Special Article: education
Appropriateness of behavioural scales in the monitoring of pain in the critically ill patient unable to self-report
Adecuación de las escalas conductuales en la monitorización del dolor en el paciente crítico incapaz de autoinformar
G. Robleda-Fonta,b,c, C. López-Lópezc,d,e,
, I. Latorre-Marcof,g, J. Pozas-Peñaa,h,i, D. Alonso-Crespoc,j,k, O. Vallés-Fructuosoc,l,m, A. Castanera-Duroc,n,o
Corresponding author
a Campus Docent Sant Joan de Déu, Universidad de Barcelona, Sant Boi de Llobregat, Spain
b Centro Cochrane Iberoamericano, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
c Grupo de Trabajo de Analgesia, Sedación, Contenciones y Delirio de la Sociedad Española de Enfermería Intensiva y Unidades Coronarias (GT-ASCyD-SEEIUC), Spain
d Unidad de Cuidados Intensivos de Trauma y Emergencias, Hospital Universitario 12 de Octubre, Madrid, Spain
e Grupo de Investigación en Cuidados (InveCuid), Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
f Unidad de Cuidados Intensivos, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
g Grupo de Investigación en Enfermería y Cuidados de Salud, Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana, Madrid, Spain
h Unidad de Cuidados Intensivos, Hospital del Mar, Barcelona, Spain
i Grupo de Investigación en Patología Crítica (GREPAC), Instituto de Investigación Hospital del Mar, Barcelona, Spain
j Unidad de Cuidados Intensivos, Hospital Álvaro Cunqueiro, Vigo, Spain
k Grupo de Investigación Traslacional en Cuidados, Hospital Álvaro Cunqueiro, Vigo, Spain
l Unidad de Cuidados Intensivos, Hospital Vall d’Hebrón, Barcelona, Spain
m Coordinadora del Grupo de Trabajo Analgesia, Sedación y Delirium de la Sociedad Catalana de Medicina Intensiva, Barcelona, Spain
n Área del Paciente Crítico, Reanimación y Anestesia, Hospital Universitario de Girona Dr. Josep Trueta, Girona, Spain
o Departamento de Enfermería Universitat de Girona (UdG), Girona, Spain
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The use of health resources should be based on criteria with a solid scientific basis. However, therapeutic procedures are performed without having updated knowledge about their usefulness, indication or effectiveness, and this generates situations of inefficiency and clinical variability.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Variability analysis is one of the most used methods to evaluate the quality of clinical practice and the different styles of professional practice<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> that often respond to discrepancies or lack of consensus on the most appropriate action in a given situation and response to specific characteristics of the patients.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is not enough to identify inequalities in the quality of care, since it is also essential to assess the type of interventions/procedures in which they occur, and adapt them to the clinical situation of the patients.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In an environment such as the ICU, research into the quality of pain care is significantly challenging, particularly in patients unable to self-report, with deep sedation, neuromuscular blockade, motor disability (tetraplegia, polyneuropathy) or neurocritical patients, for whom there is currently no validated pain assessment instrument.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Clinical Practice Guidelines (CPG) are tools designed to help decision-making and promote quality of care by optimising resources in situations where patients have multiple comorbidities and critical health situations. Even so, quality improvement does not depend only on the attitudes of professionals, but also on institutional support and improvements in its development and implementation.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> The ICU CPGs recognise the right of patients to appropriate pain management. Despite this, the majority of patients present with pain at some point during their stay in the ICU and pain continues to be under-evaluated and under-treated.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Concept of appropriateness of clinical practice</span><p id="par0020" class="elsevierStylePara elsevierViewall">Avedis Donabedian first introduced the concept of appropriateness as one of the essential dimensions to achieve good quality of care.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Strictly speaking, the concept of appropriateness refers to the “use of technologies, resources or interventions of proven effectiveness, with evidence that supports their usefulness in clinical trials or other studies with sufficient validity, in situations or populations in which they are effective”.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The concept of appropriateness is also used to assess the risk-benefit balance of a procedure, treatment, tool or diagnostic test in a specific clinical situation; that is, in a patient with certain characteristics and in the context of available resources. Therefore, the appropriateness criteria must provide a guide that complements the clinical judgment on whether or not a patient is a candidate for a certain procedure, and this is considered an aspect of high-quality healthcare. These criteria are based on explicit recommendations made by panels of clinical experts, which define the conditions of use of the tool, diagnostic test, etc., along with the formulation of improvement actions that are subsequently monitored and evaluated.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The objective of establishing appropriateness criteria in the ICU is to improve patient care and health outcomes in a cost-effective manner, without neglecting clinical judgment in view of the wide diversity of patients and clinical situations. Unlike CPGs, appropriateness criteria focus on common scenarios and include the following requirements: that care is effective (based on valid evidence), that it is efficient, cost-effective and consistent with ethical principles and the person's preferences, whenever possible. To avoid the concept of appropriateness having only a qualitative aspect, some authors have incorporated quantitative aspects into the definition, such as clinical practices of little value quantified in frequency of adverse events. From this perspective, we can categorise inadequacy as: underuse/undervaluation, excessive use/overestimation or misuse. Thus, underuse/undervaluation occurs when an intervention or procedure that has a proven net benefit is not performed; excessive use/overestimation, when an intervention that has no proven net benefit is carried out, and misuse, when an intervention or procedure that has a negative net benefit is performed.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general, scarce research exists on appropriateness in the context of health quality. Some procedures produce benefit, but also harm, producing a dynamic balance that requires continuous assessment of the clinical situation, since only interventions that achieve more benefits than harm are justified.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Concept of pain</span><p id="par0045" class="elsevierStylePara elsevierViewall">The classic definition of pain from 1979, revised by the International Association for the Study of Pain (IASP) in 2020, conceptualises pain as “<span class="elsevierStyleItalic">an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.</span>” Among the main changes, with respect to the previous definition, was the elimination of a person's ability to describe the experience of pain, since this excluded people who could not verbally articulate their pain. Verbal description is just one of several behaviours to express pain, and the inability to communicate does not negate the possibility of a person experiencing pain.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In critically ill patients, the aetiology of pain is multifactorial, and may be due to the disease itself, complications that may develop and/or procedures that cause pain.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The psychological, haemodynamic, metabolic and neuro-endocrine response to inadequate pain control can trigger a greater morbidity, and even increases chronic pain.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Monitoring pain in the ICU</span><p id="par0055" class="elsevierStylePara elsevierViewall">There is no standard recommendation on the frequency of pain monitoring in a critically ill patient. The CPGs and recommendations published in recent years suggest using a standardised protocol for pain management through regular pain assessment with appropriate tools, with the aim of improving pain control and more efficient use of analgesics, although it is essential to individualise in keeping with the clinical requirements of each patient.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">It is also especially recommended to manage iatrogenic pain associated with procedures, assuming the presence of pain and treating it before starting the procedures with preventive analgesia. Similarly, pain should be reassessed after an intervention (pharmacological/non-pharmacological) to determine analgesic efficacy.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">New electrophysiological devices have been developed for monitoring nociception and pain including the automated infrared pupillometry, the Analgesia Nociception Index (ANI) monitor and the Nociception Level Index (NOL®), which could be used in situations in which self-reporting or behavioural pain tools cannot be used. These devices are based on the measurement of physiological markers related to sympathetic-parasympathetic responses, for example pupillary dilation, heart rate variability or sweating.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Patient unable to self-report</span><p id="par0070" class="elsevierStylePara elsevierViewall">The inability to self-report pain is the greatest barrier to an adequate assessment of pain and leaves the patient in a vulnerable state for under-recognition and under-/over-treatment of their pain.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Although there is no agreed upon and explicit definition in the CPGs, authors such as Herr K define the patient unable to self-report as <span class="elsevierStyleItalic">“a patient who cannot provide self-report of pain verbally, in writing, or by other means such as nodding or blinking to answer “yes” or “no” questions</span>”.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> This proposal incorporates the key elements for good communication, and therefore, could be taken as a reference for future research.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patient's ability to self-report should be periodically re-evaluated and when absent or limited, the inability to obtain reliable self-report should be documented and another method of pain assessment should be selected, such as behavioural pain assessment tools.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Scales for the pain assessment in patients unable to self-report</span><p id="par0085" class="elsevierStylePara elsevierViewall">Different populations that are unable to self-report pain are currently identified as: neonates and children of preverbal age; people with intellectual disabilities; unconscious critically ill patients; adult patients with advanced dementia, and patients in the end-of-life process. For these patients, incapable of self-reporting behavioural pain, assessment tools are recommended.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The first step in detecting the presence of pain in a critically ill patient is to know the cause and begin its assessment, and to do so, the most appropriate tool must be chosen. Pain in critically ill patients may be present at rest and increase during procedures.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6,15</span></a> In addition, surgical and traumatic processes and factors such as immobility or hidden infections are associated with more pain.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In all critically ill patients, an attempt should be made to obtain a self-report. However, there are factors such as delirium, agitation, altered level of consciousness, sedatives and neuromuscular blockers that impact the ability to obtain a reliable self-report.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Depending on the recommendation for the use of behavioural pain assessment tools in patients unable to self-report, different tools exist and the choice of the most appropriate one should take into account both the population on which it has been applied and validated, and the strength of its psychometric properties. The tools with the greatest use globally in different populations of critical patients and ICU context are the Behavioural Pain Scale (BPS) and Critical-Care Pain Observation Tool (CPOT).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> In Spain, the behavioral indicators of pain scale (ESCID for its initials in Spanish) tool is available, which also has good psychometric properties and has been validated in critical medical and post-surgical populations.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Behavioural scales have some limitations. On the one hand, the behavioural pain score is not equivalent to the self-report of pain intensity, pain behaviours are not a specific reflection of pain intensity and it is sometimes difficult to discern pain intensity, unpleasantness and emotions such as fear.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,15</span></a> On the other hand, behavioural scales are not appropriate for patients on muscle relaxants or who cannot respond behaviourally to pain (Glasgow Coma Scale (GCS) = 3, Richmond Agitation Sedation Scale (RASS) = −5). Finally, behavioural scales are not appropriate for patients with brain damage/injury and altered level of consciousness. Behavioural tools may need to be adapted for this type of patient, since research published in recent years has documented specific pain behaviours in this population<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Application of the concept of appropriateness in the assessment of pain in ICU patients unable to self-report</span><p id="par0105" class="elsevierStylePara elsevierViewall">Transferring the concept of appropriateness to the assessment of pain in patients unable to self-report, enables it to be defined as a component of healthcare quality in which the reasonable use (with clear clinical benefit) of a behavioural pain assessment tool is evaluated, depending on the patient's cognitive status and their ability to self-report. Furthermore, it must be ensured that the assessment is effective, i.e., based on validated tools for populations that cannot self-report, that patients maintain intact motor functions, and that pain behaviours can be observed, that are efficient and consistent with the ethical principles of beneficence (doing good), non-malfeasance (doing no harm), autonomy (respect for human dignity) and justice (equal treatment of people who can communicate).</p><p id="par0110" class="elsevierStylePara elsevierViewall">Risk analysis of underuse and undervaluation should also be incorporated when the assessment is not made. In this sense, in the pain monitoring audit carried out by the Analgesia, Sedation, Restraints and Delirium (ASCyD) working group, in 158 ICUs in Spain between the years 2017−18, it was found that 35.6% (56) of units still did not use tools to assess pain in patients unable to self-report.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Likewise, the risk of assessment carried out with inappropriate tools should be analysed. For example, using behavioural scales in patients capable of self-reporting. Furthermore, it is essential to analyse the risk of excessive use or misuse of the tools in inappropriate patients, such as using behavioural scales in patients with deep sedation in whom the motor response is limited or absent, applying behavioural scales in situations of agitation and finally available scales adapted for specific populations, such as patients with brain damage and low levels of consciousness should be restricted to those patients. In addition, the management of analgesia and misuse of sedatives instead of analgesia should also be evaluated, when this practice has no proven benefit for pain management.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Implications for clinical practice and conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">To our knowledge, there are no published data on the appropriateness of pain assessment tools in critically ill patients unable to self-report. Therefore, within the framework of continuous quality improvement in pain care, new research should incorporate an integrative approach of the best scientific evidence with current clinical practice, taking into account the benefits, harms and costs.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The benefits of pain assessment strongly outweigh the risks, which is why clinical guidelines recommend routine monitoring.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> However, the damage and cost generated by inappropriate use in pain assessment is unknown, and should be one of the core themes in the training of professionals, to improve the quality of patient care.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Some of the causes of inappropriate use of behavioural pain scales may be the lack of training of professionals in their use, or the non-uniform vision of the team towards pain management/analgesia of critically ill patients.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Nurses have a moral, ethical and professional duty to address these vulnerabilities and, therefore, their role is essential to guarantee the solution to situations of inadequacy in pain assessment, implementing this approach in evidence-based protocols that normalise clinical practice.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">No funding was received for the preparation of this study.</p></span><span id="sec1135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1155">Ethical considerations</span><p id="par1125" class="elsevierStylePara elsevierViewall">No patient data are presented in this article.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">There are no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres2151573" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1826237" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2151574" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1826236" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Concept of appropriateness of clinical practice" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Concept of pain" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Monitoring pain in the ICU" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Patient unable to self-report" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Scales for the pain assessment in patients unable to self-report" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Application of the concept of appropriateness in the assessment of pain in ICU patients unable to self-report" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Implications for clinical practice and conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 13 => array:2 [ "identificador" => "sec1135" "titulo" => "Ethical considerations" ] 14 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-10-20" "fechaAceptado" => "2023-12-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1826237" "palabras" => array:5 [ 0 => "Nurse" 1 => "Intensive care unit" 2 => "Pain" 3 => "Behavioural scales" 4 => "Appropriateness" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1826236" "palabras" => array:5 [ 0 => "Enfermera" 1 => "Unidad de cuidados intensivos" 2 => "Dolor" 3 => "Escalas conductuales" 4 => "Adecuación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Appropriateness is a dimension of quality that evaluates the effective use of technologies, resources or interventions in specific situations or populations, assessing whether our interventions do more benefit than harm.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The evidence regarding pain monitoring in the critically ill patient points to the periodic assessment of pain using appropriate tools, with the aim of improving pain management and more efficient use of analgesics in the intensive care unit. The first step would be to assess the patient's ability to communicate or self-report and, based on this, to select the most appropriate pain assessment tool. In patients who are unable to self-report, behavioural pain assessment tools are recommended.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">When we talk about the suitability of behavioural scales for pain monitoring in critically ill patients unable to self-report, we refer to their use with a clear clinical benefit, i.e. using the right tool for pain assessment to be effective, efficient and consistent with bioethical principles.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">To our knowledge, there are no published data on the suitability of pain assessment tools in unable to self-report critically ill patients, so, in the framework of continuous quality improvement in pain care, new research should incorporate this approach by integrating the best scientific evidence with current clinical practice.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La adecuación es una dimensión de la calidad en la que se evalúa el uso eficaz de tecnologías, recursos o intervenciones en situaciones o poblaciones concretas, valorando el logro de más beneficios que daños en nuestras intervenciones.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La evidencia con relación a la monitorización del dolor en el paciente crítico apunta a una evaluación regular del dolor utilizando herramientas apropiadas, con el objetivo de mejorar el manejo del dolor y el uso más eficiente de los analgésicos en la unidad de cuidados intensivos. El primer paso sería evaluar la capacidad para comunicar o autoinformar por parte del paciente,y en función de ello, seleccionar la herramienta más adecuada para evaluar el dolor. En los pacientes incapaces de autoinformar se recomiendan las herramientas de evaluación conductuales de dolor.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Cuando hablamos de adecuación de las escalas conductuales en la monitorización del dolor en el paciente crítico incapaz de autoinformar, nos referimos a su uso con claro beneficio clínico, es decir utilizar la herramienta correcta para que la evaluación del dolor sea eficaz, eficiente y coherente con los principios bioéticos.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hasta donde sabemos, no hay datos publicados sobre la adecuación de las herramientas de evaluación del dolor en los pacientes críticos incapaces de autoinformar, por lo tanto, en el marco de la mejora continua de la calidad en la atención al dolor, las nuevas investigaciones deberían de incorporar este enfoque integrador de la mejor evidencia científica con la práctica clínica actual.</p></span>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "DianaHealth.com, an On-Line Database Containing Appraisals of the Clinical Value and Appropriateness of Healthcare Interventions: Database Development and Retrospective Analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. 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