• Wayne Varndell, Margaret Fry, and Doug Elliott.
• Prince of Wales Hospital Emergency Department, Randwick, NSW, Australia.
• J Clin Nurs. 2017 Jan 1; 26 (1-2): 7-32.

Aim And ObjectiveTo examine the psychometric properties and suitability of the available observational pain instruments for potential use with nonverbal critically ill adult patients in the emergency department.BackgroundIn the emergency department, assessing pain in critically ill patients is challenging, especially those unable to communicate the presence of pain. Critically ill patients are commonly unable to verbally communicate pain due to altered oral communication (e.g. endotracheal intubation) and/or diminished consciousness (e.g. sedation, delirium), placing them at great risk of inadequate pain management. Over half of intensive care critically ill intubated patients experience moderate-to-severe pain whilst intubated and mechanically ventilated.DesignSystematic review.Data SourcesThe CINAHL, EMBASE, MEDLINE, ProQuest databases, and the Cochrane Library and the National Institute of Clinical Excellence were also searched from their date of inception to April 2016, with no language restrictions applied.Review MethodStudies were identified using predetermined inclusion criteria. Data were extracted and summarised and underwent evaluation using published classification of psychometric tests for consistency of interpretation.ResultsTwenty-six studies evaluating five observational pain assessment instruments that had been used with critically ill intubated patients were identified. All five instruments included behavioural indicators, with two including physiologic indicators. All five instruments have undergone validity and reliability testing involving nonverbal critically ill intubated patients, three were examined for feasibility, and one instrument underwent sensitivity and specificity testing. None have been tested within the emergency department with nonverbal critically ill intubated adult patients.ConclusionThe use of an appropriate and valid observational pain assessment instrument is fundamental to detecting and optimising pain management in nonverbal critically ill intubated patients in the emergency department. Of the observational pain assessment instruments reviewed, the Critical-Care Pain Observation Tool was identified as most appropriate for testing in a prospective trial in an emergency department setting.© 2016 John Wiley & Sons Ltd.

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