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Using the Model for Improvement to implement the Critical-Care Pain Observation Tool in an adult intensive care unit
  1. Mairi Mascarenhas1,
  2. Michelle Beattie2,
  3. Michelle Roxburgh2,
  4. John MacKintosh3,
  5. Noreen Clarke1,
  6. Devjit Srivastava4
  1. 1Intensive Care Unit, Raigmore Hospital, Inverness, UK
  2. 2Department of Nursing, University of the Highlands and Islands, Inverness, UK
  3. 3Quality Improvement - Patient Safety, Raigmore Hospital, Inverness, UK, UK
  4. 4Department of Anaesthesia and Pain, Raigmore Hospital, Inverness, UK
  1. Correspondence to Ms Mairi Mascarenhas, Intensive Care Unit, Raigmore Hospital, NHS Highland; mairi.mascarenhas{at}


Managing pain is challenging in the intensive care unit (ICU) as often patients are unable to self-report due to the effects of sedation required for mechanical ventilation. Minimal sedative use and the utilisation of analgesia-first approaches are advocated as best practice to reduce unwanted effects of oversedation and poorly managed pain. Despite evidence-based recommendations, behavioural pain assessment tools are not readily implemented in many critical care units. A local telephone audit conducted in April 2017 found that only 30% of Scottish ICUs are using these validated pain instruments. The intensive care unit (ICU) at Raigmore Hospital, NHS Highland, initiated a quality improvement (QI) project using the Model for Improvement (MFI) to implement an analgesia-first approach utilising a validated and reliable behavioural pain assessment tool, namely the Critical-Care Pain Observation Tool (CPOT). Over a six-month period, the project deployed QI tools and techniques to test and implement the CPOT. The process measures related to (i) the nursing staff’s reliability to assess and document pain scores at least every four hours and (ii) to treat behavioural signs of pain or CPOT scores ≥ 3 with a rescue bolus of opioid analgesia. The findings from this project confirm that the observed trends in both process measures had reduced over time. Four hourly assessments of pain had increased to 89% and the treatment of CPOT scores ≥3 had increased to 100%.

  • quality improvement
  • pain
  • Critical Care
  • Control charts/run charts
  • quality measurement

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  • Contributors MM: designed and conducted all stages of the project; drafted the manuscript. MB and MR: supervised the project and advised on methods. JM: provided data expertise and devised run charts. NC: conducted the telephone audit. DS: provided expertise and advice on the improvement methods.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Ethics approval This work met criteria for operational service improvement work exempt from research ethical review

  • Provenance and peer review Not commissioned; externally peer reviewed.

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