Implementation of a Behavioral Pain Scale for Traumatic Brain Injured Patients

Abstract

Problem & Purpose: Each year, 1.7 million Americans suffer traumatic brain injuries (TBI) with many patients requiring intensive care, resulting in increased pain due to aggressive treatments, frequent neurological exams, and invasive procedures. Patients with TBIs present with atypical pain behaviors (PB) and decreased levels of consciousness that impede effective pain assessments, leading to inadequate pain management and poor outcomes. Pre- and postadministration pain score documentation compliance of a neurotrauma critical care unit (CCU) were below organizational benchmarks, averaging 75% and 56% respectively. Additionally, anecdotal reports from nurses found dissatisfaction with the organization’s current pain scales. Methods: A nurse-driven team, entitled the “Brain Pain Squad,” led a quality improvement (QI) project to implement the Behavioral Pain Scale (BPS) for noncommunicative, critically ill adult patients with TBIs who were mechanically ventilated (MV). Staff education was provided in small groups with hands-on application of the scale. Handouts as well as promotional signage were readily available on the unit. Presentations during staff meetings and weekly email reminders called, “Brain Pain Project Pearls” enhanced education and provided updates. Periodic rewards and recognition events increased staff support throughout operationalization. Data collection included weekly compliance rates of pre- and post-administration pain score documentation as well BPS usage. Usability testing via electronic staff survey occurred following a nine-week implementation period. Results: Staff readily adopted the BPS with an average compliance of 92.04%. Preadministration compliance improved by 4.57% whereas post-administration compliance declined by 6.46%. The overall usability score of the BPS was 86, equating to excellent usability. Conclusion: A nurse-driven team and formal education plan led to the successful implementation of the BPS with minor improvements in pre-administration pain score compliance and a decline in post-administration pain score compliance. Variations in compliance may be due to discrepancies between organizational policy, clinical practice, and data collection methods. Policy changes, additional education, and better functionality of the electronic health record (EHR) may increase compliance further. Critical care units who care for the neurologically impaired should consider instituting the BPS and future QI efforts should focus on the implementation of the BPS for noncommunicative TBI patients who are not intubated.