Dianne Crellin1, Denise Harrison1, Nick Santamaria1, Franz E Babl1
1) Australia
Background and aim: The Face Legs Activity Cry Consolability (FLACC) scale is widely used to assess procedural pain without convincing validation for this purpose. This study sought to evaluate the psychometric and practical properties of the FLACC scale used to assess procedural pain in children aged six to 42 months experiencing one of four painful and/or distressing procedures (intravenous catheter (IV) or nasogastric tube (NGT) insertion, medication administration via spacer and metered dose inhaler (MDI) and oxygen saturation (SpO2) measurement).
Methods: Infants and young children were recruited from the emergency department and 100 procedures were digitally video recorded. Clinicians (n = 26) independently applied the FLACC scale, the observer Visual Analogue Scale (VASobs) pain and VASobs distress to video segments depicting baseline, preparation and procedure phases to establish; feasibility, inter-rater reliability, and validity. Reviewers reviewed a subset of the segments one month later to establish intra-rater reliability.
Results: Scores were available for 929 of the total 1088 observations (85.4%). Restraint was the most common reason reviewers were unable to apply the FLACC scale (14.6%). The intra-class correlations (ICC) for intra-rater and inter-rater reliability were 0.87 and 0.92, respectively. Mean pain scores were highest during NGT insertion (9.5 ± 0.8). However, the mean scores during the two non-painful procedures were 0.5 (± 0.9) and 4.2 (± 3.2). The increase in scores across phases was 4.2 times greater for painful than non-painful procedures. However, scores increased significantly across phases for non-painful procedures. Correlation between the FLACC and VASobs distress scores (r = 0.89) was higher than between FLACC and VASobs pain scores (r = 0.74).
Conclusions: The FLACC scale shows excellent reliability and sensitivity to procedural pain. However, it also captures non-pain related distress behaviours. Furthermore, the circumstances of the procedure e.g. restraint, interferes with the ability to apply the scale.
