Standardizing Pain Assessment Documentation in Non-Verbal ICU Patients: A Quality Improvement Study

Abstract

Background: Pain is recognized as the fifth vital sign and must be assessed routinely, including in non-verbal ICU patients unable to self-report due to intubation, sedation, or neurological conditions. Baseline audits at WDGH revealed inconsistent documentation practices, lack of standard assessment tools, and delayed reassessment following analgesia administration. Such gaps place patients at risk of unrecognized and unmanaged pain, jeopardizing both safety and care quality.

Objectives: To standardize the use of validated behavioral pain assessment tools (CPOT/BPS) and achieve ≥95% compliance in pain documentation among non-verbal ICU patients within three months.

Methods: A quasi-experimental pre–post intervention study was conducted in the ICU from July–September 2025. Interventions included staff training, introduction of standardized checklists, bedside visual aids, revision of hourly rounding forms, and continuous audits with feedback. Data were collected using structured audit tools, and compliance trends were analyzed descriptively.

Results: Pain documentation compliance improved significantly from 70% (June baseline) to 98% (September post-implementation). Nurse competency scores increased from 60% to 100%, and timely reassessment after analgesia improved from 65% to 96%. All indicators exceeded project targets.

Conclusion: Standardizing behavioral pain assessments through CPOT/BPS, combined with staff training and ongoing monitoring, resulted in substantial and sustained improvement in documentation compliance. Integration of structured checklists and visual aids supported workflow efficiency and enhanced patient comfort outcomes.