The Neonatal Pain, Agitation and Sedation Scale
During a 6-month period, all infants admitted to the 45 bed, level III C, neonatal intensive care unit (NICU) at the Johns Hopkins Hospital were evaluated for enrollment in the study. Infants on day of birth and those with limited viability were excluded. The first day of life was potentially confounded by the events surrounding delivery and the natural tendency of infants to sleep more during the first 24 h. Limited viability was determined by the attending physician. If an infant was so critically ill that death appeared inevitable, the severity of illness may have an impaired response to pain or sedation in a way that would not allow extrapolation to the general NICU population.
All infants enrolled in the study had a single evaluation at greater than 1day of age, using the N-PASS by study personnel. A single evaluation was done to allow broad sampling, across a wide range of gestational and chronological ages, varying degrees of severity of illness and to avoid clustering of data around sicker infants with longer lengths of stay. A subjective questionnaire assessing pain, agitation and sedation, and need for pain or sedative therapy was administered to the bedside nurse at the time of the performance of N-PASS. The documented NIPS score closest to the time of the study assessment was recorded. This study was approved by the Johns Hopkins Medicine Institutional Review Board.
The N-PASS is comprised of two measurements, each of which uses five criteria: crying/irritability, behavioral state, facial expression, extremity tone and vital signs. The pain/agitation score is assessed through observation without intervention, with a score range of 0 to 10, with 0 to 2 points available for each criterion. The sedation score is typically assessed for patients receiving sedating medications and requires stimulation, with a score range of 0 to −10, with points of −2 to 0 assigned for each criterion. For this study, all patients were assessed with both segments of the tool in order to evaluate the contribution of clinical factors that may impact the sedation portion of the N-PASS in patients who were not receiving sedating medications, such as neurologic conditions rendering infants, were less responsive than expected.
A questionnaire as shown in Figure 1 was designed to capture a nurse's subjective assessment of pain, agitation and sedation that is often verbally communicated to care providers. Each patient's nurse was asked to assess the level of pain, sedation and agitation of the patient using 6-point Likert scales ranging from 0 (none) to 5 (most affected). They were also asked if they would adjust pain and/or sedating medications by increasing, decreasing or initiating therapy, if the patient was not currently receiving any therapy, and given an opportunity to explain the rationale for their recommendation.
(Enlarge Image)
Figure 1.
Nurses' questionnaire. Key for Likert scale: 0 indicates no evidence of pain, agitation or sedation. 5 indicates severe pain, agitation or sedation.
Infant demographic and medical data were collected and it included gestational age, birth weight, gender, mode of delivery and day of life on which the assessment occurred. Additionally, information about disease states, medications, including narcotics and sedatives, intrauterine drug exposure (IUDE) and types of ventilator support was collected.
Patient characteristics were summarized using frequencies and percents, means and standard deviations or medians and ranges as appropriate. The association of patient characteristics and the nurses' ratings of pain, agitation and sedation with the N-PASS measures were assessed using Spearman rank correlations for ordinal or continuous measures and the Jonckheere-Terpstra test for categorical measures. Partial correlation, controlling for gestational age, day of life, IUDE and ventilation was also used to assess the association of the nurses' ratings with the N-PASS ratings. N-PASS scores and the nurses' recommendation for medication changes were coded as agreeing if the N-PASS score was ≤2 and the nurse recommended a decrease/no change, or if the score was >2 and the nurse recommended an increase; otherwise they were coded as disagreeing. Analyses were performed using SAS version 9.22 (SAS Institute Inc., Cary, NC, USA). All statistical tests were two-sided and significance was set at P<0.05.
Methods
During a 6-month period, all infants admitted to the 45 bed, level III C, neonatal intensive care unit (NICU) at the Johns Hopkins Hospital were evaluated for enrollment in the study. Infants on day of birth and those with limited viability were excluded. The first day of life was potentially confounded by the events surrounding delivery and the natural tendency of infants to sleep more during the first 24 h. Limited viability was determined by the attending physician. If an infant was so critically ill that death appeared inevitable, the severity of illness may have an impaired response to pain or sedation in a way that would not allow extrapolation to the general NICU population.
All infants enrolled in the study had a single evaluation at greater than 1day of age, using the N-PASS by study personnel. A single evaluation was done to allow broad sampling, across a wide range of gestational and chronological ages, varying degrees of severity of illness and to avoid clustering of data around sicker infants with longer lengths of stay. A subjective questionnaire assessing pain, agitation and sedation, and need for pain or sedative therapy was administered to the bedside nurse at the time of the performance of N-PASS. The documented NIPS score closest to the time of the study assessment was recorded. This study was approved by the Johns Hopkins Medicine Institutional Review Board.
The N-PASS is comprised of two measurements, each of which uses five criteria: crying/irritability, behavioral state, facial expression, extremity tone and vital signs. The pain/agitation score is assessed through observation without intervention, with a score range of 0 to 10, with 0 to 2 points available for each criterion. The sedation score is typically assessed for patients receiving sedating medications and requires stimulation, with a score range of 0 to −10, with points of −2 to 0 assigned for each criterion. For this study, all patients were assessed with both segments of the tool in order to evaluate the contribution of clinical factors that may impact the sedation portion of the N-PASS in patients who were not receiving sedating medications, such as neurologic conditions rendering infants, were less responsive than expected.
A questionnaire as shown in Figure 1 was designed to capture a nurse's subjective assessment of pain, agitation and sedation that is often verbally communicated to care providers. Each patient's nurse was asked to assess the level of pain, sedation and agitation of the patient using 6-point Likert scales ranging from 0 (none) to 5 (most affected). They were also asked if they would adjust pain and/or sedating medications by increasing, decreasing or initiating therapy, if the patient was not currently receiving any therapy, and given an opportunity to explain the rationale for their recommendation.
(Enlarge Image)
Figure 1.
Nurses' questionnaire. Key for Likert scale: 0 indicates no evidence of pain, agitation or sedation. 5 indicates severe pain, agitation or sedation.
Infant demographic and medical data were collected and it included gestational age, birth weight, gender, mode of delivery and day of life on which the assessment occurred. Additionally, information about disease states, medications, including narcotics and sedatives, intrauterine drug exposure (IUDE) and types of ventilator support was collected.
Patient characteristics were summarized using frequencies and percents, means and standard deviations or medians and ranges as appropriate. The association of patient characteristics and the nurses' ratings of pain, agitation and sedation with the N-PASS measures were assessed using Spearman rank correlations for ordinal or continuous measures and the Jonckheere-Terpstra test for categorical measures. Partial correlation, controlling for gestational age, day of life, IUDE and ventilation was also used to assess the association of the nurses' ratings with the N-PASS ratings. N-PASS scores and the nurses' recommendation for medication changes were coded as agreeing if the N-PASS score was ≤2 and the nurse recommended a decrease/no change, or if the score was >2 and the nurse recommended an increase; otherwise they were coded as disagreeing. Analyses were performed using SAS version 9.22 (SAS Institute Inc., Cary, NC, USA). All statistical tests were two-sided and significance was set at P<0.05.
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