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The Critically Ill Adults scale


An ICU stay is unfortunately associated with pain and distress. For that reason, analgesics and sedatives are prescribed in large quantities to critically ill adult patients. These patients are often not able to express their pain or distress verbally due to mechanical ventilation and sedation itself. But is treatment adequate? Because no satisfactory pain and distress instrument was found, the Critically Ill Adults (CIA) scale was developed loosely based on the COMFORT scale. Nurses were trained to use this scale. In this study the CIA was validated and cut-off scores were determined to develop useful guidelines for clinical practice.


During a 3-month period, assessments were performed in critically ill adult patients at an 18-bed general surgery/trauma intensive care unit of the University Hospital in Rotterdam, The Netherlands, a tertiary referral centre.

The newly developed CIA tool was tested and adjusted during a prior pilot study. This study resulted in deletion of physiological items and an awareness for polyneuropathy. The latter reduces body movements and therefore influences pain behaviour. The final CIA consists of five items (alertness, facial tension, muscle tone, body movements and respiratory response) with a total score of 5–20 maximally. The CIA was assessed by the researcher or care giving nurse and combined with a Numeric Rating Scale for pain intensity and distress, either filled in by the observer or the patient when self-report was feasible. The two instruments were compared and the CIA was tested before and during handling in a subsample of patients. Based on a large number of observations, cut-off scores were determined to introduce treatment guidelines.


Inter-rater reliability of 46 nurses, researchers and intensivists was excellent, with a median Cohen's Kappa of 0.86. Internal consistency of the CIA with five items was good (0.80). In 125 patients, 870 CIA and NRS scores were assessed and recorded in the Patient Data Management System. When NRS pain or distress was ≥ 4 (22.5% of all observations) the median CIA was 11 (IQR 10–13). When NRS pain or distress was below 4 the median NRS pain or distress was 9 (IQR 6–10). The median score of 9 before handling increased significantly to 11 during handling in 20 patients (Mann–Whitney U test, P = 0.016). A cut-off score of 10 or higher relates to good sensitivity of 0.84 and moderate specificity of 0.63.


Despite beginning validity a major drawback was seen in the relatively low cut-off scores. A score of 10 could be observed when all items were scored 2, which is 'normal'. Our data suggest oversedation in these ICU patients. Further research by implementation of a CIA-based algorithm should determine whether or not this can be reduced in this specific patient population.

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Schoonderbeek, J., van Leeuwen, P., van der Hoven, B. et al. The Critically Ill Adults scale. Crit Care 9, P143 (2005).

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  • Polyneuropathy
  • Numeric Rate Scale
  • Data Management System
  • Tertiary Referral Centre
  • Pain Behaviour