Background Few investigators have evaluated pain assessment tools in the critical care setting.Objective To evaluate the reliability and validity of the Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale in assessing pain in critically ill adults and children unable to self-report pain.Methods Three nurses simultaneously, but independently, observed and scored pain behaviors twice in 29 critically ill adults and 8 children: before administration of an analgesic or during a painful procedure, and 15 to 30 minutes after the administration or procedure. Two nurses used the FLACC scale, the third used either the Checklist of Nonverbal Pain Indicators (for adults) or the COMFORT scale (for children).Results For 73 observations, FLACC scores correlated highly with the other 2 scores (ρ = 0.963 and 0.849, respectively), supporting criterion validity. Significant decreases in FLACC scores after analgesia (or at rest) supported construct validity of the tool (mean, 5.27; SD, 2.3 vs mean, 0.52; SD, 1.1; P < .001). Exact agreement and κ statistics, as well as intraclass correlation coefficients (0.67–0.95), support excellent interrater reliability of the tool. Internal consistency was excellent; the Cronbach α was 0.882 when all items were included.Conclusions Although similar in content to other behavioral pain scales, the FLACC can be used across populations of patients and settings, and the scores are comparable to those of the commonly used 0-to-10 number rating scale.

Professional experience and wisdom have taught us that immobility is a risk factor for various adverse outcomes, such as deep vein thrombosis, joint contractures, pulmonary dysfunction, and bone demineralization to name a few. Balancing bed rest and mobility may improve both short- and long-term outcomes for our patients. Moreover, early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, improves muscle strength, and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving through the use of a standardized mobility protocol. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The activities are grounded in the evidence and well thought out to prevent complications and promote mobilization. The purpose of this article was to present the science behind the development of a multidisciplinary protocol for early mobilization of critically ill patients that can be adapted to any intensive care unit patient with minor modifications.

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