Efficacy, feasibility and usability of a facial recognition technology integrated mobile app for identifying the presence and severity of pain in institutionalised patients with dementia.

The study consists of 3 phases I. Pre-implementation phase 1) Face to face training of “Pain Champions” (half day) 2) Retrospective clinical audit (8 weeks prior to the commencement of the clinical trial undertaken by a research assistant employed by the project team) 3) Care staff familiarisation period with the use and operation of the ePAT (2 weeks) 4) Baseline data collection (Week 0) II.Clinical implementation (8 weeks) 1) Commencement of the clinical trial and introduction of the tool (Week 1-Week 8) III.Post-implementation (8 weeks) 1) Cessation of the clinical trial and return to standard (normal) practice. 2) Data collection points at Week 9 Intervention: Electronic Pain Assessment Tool (ePAT) is a point of care app which uses automated facial recognition technology in real-time to identify facial micro-expressions indicative of the presence of pain. These data are then used in combination with other non-facial pain cues such as vocalisation, movements and behaviours to automatecally calculate a pain severity score. The ePAT consists of 6 domains, which are derived from American Geriatric Society's Indicators of Persistent Pain in Older Adults. For each pain assessment encounter, staff member videos the resident's face for 10 seconds which is analysed by the app in real-time to identify facial micro-expressions. Then, staff member navigates through other non-facial domains to answer Yes/No questions for a checklist of indicators, using the app, to arrive at a pain intensity score. Pain Champions As a strategy of implementation, nurse from each care home will be nominated as “Pain Champion”. Nomination will occur when an expression of interest of an employee nurse is initially raised with the nurse manager of the care home to participate in the project. According to Knowledge for Health (K4Health) initiative, “champions are charismatic opinion leaders who advocate for a particular program, policy or technology”. Champions should be characterised by “passion, persistence and persuasiveness”. The role of “Pain Champions” is to administer the study where they work and train and encourage the rest of the staff within the care home to perform electronic pain assessments. Within each care home, each champion will be finally selected by the general manager based on certain criteria agreed on by both parties. Face-to-face Training of Pain Champions will be conducted by the researcher. It is comprised of 2 parts: 1) Theoretical session This session includes lectures, educational videos and case studies and has the following four modules: Module 1: Background about pain Definition of pain, subjective nature of pain, pathophysiology of pain, types of pain, causes of pain, consequences of pain (including behavioural change), Module 2: Pain in dementia and residential care Prevalence of pain in dementia, pain in mild dementia, pain in moderate-to-severe dementia, pain assessment tools (self-rating instruments e.g. VDS or FPS), (behavioural or observational (proxy) pain assessment tools e.g. Abbey, ePAT), challenges of currently available pain assessment methods Module 3: Pain management in residential care Discussion about current recommendations from clinical guidelines, and different therapeutic options available for pain management in residential care such as pharmacotherapy (e.g. opioids or paracetamol) and non-drug therapy (e.g. message or essential oil therapy) Module 4: Overview of study protocol for ePAT implementation The study protocol will be worked through step by step and staff members will have the opportunity to complete data collection forms. 2) Practical session During this session the following will be conducted: Module 1: Conditions that might affect the operation of the ePAT Module 2: Live demo of the ePAT Module 3: Hand-on practice using the ePAT by staff in pairs (i.e. completing facial assessments and questionnaire checklist domains) and on residents (if possible) Participants will be sampled using non-probability convenience sampling strategy. Participants will be served as own control and will be subjected to the ePAT as an intervention of measuring pain. The ePAT uses the combination of a digital AGS-based checklist and automated facial recognition technology in a smart device to capture micro-facial expressions, behaviours and physical features indicative of pain. Residents’ pain will be assessed by aged care staff for 8 weeks whenever is suspected during rest and on movement (upon receiving routine care activities known to be associated with pain e.g. assisted transfer, repositioning, bathing and toileting or when a resident performing his/her own daily activities e.g. self-transfer or walking within the care home) as per usual practice. There is no independent control group in this study. Communication with GPs GPs will be formally consented to be part of the study as they will be making decisions regarding ePAT scores. Each GP will be briefed about a previous validation study and the objectives and implementation of current trial. Participating GPs will be regularly consulted about ePAT pain scores as per standard practice, with particular focus on those residents with behavioural issues. The outcome of consultation together with respective reasons for selecting therapeutic actions (if any) will also be documented on the Pain Management Record Form. Treating GPs will be under no pressure to recommend anything under the umbrella of the trial but rather will do so when necessary as part of standard care. Feedback about the clinical utility of the tool will be gathered using focus group interview. Responding to Pain Rating in Patients with Cognitive Impairment during the Clinical Trial During implementation phase, each pain assessment is to be documented on a Pain Management Record designed for the purpose of this study. Resident’s pain will be reviewed using electronic Pain Assessment Tool (ePAT) unless the Assessor wishes to validate the result obtained against a standard tool such Abbey Pain Scale (APS). Following the ePAT assessment, the standard practice will be followed. Weekly outcome review for pain management for each resident will also be documented Total number of ePAT assessments for resident sample, number of ePAT assessments per resident, number of ePAT assessments at rest, number of ePAT assessments after a movement or activity will also be recorded. Ease of use and staff satisfaction are expressed in percentages. Responses (scores of entire tool and subscales) of Clinical Utility Attribute Questionnaire (CUAQ) and Mobile Application Rating Scales (MARS) will be presented as percentages, mean +/-SD and median with interquartile ranges.