Validation of the COMFORT Behavior Scale and the FLACC Scale for pain assessment in Chinese children after cardiac surgery

School of Nursing, Tianjin Medical University, Tianjin, China.
Pain management nursing: official journal of the American Society of Pain Management Nurses (Impact Factor: 1.53). 03/2012; 13(1):18-26. DOI: 10.1016/j.pmn.2010.07.002
Source: PubMed


Appropriate pain assessment plays a key role in understanding the pain status of critically ill children. However, the utility of the face, legs, activity, cry, consolability (FLACC) scale and the COMFORT Behavior (COMFORT-B) scale have not been extensively explored for children after cardiac surgery in China. A repeated-observation study was conducted to evaluate the concurrent validity and the sensitivity and specificity of the COMFORT-B and FLACC scales for pain assessment after cardiac surgery in 0-7-year-old patients. Patients were assessed with the observational visual analog scale (VASobs), FLACC scale, and COMFORT-B scale simultaneously at 18 fixed time periods for 3 days. Correlations among pain assessments were computed to calculate concurrent validity. Receiver operating characteristic curve analyses identified the FLACC and COMFORT-B scores that could best discriminate pain and no pain based on the VASobs. Multiple regression analyses were performed with FLACC and COMFORT-B pain scores as dependent variables and disease-related treatment characteristics as predictor variables for conducting the analysis. A total of 170 children (98 boys and 72 girls) were included. Significantly positive correlations, ranging from 0.31 to 0.86, were found among the COMFORT-B, FLACC, and VASobs pain assessment instruments. The COMFORT-B and the FLACC scores for children assessed to be in pain (i.e., VASobs ≥4), were significantly higher than scores for children not in pain (VASobs <4). COMFORT-B showed good sensitivity (86%) and specificity (83%) with a cutoff point of 13. FLACC showed excellent sensitivity (98%) and good specificity (88%) for a cutoff point of 2. The COMFORT-B and FLACC scales seem to be useful tools in pain assessment for Chinese children at postcardiac surgery stages, but the study identified that this group of children demonstrated a lower cutoff point for pain than originally set for these two instruments.

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    • "COMFORT-B (Bai et al., 2012; Jia, 2012) POCIS (Jia, 2012) Asian Version of Oucher (Yeh, 2005) NFCS (Chen et al., 2012) PASPI (Liaw et al., 2011) "
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    ABSTRACT: Systematic pain assessment using reliable and valid pain scales is the foundation for optimal pain management in children. To evaluate the available scales for pain assessment in Chinese children, we systematically evaluated the psychometric properties of pain measurements used in Chinese children. We searched Chinese- and English-language databases from their inception to September 2013. Studies were eligible for inclusion if the psychometric properties of pain measures were examined in Chinese children (aged 0–18 years). Two bilingual reviewers independently evaluated the psychometric properties of the identified pain scales by a revised 11-item coding system. In all, 6 studies involving 775 participants were included in this review with six pain scales examined, including the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale, COMFORT-Behavior Scale, Asian Version of Oucher Scale, Pain Observation Scale for Young Children (POCIS), Neonatal Facial Coding System (NFCS) and Pain Assessment Scale for Preterm Infants (PASPI). The FLACC, COMFORT-Behavior Scale, and PASPI had very good psychometric qualities when administered in Chinese children; the Asian Version of Oucher Scale and POCIS showed acceptable to good psychometric qualities; and the NFCS had unacceptable psychometric qualities. Further psychometric testing of these observational measures and self-report pain scales in particular are needed among Chinese children of various age groups and in different pain situations.
    Full-text · Article · Dec 2014 · Pain management nursing: official journal of the American Society of Pain Management Nurses
    • "In addition, level of sedation (Carnevale and Razack, 2002; Ista et al., 2005) measured with this scale was found to be moderately to highly correlated with several other pain scales (van Dijk et al., 2000; Johansson and Kokinsky, 2009; Bai et al., 2010; de Jong et al., 2010). The COMFORT-B scale gained ground as a reliable pain assessment instrument with excellent face validity, i.e., from China to the United States (Bai et al., 2010; Franck et al., 2011). A scale's external validity should be established by psychometric evaluation in different populations and settings across time (Carnevale and Razack, 2002; Ista et al., 2005; Bear and Ward-Smith, 2006; Caljouw et al., 2007; Gelinas et al., 2008). "
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    ABSTRACT: Background The COMFORT behaviour scale (COMFORT-B scale) is widely used in paediatric intensive care units to assess young children's pain and distress. It is also used to assess the impact of treatment interventions, but little is known on the scale's sensitivity to detect changes between before and after measurements following an intervention. This study explored the sensitivity to change of the COMFORT-B scale.MethodsCOMFORT-B scores, originally and prospectively collected as part of standard care, were retrieved from the digital patient data management system. We analysed scores obtained in 747 paired observations, i.e., before and after a pharmacological intervention in 180 paediatric intensive care patients between September 2009 and September 2010.ResultsThe mean scores before and after an intervention were 20.0 [standard deviation (SD) 3.7] and 14.1 (SD 4.7), respectively. Multilevel regression analysis showed a 6-point mean decline after an intervention (p < 0.0001). The magnitude of this decline was not statistically significantly related to number and type of interventions or time between assessments. In almost three-quarters of cases (74%), the COMFORT-B score dropped to below 17 after a pharmacological intervention, indicating good responsiveness.Conclusions This is the first study demonstrating that the COMFORT-B scale detects treatment-related changes in pain or distress intensity. This implies that COMFORT-B assessments can effectively guide analgesic and sedation treatment in critically ill children.
    No preview · Article · Aug 2014 · European journal of pain (London, England)
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    • "The COMFORT - B also showed moderate concurrent validity ( 0AE31 – 0AE51 ) , good sensitivity ( 86% ) and specificity ( 83% ) for pain detection in Chinese children after cardiac surgery ( Bai et al . 2012 ) ."
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    ABSTRACT: Aims and objectives. This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background. Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under-implemented for children after major surgery. Design. Repeated observational design. Methods. This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time-points for three consecutive postoperative days. Results. The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD-0) to the 2nd postoperative day (POD-2) with the lowest score on POD-2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD-0 to POD-2 with the highest score on POD-2. The rate of over-sedation was 50·3% with <1% under-sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72). Conclusions. Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over-sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population. Relevance to clinical practice. The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children’s pain and sedation levels.
    Full-text · Article · Sep 2012 · Journal of Clinical Nursing
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