CPOT Pain Scale Calculator

CPOT scoring system explained

The CPOT was designed from retrospective reviews of common pain characteristics and vetted by ICU nurses and physicians.

The scale is based on two preliminary studies with expert selected variables and prior research of behavioral indicators for pain.

The CPOT assesses pain based on facial expressions, muscle tension and movement as well as compliance with ventilated breaths for intubated patients or vocalized pain for non-intubated patients, as described in the table below:

The patient must initially be observed at rest for 60 seconds and the scale applied to the findings, to obtain a baseline result. Changes in patient’s behaviour to pain may be observed during nociceptive procedures, such as wound care or turning.

• CPOT scores of 2 or less indicate that there is likely minimal to no pain present. Patient should be re-evaluated regularly.
• CPOT scores of more than 2 indicate an unacceptable level of pain. Management with alternative analgesia and sedation is required. Patient should be evaluated before and at the peak effect of medication to check for treatment efficacy.

CPOT scores were higher when conscious and intubated than when unconscious or extubated. This may be due to endotracheal tube discomfort or positive pressure causing incision site pain.

This straightforward pain assessment method has shown good interrater reliability in multiple studies and high sensitivity when pain is present.

Appropriate pain management may result in fewer days on mechanical ventilation and a decreased rate of infections.

About the original study

Gélinas et al. set out to design and validate a pain assessment tool to aid in the management of pain in critical care settings, especially in intubated, non-verbal patients. The study described pain indicators commonly used for pain assessment, pain relief options of treatment and pain indicators used in the reassessment of pain management effectiveness.

Data from 2 health centres has been analysed with pain indicators being divided into a category of patient self-report of pain and a category of observable, physiological and behavioral indicators.

From 183 pain episodes in 52 patients under mechanical ventilation, observable indicators were recorded 97% of the time whilst patient pain self-report was recorded only 29% of the time. The original study also found that pain documentation in medical files was inadequate and may contribute to the difficulties in pain assessment.

Validation studies

Several validation studies have focused on confirming the properties of the CPOT and its validity.

A study by the same author as that of the original study, on a total of 105 cardiac surgery patients in ICU, found that the Critical Care Pain Observation Tool could be accurately used to assess the effect of pain management intervention.

A study by Buttes et al. set out to examine the reliability and validity of the CPOT in a general population of critically ill adult patients. Pain was evaluated via CPOT, FLACC scale and Pain Intensity Numeric Rating Scale, at three moments (prerepositioning, during repositioning, and postrepositioning). Interrater reliability was supported by strong intraclass correlations (ranging from 0.74 to 0.91). Discriminant validity was supported by significantly higher scores during repositioning (mean, 1.85) versus at rest (pre mean, 0.60; post mean, 0.65).

A further study by Gélinas et al. evaluated the additional psychometric qualities (sensitivity and specificity) of the Critical-Care Pain Observation Tool. The patients' self-reports of pain were obtained while intubated and extubated, during the nociceptive exposure. The CPOT had a sensitivity of 86%, a specificity of 78%, a positive likelihood ratio (LR(+)) of 3.87 (1.63-9.23), and a negative LR (LR(-)) of 0.18 (0.09-0.33). The CPOT adequately classified most severe pain cases.

Rijkenberg et. al. compared the discriminant validation and reliability of the CPOT and the Behavioral Pain Scale (BPS), simultaneously, in mechanically ventilated patients on a mixed-adult ICU. The interrater reliability of the BPS and CPOT scores showed a fair to good agreement (0.74 and 0.75, respectively). Both methods report scores increased with a presumed painful stimulus.

The CPOT is most certainly a very useful behavioural pain scale in assessing the presence of pain in critically ill patients and provides a standardised way of describing pain in patient files.

References

Original reference

Gélinas C, Fortier M, Viens C, Fillion L, Puntillo KA. Pain assessment and management in critically ill intubated patients: a retrospective study. Am J Crit Care. 2004; 13:126-135.

Validation

Gelinas C, Fillion L, Puntillo K, Viens C, Fortier M. Validation of the Critical-Care Pain Observation Tool in adult patients. Am J Crit Care. 2006;15:420-427.

Buttes P, Keal G, Cronin SN, Stocks L, Stout C. Validation of the critical-care pain observation tool in adult critically ill patients. Dimens Crit Care Nurs. 2014 Mar-Apr;33(2):78-81.

Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage. 2009; 37(1):58-67.

Rijkenberg S, et. al. Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain Scale versus Critical-Care Pain Observation Tool. J Crit Care. 2015; 30(1):167-72.

Other references

Stites M. Observational pain scales in critically ill adults. Crit Care Nurse. 2013; 33(3):68-78.

Gélinas C. Nurses' evaluations of the feasibility and the clinical utility of the Critical-Care Pain Observation Tool. Pain Manag Nurs. 2010; 11(2):115-25.