressure injury prevalence in Australian & New Zealand hospitals : Systematic review protocol
Rodgers, Kyrie, Sim, Jenny and Clifton, Ross. (2020). Pressure injury prevalence in Australian & New Zealand hospitals : Systematic review protocol. Collegian : The Australian Journal of Nursing Practice, Scholarship and Research. 27(4), pp. 471-475. https://doi.org/10.1016/j.colegn.2019.11.003
Health-related quality of life among adults living with diabetic foot ulcers : A meta-analysis
Khunkaew, Saneh, Fernandez, Ritin and Sim, Jenny. (2019). Health-related quality of life among adults living with diabetic foot ulcers : A meta-analysis. Quality of Life Research. 28(6), pp. 1413-1427. https://doi.org/10.1007/s11136-018-2082-2
A psychometric analysis of the Caring Assessment Tool version V
Sim, Jenny, Lapkin, Samuel, Joyce, Joanne, Gordon, Rob, Kobel, Conrad and Fernandez, Ritin. (2019). A psychometric analysis of the Caring Assessment Tool version V. Nursing Open. 6(3), pp. 1038-1046. https://doi.org/10.1002/nop2.286
Development of a data registry to evaluate the quality and safety of nursing practice
Sim, Jenny, Joyce-McCoach, Joanne, Gordon, Rob and Kobel, Conrad. (2019). Development of a data registry to evaluate the quality and safety of nursing practice. Journal of Advanced Nursing. 75(9), pp. 1877-1888. https://doi.org/10.1111/jan.13967
Demographic and clinical predictors of health-related quality of life among people with type 2 diabetes mellitus living in northern Thailand : A cross-sectional study
Khunkaew, Saneh, Fernandez, Ritin and Sim, Jenny. (2019). Demographic and clinical predictors of health-related quality of life among people with type 2 diabetes mellitus living in northern Thailand : A cross-sectional study. Health and Quality of Life Outcomes. 17(1), p. Article 177. https://doi.org/10.1186/s12955-019-1246-2
Health-related quality of life and self-care management among people with diabetic foot ulcers in Northern Thailand
Khunkaew, Saneh, Fernandez, Ritin and Sim, Jenny. (2019). Health-related quality of life and self-care management among people with diabetic foot ulcers in Northern Thailand. SAGE Open Nursing. 5, pp. 1-10. https://doi.org/10.1177/2377960819825751
The experiences of people in Northern Thailand living with diabetic foot ulcers : A descriptive qualitative study
Khunkaew, Saneh, Tungpunkom, Patraporn, Sim, Jenny and Fernandez, Ritin. (2018). The experiences of people in Northern Thailand living with diabetic foot ulcers : A descriptive qualitative study. Pacific Rim International Journal of Nursing Research. 22(4), pp. 304-318.
Linguistic and psychometric validation of the Thai version of Simplified Diabetes Knowledge Scale : A measure of knowledge of diabetes in a Thai population
Khunkaew, Saneh, Fernandez, Ritin and Sim, Jenny. (2018). Linguistic and psychometric validation of the Thai version of Simplified Diabetes Knowledge Scale : A measure of knowledge of diabetes in a Thai population. SAGE Open Nursing. 4, pp. 1-8. https://doi.org/10.1177/2377960818791849
Australian general practice nurse's knowledge, attitudes and practices regarding influenza vaccination : A cross-sectional survey
Smith, Sarah, Sim, Jenny and Halcomb, Elizabeth. (2016). Australian general practice nurse's knowledge, attitudes and practices regarding influenza vaccination : A cross-sectional survey. Journal of Clinical Nursing. 25(17-18), pp. 2502-2510. https://doi.org/10.1111/jocn.13287