Inter observer agreement in the assessment of the motor response of the Glasgow 'coma' scale

Effects of a scoring aid on glasgow coma score assessment and physicians' comprehension: a simulator-based randomized clinical trial

PURPOSE

Examining the impact of scoring aids on the accuracy of assessing the Glasgow Coma Score (GCS) in a standardized trauma scenario (primary outcome). Evaluating physicians' understanding of the GCS assessment and clinical application (secondary outcome).

MATERIALS AND METHODS

This randomized trial was performed at the simulator center of a Swiss tertiary academic medical hospital. Participants included intensivists, emergency physicians, internists, and neurologists. The setting involved a trauma patient portraying a GCS of 8 (eyes 1, verbal 2, motor 5). Participants were randomized to receiving or not receiving a scoring aid. Video/audio recordings of the assessments and questionnaires were analyzed by two investigators.

RESULTS

Among 109 participants, 55 received a scoring aid. Overall, 52% scored correctly (score interquartile range 7-8); 43% scored too low and 90% scored within a range of ± 1. A scoring aid increased accuracy (62% vs. 43%, p = 0.045) and participants' confidence, whilst decreasing assessment duration. Clinical experience further improved reliability. 89% found assessing a GCS of 8 most challenging, particularly with motor response evaluation (64%). 26% indicated tracheal intubation to be mandatory with a score of GCS ≤ 8.

CONCLUSIONS

GCS assessment is improved by professional experience and a scoring aid, the use of which needs to be promoted in daily clinical practice. Frequent inaccuracy and misunderstanding regarding clinical applications may alter patient management and misguide treatment and prognosis.

TRIAL REGISTRATION

ISRCTN registry (IDISRCTN12257237) https://www.isrctn.com/ISRCTN12257237 Retrospectively registered (last amendment 08/22/2023).

Collision of Priorities in Posttraumatic Coma and Suspected Multiple Injuries: A Prospective Multicenter Trial

OBJECTIVE

 The presence of multiple injuries in addition to a traumatic brain injury (TBI) is initially uncertain in most patients with posttraumatic coma. The interdisciplinary team of physicians in charge of initial treatment after hospital admission may face a collision of vital priorities. The purpose of this study was to analyze which diagnostic and surgical measures were given priority over others in comatose patients after injury and to draw conclusions from these data.

METHODS

 In this prospective multicenter cohort study, the outcomes of 1,003 comatose patients with suspected multiple injuries were studied. The analysis was divided into an early and a late stage. Diagnostic and surgical measures were analyzed for a 6-month period. The prognostic value of the Glasgow Coma Scale (GCS) and the World Federation of Neurosurgical Societies grading scale were investigated.

RESULTS

 Removal of intracranial hematomas and decompressive craniotomies were the most frequent procedures within the first 48 hours after admission to the hospital. Prognosis depends on the location and the combination of injuries. Outcome is significantly correlated to initial signs of brainstem dysfunction. The GCS did not adequately predict clinical outcome.

CONCLUSION

 Comatose patients with suspected multiple injuries should only be admitted to hospitals with a continuous neurosurgical service because intracranial operations are more frequent in the first 48 hours than extracranial operations. Depending on the neurologic status of the patient, an urgent surgical decompression may be essential for a good outcome. The GCS alone is not a sufficient tool for the neurologic assessment and the prognosis of patients with multiple injuries. The onset of clinical signs of brainstem dysfunction indicates a critical deterioration of the functioning of the central nervous system. The priority of surgical measures should be tailored accordingly.

Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review

BACKGROUND

The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS.

OBJECTIVE

The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS.

METHODS

A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables.

RESULTS

Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers.

CONCLUSION

Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.

The Glasgow Coma Scale and evidence-informed practice: a critical review of where we are and where we need to be

AIMS AND OBJECTIVES

This paper aims to critically consider the evidence since the Glasgow Coma Scale was first launched, reflecting on how that evidence has shaped practice. It illustrates the lack of clarity and consensus about the use of the tool in practice and draws upon existing evidence to determine the route to clarity for an evidence-informed approach to practice.

BACKGROUND

The Glasgow Coma Scale has permeated and influenced practice for over 40 years, being well-established worldwide as the key tool for assessing level of consciousness. During this time, the tool has been scrutinised, evaluated, challenged and re-launched in a plethora of publications. This has led to an insight into the challenges, and to some extent the opportunities, in using the Glasgow Coma Scale in practice but has also resulted in a lack of clarity.

DESIGN

This is a discursive paper that invites readers to explore and arrive at a more comprehensive understanding of the Glasgow Coma Scale in practice and is based on searches of Scopus, Web of Knowledge, PubMed, Science Direct and CINAHL databases.

RESULTS

While the Glasgow Coma Scale has been rivalled by other tools in an attempt to improve upon it, a shift in practice to those tools has not occurred. The tool has withstood the test of time in this respect, indicating the need for further research into its use and a clear education strategy to standardise implementation in practice.

CONCLUSION

Further exploration is needed into the application of painful stimuli in using the Glasgow Coma Scale to assess level of consciousness. In addition, a robust educational strategy is necessary to maximise consistency in its use in practice.

RELEVANCE TO CLINICAL PRACTICE

The evidence illustrates inconsistency and confusion in the use of the Glasgow Coma Scale in practice; this has the potential to compromise care and clarity around the issues is therefore necessary.

The Glasgow Coma Scale: History and current practice

The Glasgow Coma Scale (GCS) was devised to assess injury severity in a multi-centre study of outcome after severe brain damage. It uses unambiguous terms that are readily understood by a wide range of observers. Giving numbers to responses makes communication and display of responsiveness easy and the overall score allows classifi cation of overall severity of brain injury for triage and for epidemiological studies. The total score involves some loss of predictive information. Outcome correlates well with the early GCS both in head injuries and other intensive care patients. When early sedation and ventilation after head injury makes GCS assessment difficult, the motor score is often available and is a useful index of injury severity. The GCS also facilitates monitoring in the early stages after injury, allowing rapid detection of complications. Even among mild injuries (GCS 13- 15) the scale can discriminate between those more or less likely to have detectable brain damage and to be at risk of complications.

Patient-Related Determinants of the Administration of Continuous Palliative Sedation in Hospices and Palliative Care Units: A Prospective, Multicenter, Observational Study

CONTEXT

Knowledge of determinants that are associated with the administration of continuous palliative sedation (CPS) helps physicians identify patients who are at risk of developing refractory symptoms, thereby enabling proactive care planning.

OBJECTIVES

This study aims to explore which patient-related factors at admission are associated with receiving CPS later in the terminal phase of life.

METHODS

A prospective multicenter observational study was performed in six Dutch hospices and three nursing home-based palliative care units. The association between patient-related variables at admission (age, gender, diagnosis, use of opioids or psycholeptics, number of medications, Karnofsky Performance Status scale score, Edmonton Symptom Assessment System distress score, and Glasgow Coma Scale score) and the administration of CPS at the end of life was analyzed.

RESULTS

A total of 467 patients died during the study period, of whom 130 received CPS. In univariate analysis, statistically significant differences were noted between the sedated and nonsedated patients with respect to younger age (P = 0.009), malignancy as a diagnosis (P = 0.05), higher Karnofsky Performance Status score (P = 0.03), the use of opioids (P < 0.001), the use of psycholeptics (P = 0.003), and higher Edmonton Symptom Assessment System distress score (P = 0.05). Multivariate logistic regression analysis showed that only the use of opioids at admission (odds ratio 1.90; 95% confidence interval 1.18-3.05) was significantly associated with the administration of CPS.

CONCLUSION

Physicians should be aware that patients who use opioids at admission have an increased risk for the administration of CPS at the end of life. In this group of patients, a comprehensive personalized care plan starting at admission is mandatory to try to prevent the development of refractory symptoms. Further research is recommended, to identify other determinants of the administration of CPS and to investigate which early interventions will be effective to prevent the need for CPS in patients at high risk.

The reliability of the Glasgow Coma Scale: a systematic review

INTRODUCTION

The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS.

METHODS

A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively.

RESULTS

We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used.

CONCLUSIONS

Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.

Comparison of changes in tidal volume associated with expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation

[Purpose] This study was designed to compare and clarify the relationship between expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation, with a focus on tidal volume. [Subjects and Methods] The subjects were 18 patients on prolonged mechanical ventilation, who had undergone tracheostomy. Each patient received expiratory rib cage compression and expiratory abdominal compression; the order of implementation was randomized. Subjects were positioned in a 30° lateral recumbent position, and a 2-kgf compression was applied. For expiratory rib cage compression, the rib cage was compressed unilaterally; for expiratory abdominal compression, the area directly above the navel was compressed. Tidal volume values were the actual measured values divided by body weight. [Results] Tidal volume values were as follows: at rest, 7.2 ± 1.7 mL/kg; during expiratory rib cage compression, 8.3 ± 2.1 mL/kg; during expiratory abdominal compression, 9.1 ± 2.2 mL/kg. There was a significant difference between the tidal volume during expiratory abdominal compression and that at rest. The tidal volume in expiratory rib cage compression was strongly correlated with that in expiratory abdominal compression. [Conclusion] These results indicate that expiratory abdominal compression may be an effective alternative to the manual breathing assist procedure.

Glasgow Coma Scale Scoring is Often Inaccurate

INTRODUCTION

The Glasgow Coma Scale (GCS) is widely applied in the emergency setting; it is used to guide trauma triage and for the application of essential interventions such as endotracheal intubation. However, inter-rater reliability of GCS scoring has been shown to be low for inexperienced users, especially for the motor component. Concerns regarding the accuracy and validity of GCS scoring between various types of emergency care providers have been expressed. Hypothesis/Problem The objective of this study was to determine the degree of accuracy of GCS scoring between various emergency care providers within a modern Emergency Medical Services (EMS) system.

METHODS

This was a prospective observational study of the accuracy of GCS scoring using a convenience sample of various types of emergency medical providers using standardized video vignettes. Ten video vignettes using adults were prepared and scored by two board-certified neurologists. Inter-rater reliability was excellent (Cohen's κ = 1). Subjects viewed the video and then scored each scenario. The scoring of subjects was compared to expert scoring of the two board-certified neurologists.

RESULTS

A total of 217 emergency providers watched 10 video vignettes and provided 2,084 observations of GCS scoring. Overall total GCS scoring accuracy was 33.1% (95% CI, 30.2-36.0). The highest accuracy was observed on the verbal component of the GCS (69.2%; 95% CI, 67.8-70.4). The eye-opening component was the second most accurate (61.2%; 95% CI, 59.5-62.9). The least accurate component was the motor component (59.8%; 95% CI, 58.1-61.5). A small number of subjects (9.2%) assigned GCS scores that do not exist in the GCS scoring system.

CONCLUSIONS

Glasgow Coma Scale scoring should not be considered accurate. A more simplified scoring system should be developed and validated.

Palliative sedation, not slow euthanasia: a prospective, longitudinal study of sedation in Flemish palliative care units

CONTEXT

Palliative sedation remains a much debated and controversial issue. The limited literature on the topic often fails to answer ethical questions concerning this practice.

OBJECTIVES

The aim of this study was to describe the characteristics of patients who are being sedated for refractory symptoms in palliative care units (PCUs) from the time of admission until the day of death.

METHODS

A prospective, longitudinal, descriptive design was used to assess data in eight PCUs. The total sample consisted of 266 patients. Information on demographics, medication, food and fluid intake, decision making, level of consciousness, and symptom experience were gathered by nurses and researchers three times a week. If patients received palliative sedation, extra information was gathered.

RESULTS

Of all included patients (n=266), 7.5% received palliative sedation. Sedation started, on average, 2.5 days before death and for half of these patients, the form of sedation changed over time. At the start of sedation, patients were in the end stage of their illness and needed total care. Patients were fully conscious and had very limited oral food or fluid intake. Only three patients received artificial fluids at the start of sedation. Patients reported, on average, two refractory symptoms, the most important ones being pain, fatigue, depression, drowsiness, and loss of feeling of well-being. In all cases, the patient gave consent to start palliative sedation because of increased suffering.

CONCLUSION

This study revealed that palliative sedation is only administered in exceptional cases where refractory suffering is evident and for those patients who are close to the ends of their lives. Moreover, this study supports the argument that palliative sedation has no life-shortening effect.

Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging

Traumatic brain injury (TBI) is a common and potentially devastating problem. The classification of TBI is necessary for accurate diagnosis and the prediction of outcomes. The increased use of early sedation, intubation and ventilation in more severely injured patients has decreased the value of the Glasgow Coma Scale for the purposes of classification. An alternative is the classification of TBI according to morphological criteria based on computed tomography (CT) investigations. This article reviews the current classification and prediction of outcomes in TBI based on CT imaging. Classifications based on the presence or absence of intracranial local lesions, diffuse injury, signs of subarachnoid or intra-ventricular haemorrhage and fractures or foreign bodies are considered, and their predictive value is discussed. Future studies should address the complicated issue of how optimally to combine CT characteristics for prognostic purposes and how to improve on currently used CT classifications to predict outcomes more accurately.

Pediatric traumatic brain injury: an update of research to understand and improve outcomes

PURPOSE OF REVIEW

Traumatic brain injury is the leading cause of death in the pediatric population. The purpose of this review is to highlight recent contributions in evaluation, management, and predictors of outcome in pediatric traumatic brain injury.

RECENT FINDINGS

Advances have been made in defining the critical Glasgow Coma Score for predicting poor outcome and in developing the Relative Head Injury Severity Score, which can assess severity of traumatic brain injury from administrative datasets. More information regarding the radiation risks of head computed tomography imaging and guidelines for the appropriate use of imaging have recently been evaluated. Important steps have also been taken to reduce secondary brain injury through the use of hypertonic saline and induced hypothermia. There continues to be long-term neurodevelopmental deficits among survivors and new tools to assess these deficits have been developed and tested. Finally, increased investigation into understanding the impact of minority race and socioeconomic status has on outcome following traumatic brain injury has determined the existence of disturbing disparities.

SUMMARY

Traumatic brain injury is the leading cause of mortality and is a major public health issue in the pediatric population. There have been many recent contributions in the diagnosis, treatment, and long-term morbidity of traumatic brain injury. Ongoing work is needed to improve outcomes of traumatic brain injury equitably for all patients.

Bryan Jennett and the field of traumatic brain injury. His intellectual and ethical heritage in neuro-intensive care

William Bryan Jennett, one of the leading figures in neurosurgery of the twentieth century, has died on 26 January 2008, at the age of 81. He made fundamental contributions to the field of traumatic brain injury (TBI) that still shape diagnosis, management and prognosis worldwide, in the second part of the last century. This paper is meant to gratefully acknowledge his contributions and to reflect on the implications that his work has for neurointensive care today. Starting from his early steps, we tried to highlight his fundamental work on diagnosis of severity in TBI, on rescue, treatment and prognosis of severe TBI. Moreover, his contribution in the definition of vegetative state, minimally conscious state and brain death has been emphasized. The contribution of Professor Bryan Jennett was in fact seminal in many aspects: the application of a common language in brain damage evaluation, where GCS and GOS are now universally employed; a critical approach to TBI diagnosis and treatment, in the search of proven better therapies; a quantitative approach to TBI prognosis, based on large clinical series and appropriate statistics; a strong commitment to the ethical implication of survival after severe injury, including the vegetative status; social responsibility in the diagnosis of brain death and in organ donors procurement. For these reasons, he can be considered one of the leading figures in neurosurgery and neurology of the twentieth century. This paper is meant to gratefully acknowledge his contributions and to reflect on the implications that his work has for neuro-intensive care today.

Paediatric coma scales

Traumatic and non-traumatic coma is a common problem in paediatric practice with high mortality and morbidity. Early recognition of the potential for catastrophic deterioration in a variety of settings is essential and several coma scales have been developed for recording depth of consciousness that are widely used in clinical practice in adults and children. Prediction of outcome is probably less important, as this may be able to be modified by appropriate emergency treatment, and other clinical and neurophysiological criteria allow a greater degree of precision. The scales should be reliable, i.e. with little variation between observers and in test-retest by one observer, since this promotes confidence in the assessments at different time points and by different examiners. This is particularly important when the patient is being assessed by personnel dealing with adults as well as children, discussed on the telephone, handed over at shift change, or transferred between units or hospitals. The British Paediatric Neurology Association has recommended one of the modified child's Glasgow coma scales (CGCS) for use in the UK. This review looks at the recent history of the development of coma scales and the rationale for recommending the CGCS.

Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness

OBJECTIVE

To assess the interrater reliability of the Glasgow Coma Scale (GCS) between nurses and senior doctors in the ED.

METHODS

This was a prospective observational study with a convenience sample of patients aged 18 or above who presented with a decreased level of consciousness to a tertiary hospital ED. A senior ED doctor (emergency physicians and trainees) and registered nurse each independently scored the patient's GCS in blinded fashion within 15 min of each other. The data were then analysed to determine interrater reliability using the weighted kappa statistic and the size and directions of differences between paired scores were examined.

RESULTS

A total of 108 eligible patients were enrolled, with GCS scores ranging from 3 to 14. Interrater agreement was excellent (weighted kappa > 0.75) for verbal scores and total GCS scores, and intermediate (weighted kappa 0.4-0.75) for motor and eye scores. Total GCS scores differed by more than two points in 10 of the 108 patients. Interrater agreement did not vary substantially across the range of actual numeric GCS scores.

CONCLUSIONS

Although the level of agreement for GCS scores was generally high, a significant proportion of patients had GCS scores which differed by two or more points. This degree of disagreement indicates that clinical decisions should not be based solely on single GCS scores.

Comparing logistic models based on modified GCS motor component with other prognostic tools in prediction of mortality: results of study in 7226 trauma patients

A simple reproducible and sensitive prognostic trauma tool is still needed. In this article we have introduced modified GCS motor response (MGMR) and evaluated the performance of logistic models based on this variable. The records of 8452 trauma patients admitted to major hospitals of Tehran from 1999 to 2000 were analysed. 7226 records with known outcome were included in our study. Logistic models based on outcome (death versus survival) as a dependent variable and Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS), GCS motor component (GMR) and MGMR (following command [=2], movement but not following [=1] command and without movement [=0]) were compared based on their accuracy and area under the Receiver Operating Characteristic (ROC) curve. The accuracy of the Trauma and Injury Severity Score (TRISS), RTS, GCS, GMR and MGMR models were almost the same. Considering both the area under the ROC curve and accuracy, the age included MGMR model was also comparable with other age included models (RTS+age, GCS+age, GMR+age). We concluded that although in some situations we need more sophisticated models, should our results be reproducible in other populations, MGMR (with or without age added) model may be of considerable practical value.

Traumatic brain injury and stabilisation of long bone fractures: an update

In the era of "damage control orthopaedics", the timing and type of stabilisation of long bone fractures in patients with associated severe traumatic brain injury has been a topic of lively debate. This review summarises the current evidence available regarding the management of these patients. There appear to be no clear treatment guidelines. Irrespective of the treatment protocol followed, if secondary brain damage is to be avoided at all times, ICP monitoring should be used, both in the intensive care unit and in the operating theatre during surgical procedures, since aggressive ICP management appears to be related to improved outcomes. Treatment protocols should be based on the individual clinical assessment, rather than mandatory time policies for fixation of long bone fractures.

Effectiveness of a Glasgow Coma Scale instructional video for EMS providers

INTRODUCTION

The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness of patients who have sustained head injuries. Rapid and accurate GCS scoring is essential.

OBJECTIVE

To evaluate the effectiveness of a GCS teaching video shown to prehospital emergency medical services (EMS) providers.

METHODS

Participants and setting--United States, Mid-Atlantic region EMS providers. Intervention--Each participant scored all of the three components of the GCS for each of four scenarios provided before and after viewing a video-tape recording containing four scenarios. Design--Before-and-after single (Phase I) and parallel Cohort (Phase II). Analysis--Proportions of correct scores were compared using chi-square, and relative risk was calculated to measure the strength of the association.

RESULTS

75 participants were included in Phase I. In Phase II, 46 participants participated in a parallel cohort design: 20 used GCS reference cards and 26 did not use the cards. Before observing the instructional video, only 14.7% score all of the scenarios correctly, where as after viewing the video, 64.0% scored the scenarios results were observed after viewing the video for those who used the GCS cards (p = 0.001; RR = 2.0; 95% CI = 1.29 to 3.10) than for those not using the cards (p < 0.0001; RR = 10.0; 95% CI = 2.60 to 38.50).

CONCLUSIONS

Post-video viewing scores were better than those observed before the video presentation. Ongoing evaluations include analysis of long-term skill retention and scoring accuracy in the clinical environment.

Interrater reliability of the Glasgow Coma Scale scoring among nurses in sub-specialties of critical care

The Glasgow Coma Scale (GCS) is used as an assessment tool to measure the levels of consciousness and coma in patients. This research investigated the reliability of scoring the GCS among registered nurses (RNs) working in five different sub-specialty clinical areas of critical care; general intensive care, neurosurgical intensive care, coronary care, emergency room and post anaesthetic recovery room. Seven video recordings were made of six patients (one patient was recorded twice) having their level of neurological response assessed utilising the GCS. Seventy five RNs (15 from each sub-specialty) viewed each of the GCS assessments on the videotape and rated each patient on the scoring sheet provided. Analysis was performed for all RN subjects as a single group as well as separately for each of the five groups under investigation. The ratings for the first six videos were used to test interrater reliability and the scores from videotape four and seven (same patient) were used to calculate intrarater reliability. Based on comparison with expert scores, of the 75 participants, 38 responded correctly to eye opening responses; only 26 responded correctly to the motor response ratings. However, a better accuracy was achieved in the verbal response category with 67 participants responding correctly. Education qualifications and previous neurosurgical experience were statistically significant with regard to the nurses' accuracy of GCS assessment with p values of 0.004 and 0.043 respectively. The results were consistent with previously published studies demonstrating the motor response rating is most problematic in relation to rate accuracy.

Evaluation of the traumatic coma data bank computed tomography classification for severe head injury

This study determines the interrater and intrarater reliability of the Traumatic Coma Data Bank (TCDB) computed tomography (CT) scan classification for severe head injury. This classification grades the severity of the injury as follows: I = normal, II = diffuse injury, III = diffuse injury with swelling, IV = diffuse injury with shift, V = mass lesion surgically evacuated, or VI = mass lesion not operated. Patients with severe closed head injury were included. Outcome was assessed using the Glasgow Outcome Score (GOS) at 3 and 6 months. Four observers, two of them classifying the scans twice, independently evaluated CT scans. Of the initial CT scans of 63 patients (36 males, 27 females; age, 34+/-24 years), 6.3% were class I, 26.9% class II, 28.6% class III, 6.3% class IV, 22.2% were class V, and 9.6% class VI. The overall interrater and intrarater reliability was 0.80 and 0.85, respectively. Separate analyses resulted in higher inter- and intrarater reliabilities for the mass lesion categories (V and VI), 0.94 and 0.91, respectively, than the diffuse categories (I-IV) 0.71 and 0.67. Merging category III with IV, and V with VI resulted in inter- and intrarater reliabilities of 0.93 and 0.78, respectively. Glasgow outcome scores after 6 months were as follows: 19 dead (30%), one vegetative (2%), five severely disabled (8%), 17 moderately disabled (27%), and 21 good recovery (33%). Association measures (Sommers' D) between CT and GOS scores were statistically significant for all observers. This study shows a high intra- and interobserver agreement in the assessment of CT scan abnormalities and confirms the predictive power on outcome when the TCDB classification is used.

Infection as a trigger of diabetic ketoacidosis in intensive care-unit patients

We determined the prevalence and indicators of infection in intensive care unit (ICU) patients with diabetic ketoacidosis (DKA) by performing a retrospective analysis of 123 episodes of DKA (in 113 patients) managed in a medical ICU between 1990 and 1997. In univariate analysis, features associated with infection were female sex, neurological symptoms at admission, fever during the week before admission, a need for colloids, a high blood lactate level at admission, and lack of complete clearance of ketonuria within 12 h. Multivariate analysis identified 3 independent predictors of infection: female sex (odds ratio [OR], 2.31; confidence interval [CI], 1.05-5.35), neurological symptoms at admission (OR, 2.83; CI, 1.18-6.8), and lack of complete clearance of ketonuria within 12 h (OR, 3.73; CI, 1.58-9.09). Infection is the leading trigger of DKA in ICU patients. Neurological symptoms at admission and lack of complete clearance of ketonuria within 12 h are useful warning signals of infection.

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Glasgow coma scale score

When considering the use of the initial GCS for prognosis, the two most important problems are the reliability of the initial measurement, and its lack of precision for prediction of a good outcome if the initial GCS is low. If the initial GCS is reliably obtained and not tainted by prehospital medications or intubation, approximately 20% of the patients with the worst initial GCS will survive and 8-10% will have a functional survival (GOS 4-5).

[Use of Glasgow coma scale by anesthesia and intensive care internists in brain injured patients]

OBJECTIVE

To evaluate the quality and reliability of the Glasgow coma scale (GCS) score when determined, in head trauma patients, by trainees in anaesthesiology.

STUDY DESIGN

Prospective survey. USERS: One hundred trainees in their first to fourth year of training in anaesthesiology.

METHODOLOGY

A questionnaire completed by the trainees concerning: demographic data; place, time and qualification of the physician determining the first GCS score; time and qualification of the physician determining the subsequent GCS score; assessment of the GCS score in case of asymmetrical motor response, tracheal intubation, bilateral eyelid oedema, or circulatory or ventilatory failure.

RESULTS

Sixty questionnaires were available for analysis. Lack of compliance with the rules for the GCS score evaluation resulted in many errors by most of the trainees. Only a few of them determined an accurate GCS score in cases of asymmetric motor response or impossibility to determine verbal or ocular response. Finally, GCS scores were determined later only very rarely.

CONCLUSION

In order to provide optimal care and allow an accurate assessment of therapeutic efficiency, special attention should be given to the teaching of the GCS scoring method in head trauma patients.

Agreement between the neonatal neurological examination and a standardized assessment of neurobehavioural performance in a group of high-risk newborns

The degree of agreement between the neonatal neurological examination and a standardized neurobehavioural assessment was investigated in a group of 32 newborns with congenital heart defects. A paediatric neurologist performed a neurological examination, and an occupational therapist administered the Einstein Neonatal Neurobehavioural Assessment Scale on all subjects. Both examiners independently evaluated each subject, and were blinded to the diagnosis, to perinatal status and to each other's clinical findings. Statistical analysis demonstrated a significant association between the overall impression between both examiners (p < .0001), with a crude agreement of 96.9%. Sixteen neonates were determined to be normal and 15 abnormal by both examiners, with disagreement in only one subject. Although two distinct approaches were employed in the neurological assessment of high-risk newborns, both assessments evaluate the maturity and integrity of the immature central nervous system. The results demonstrate a strong agreement between these two approaches, suggesting that the neonatal neurological examination is consistent and valid.

Observer reliability in histological grading of astrocytoma stereotactic biopsies

This study provides an objective assessment of the reliability of histological grading of astrocytoma specimens obtained using stereotactic biopsy. Pathological diagnosis of brain tumors provides an index of disease severity and guides clinical practice in their treatment. It also functions as the gold standard in assessing the validity of diagnostic tests such as magnetic resonance imaging. Often diagnoses are made from biopsy material obtained using stereotactic technique. The current study was designed to evaluate this gold standard with regard to interobserver and intraobserver variability. Four certified neuropathologists from academic centers in the United States and Canada were asked to grade 30 brain biopsy specimens obtained stereotactically in patients with astrocytomas. Intraobserver agreement was analyzed in individual observers by comparing their first and second readings, separated by 5 to 14 weeks. Interobserver data were analyzed by comparing initial readings across all observers for individual diagnoses. Kappa analysis was used to measure agreement beyond chance. Intraobserver agreement was 74.73% for glioblastomas multiforme, 51.43% for anaplastic astrocytomas, and 65.22% for low-grade astrocytomas. The most common disagreements were between anaplastic astrocytomas and glioblastomas multiforme, followed by disagreements between anaplastic and low-grade astrocytomas. Interobserver agreement on initial readings was 62.41% (kappa 0.39) for glioblastomas, 36.04% (kappa 0.06) for anaplastic astrocytomas, and 57.14% (kappa 0.48) for low-grade astrocytomas. A significantly greater degree of reliability was seen in histopathological diagnoses of low- or high-grade astrocytomas than in those of intermediate-grade astrocytomas. Therefore, the highest variability occurs at the point of clinical decision making--namely, intermediate-grade tumors that may or may not be selected to receive adjuvant therapy. This considerable variability is an issue that needs to be recognized and further addressed by analysis of current and proposed astrocytoma grading schemes.

An educational intervention to increase use of the Glasgow Coma Scale by emergency department personnel

Data from a large series of acutely injured patients revealed the Glasgow Coma Score was acquired in less than one half of those for whom it should have been documented. To improve these statistics, a five-part educational intervention based on an application of the PRECEDE-PROCEED model was developed. The study populations consisted of hospital-based nurse-managers and their emergency department nursing staff. Evaluation of the educational intervention's effectiveness suggested (1) simply conveying benefits of a particular patient care practice is insufficient to bring about immediate and permanent changes and (2) the most significant changes occurred in settings in which a formal policy and formal data collection procedures were established to accompany and reinforce the educational intervention. On-site advocacy and physician support are essential if changes in nursing practice are to occur in hospital emergency departments.

Separation of systematic and random differences in ordinal rating scales

We introduce a new statistical method, which separates and measures different types of variability between paired ordered categorical measurements. The key to the separation is a two-way augmented ranking approach of observations in a contingency table. It means that cases classified in a specific category by one rater will be internally ranked according to the classifications from the other. This enables us to extract the component of interobserver variation which is not systematic. The variance of the rank differences between judgements is a suitable measure of this interrater variability, which we characterize as random. The empirical measure of random interjudge disagreement, which lies between 0 and 1, is called the relative rank variance and is an estimate of a parameter defined on the multinomial probability distribution in the contingency table. The systematic differences are determined by the marginals and described by two empirical measures, relative position and relative concentration; both measures lie between -1 and 1. Our method is applied to data sets from a reliability study of two clinical rating scales for assessing hydrocephalus and subarachnoid haemorrhage.

Assessment and communication of conscious level: an audit of neurosurgical referrals

Telephone referrals of 100 head-injured patients to a neurosurgical service were assessed to determine if altered consciousness was adequately described by the referring doctor. Of the patients, 60 per cent were resuscitated, assessed and referred by SHOs. Only 30 per cent of doctors were fully conversant with the Glasgow Coma Scale and 18 per cent were unable to describe altered consciousness. Assessment of motor response was often described inaccurately and this was frequently due to the use of an inappropriate stimulus. The use of a pictorial guide to motor responses and a 'Head Injury Proforma' are suggested as means of improving referral and enhancing audit. The majority of doctors had not received formal training in the assessment of conscious level during their undergraduate or postgraduate training. Training video tapes from neurosurgical units showing standard examination methods and typical responses would allow self-assessment and training.

Prediction of motor status 3 and 6 months post severe traumatic brain injury: a preliminary study

The prediction of outcome following severe traumatic brain injury has received considerable attention in recent years. Previous prediction studies have focused on a long-term follow-up or prediction period. The reported outcome measures generally adopted a global approach (e.g. independent living) in terms of the prediction of physical function. The objective of the present study was to construct clinically useful predictive equations of motor system status, as represented by selected postural reactions (indicators of central nervous system function). Specifically, these equations would serve to predict the recovery of equilibrium and protective reactions both at 3 and 6 months post-injury, respectively. A stepwise multiple logistic regression analysis was performed, where nine predictive variables were considered using a multivariate approach. The results indicate that coma duration followed by age contribute significantly to the predictive capability of the models at both 3 and 6 months post-injury. Specifically, at 3 months, the predictive variables 'coma duration' and 'age' enabled an 84.62% correct prediction rate, whereas, at 6 months, 'coma duration' and 'age' enabled a 79.49% correct prediction rate. In addition, the exact probabilities (for given sample ages and coma durations) and associated 95% confidence intervals were calculated based on the predictive models obtained. The theoretical framework underlying these predictive models can form the basis for further studies. Furthermore, these preliminary predictive models have potential implications for early treatment planning and patient management.

Aspects of neurosurgical assessment using the Glasgow Coma Scale

The Glasgow Coma Scale (GCS) has become a cornerstone of the neurological/surgical assessment of patients used by both nursing and medical staff. Since its development in the 1970s it has been used in a variety of clinical situations to monitor changes in a number of key neurological functions, including level of consciousness, pupil reaction and limb movement. During this time, however, there have been suggestions that there are problems with some of the measurement principles underlying its use, which in part has stimulated the development of other neuro-assessment tools. Irrespective of measurement device, there is always the possibility of error or incorrect assessment. In the field of neurosurgery, as with other high dependency environments, a patient's condition can change rapidly. Additionally, there is the association of certain assessment responses with nursing and medical interventions. Thus, accuracy in all aspects of assessment and recording is paramount. Despite the growing body of literature surrounding the GCS, little is known about the pattern of errors made by nursing staff using the GCS to assess neurosurgical patients. This study compared the assessment findings of Registered General Nurses (RGNs), Enrolled Nurses and Student Nurses after viewing videotaped neuro-assessments of patients in a high dependency unit. The criterion for judging the accuracy of subject's assessments was established by a panel of experts. As expected, RGNs had the highest proportion of correct assessments and students the least. Subjects were identified as having difficulty in determining the relative amounts of weakness that a patient exhibited, and in correctly distinguishing between flexion and extension.

A comparative study of the Reaction Level Scale (RLS85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (modified) (E2CS(M))

In this work a new coma scale for the assessment of responsiveness in acute brain disorders, constructed near the year 1985 by Scandinavian investigators, the Reaction Level Scale (RLS85), is compared with two other coma scales namely: (i) the Glasgow Coma Scale: (GCS); (ii) the Edinburgh-2 Coma Scale, after modification: (E2CS(M)). The study proceeded in the form of a statistical analysis of assessments made on 46 patients according to RLS85 and GCS (i.e., when comparison was with GCS) and on 28 patients according to RLS85 and E2CS(M). In all 74 cases two physicians participating as "observers" carried out the assessments. They were both contacting the patient--not together but--successively within a time interval of less than 20'. Hence the data appeared as "pairwise" observations for any of the three scales above. The results of the analysis, arising from a rather strict statistical reasoning, can be summarized as follows: (1) The rank correlation coefficient r(s) between: (i) RLS85 and GCS sum score, (ii) RLS85 and E2CS(M), was found to be at a satisfactory level meaning that all three scales indicate almost the same "ranking order of severity". (2) Reliability was compared by taking into account as to what extent the two observers agreed on RLS85 and--simultaneously--disagreed on the other scale. The "sign" test was applied and as a result RLS85 proved to be more reliable than; (i) GCS (EMY profile), (ii) GCS sum score, and (iii) E2CS(M), in all the above mentioned at a high level of significance. (3) Apart from the test above, some values of the index kappa (kappa) of interobserver agreement were calculated. Those corresponding to RLS85 are considerably higher. In particular the overall value based on 74 pairwise assessments amounted to kappa = 0.733 associated with a standard error sigma(kappa) = 0.061. This was a satisfactory result regarding the features of RLS85. (4) As far as coverage is concerned, again--by the "sign" test--the predominance of RLS85 versus GCS (EMY profile) was accepted.

Observer agreement in the assessment of clinical signs in experimental allergic encephalomyelitis

Rats suffering from experimental allergic encephalomyelitis (EAE) were examined by a number of investigators whose assessments were compared. Considerable consensus of opinion was reached, especially when a standard, easily interpretable, scoring classification was used. More discrepancies occurred when a more expanded scale, differentiating between more clinical grades, was used. It is demonstrated that part of these discrepancies can be overcome by having the examinations done by the same investigator. Possible consequences of these findings for the assessment of clinical signs in EAE are discussed.

A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85)

The Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85) were compared for rating neurosurgical patients in regard to ranking order of deficit severity, interobserver variability, and coverage for relevant factors. Four physicians, four registered nurses, and four assistant nurses performed 72 pairwise ratings on 47 neurosurgical patients. The rank correlation between the GCS sum score and the RLS85 was -0.94, suggesting the same ranking order of severity and indicating that the underlying concepts of somnolence, delirium, and motor responses in coma are evaluated in the same way. By the sign test, the RLS85 was shown to have better interobserver agreement than the GCS sum score and the eye-motor-verbal (EMV) profile. The interobserver grading disagreements in both scales were distributed over the entire range of responsiveness, and for the GCS sum score they were slanted to combined segments 9 to 15. The RLS85 showed full coverage of relevant factors, while 43 (60%) of the 72 test occasions in the GCS sum score and the EMV profiles showed untestable features, most often because of patient intubation. The pseudoscore (that is, the choice of value given to untestable features) affects interobserver agreement as well as the estimated overall patient responsiveness in the GCS sum score. Assessment by the order of applying the scales showed a significant effect on the GCS eye-opening scale (p = 0.01) and the GCS sum score (p = 0.03), indicating a sensitivity to environmental stimuli unrelated to the patient's status. This study demonstrates that basically the same information as that found in the separate eye, motor, and verbal scales of the GCS can be combined directly into the RLS85, which has better interobserver agreement and better coverage than the GCS sum score.

Severity grading in self-poisoning

1. The reliability and validity of three different coma scales was studied in 26 patients with acute drug overdose. 2. A comparison of six painful stimulation techniques showed that sternal rubbing and retromandibular pressure were most effective. 3. The improper use of stimulation techniques may underestimate level of responsiveness in 4-19% of cases. 4. The Reaction Level Scale (RLS) was the most reliable scale. 5. Both the RLS and the Glasgow Coma Scale may be unnecessarily complicated for the evaluation of the drug overdose patient, but should be chosen if concomitant brain injury is suspected. 6. This study confirms the basic concepts and shows the reliability of the Matthew-Lawson scale for use in the poisoned patient.

Assessment of responsiveness in acute cerebral disorders. A multicentre study on the reaction level scale (RLS 85)

A new scale for assessment of overall responsiveness, the Reaction Level Scale (RLS 85), which has been shown to have better reliability than the Glasgow Coma Scale (GCS), has been tested in four neurosurgical departments regarding inter-observer agreement and coverage i.e. the proportion of patients that could be assessed by the scale. In a carefully designed study 51 observers pairwise performed 164 tests on 88 patients. Reliability was studied by the Kappa method, which is defined as inter-observer agreement corrected for agreement by chance. The inter-observer agreement measured as overall Kappa was good (K = 0.69 +/- 0.05) and there were no significant differences between the departments, professional categories or aetiologies. Regarding the separate RLS 85 levels the Kappa values were above 0.65, except for withdrawing (K = 0.51) and flexor responses (K = 0.55). There was good inter-observer agreement on coma (K = 0.71). In conclusion, the RLS 85 proved to be easily learnt, it showed full coverage without pseudoscoring, and it was used in a consistent way by doctors, nurses and assistant nurses of four different neurosurgical departments in two Scandinavian countries.

The Glasgow-Liège Scale. Prognostic value and evolution of motor response and brain stem reflexes after severe head injury

In 1982, we developed a new coma scale, the Glasgow-Liège Scale (GLS), which combines the Glasgow coma scale (GCS) with the quantified analysis of five brain stem reflexes. After severe head injury, the two most important parameters for determining the degree of encephalic disturbances are motor responses (M) and brain stem reflexes (R). The object of this study was to further evaluate the prognosis ability of M and R on admission and during the first month after injury. The study is based on 141 patients. The highest score, during the first day, was less than or equal to 7 on the GCS and 12 on the GLS. Using a multiple group logistic discriminant analysis, we confirmed that, in the first 24 hours, the study of brain stem reflexes appears to be the one factor with the best prognostic ability. We also showed that the prognostic value of certain signs is optimal for a limited period. If, within the two variables M and R, recovery follows an identical pattern whatever the final outcome may be, the restructing speed differs for each outcome. M follows an exponential curve spread over a long period explaining its importance in the course of time. On the other hand, R follows a linear model with straight lines more or less parallel for each outcome. R evolves over a short period of time. These clinical findings give us the opportunity to discuss the physio-pathology of head injury.

The Reaction Level Scale (RLS85). Manual and guidelines

The Reaction Level Scale (RLS85) is a "coma scale" for the direct assessment of overall reaction level in patients with acute brain disorders. It is devised for reliable use even in the management of patients who are difficult to assess, such as intubated patients and patients with swollen eyelids. We here present the manual of the RLS85 and the guidelines for its use. The underlying concepts as well as limitations are outlined. Condensed information of known reliability and validity is presented. A training scheme for presumed observers (doctors, nurses and assistant nurses) is outlined. It is suggested that users of the RLS85 refer to these guidelines and in scientific reports clearly state any deviations from this present manual in order to facilitate valid comparisons between different studies and different groups of patients.

Inter-observer variation on registration of signals of cancer

Previous studies have dealt with the role of seven warning signals of cancer in public health education and cancer diagnostics in general practice. Registrations of warning signals from medical records have some inconveniences common to most retrospective record studies. In the present inter-observer variation study it is found that agreement is good for warning signals in cancer patients when the warning signal has a probable connection with the disease. In control patients, and for more incidentally occurring warning signals in cancer patients, agreement is not so good. It seems that reproducible registrations from records are possible when there is a precise definition of what to look for and the data are relevant to the patient's disease. This study stresses the importance of good record keeping in medical practice.

Interobserver agreement in assessment of vestibulo-ocular responses

In 30 comatose head injured patients vestibulo-ocular responses were elicited by caloric stimulation. Inter- and intra-observer agreement of these responses was studied. The responses were shown in the form of a film to ten doctors who classified them into four categories: no reaction, tonic reaction, paradoxical nystagmus and nystagmus. The level of the coefficient Kappa (a chance-corrected measure of interobserver agreement) was 0.50; this is within the range of levels for most components of clinical examination reported in the literature.

Review of 1,000 consecutive cases of severe head injury treated before the advent of CT scanning

This is a review of 1,000 consecutive cases of severe head injury admitted to our Neurosurgical Department between January 1973 and August 1976, before the advent of CT scanning. All patients were comatose following head injury (GCS less than or equal to 8) and were treated homogeneously by the same neurosurgical team by a protocol that included immediate resuscitation on arrival, diagnosis of intracranial lesions by angiography, early surgery when needed, mechanical ventilation, steroids, and mannitol. Extracranial lesions, even if preponderant, were treated by various specialists in the Neurosurgical Department, which for all practical purposes operated as an Emergency Department. Admission criteria were very broad with no preadmission selection. The overall mortality for this series was 45%. A little less than half the patients made good recoveries or remained moderately disabled (47%); 6% were severely disabled, and 2% survived in a persistent vegetative state. More than two-thirds of the patients were brought to our Neurosurgical Department after a short stay at a general hospital; 72% were admitted within 6 hours of injury; 71% were traffic accident victims; and 34% had significant associated extracranial injuries. Carotid angiography was performed in 78% of the patients and indicated the presence of an intracranial haematoma requiring surgery in 36% of the whole series. Mortality was significantly higher in operated than in unoperated patients (56% versus 39%); those treated surgically, however, were older, in worse clinical condition, and showed a higher incidence of acute subdural haematomas associated with brain contusion. Carotid angiography proved very effective in revealing the presence of an expansive lesion but failed to reflect the severity of brain damage, since the group with "negative" angiograms showed a high mortality (52%). Patients with a lucid interval had a higher percentage of surgical lesions than those with immediate coma (58% versus 26%); but fully 42% of them did not require surgery, and 25% had negative angiograms. From the prognostic point of view the clinical data elicited after initial resuscitation were highly predictive of the outcome: some individual neurological signs, such as mydriasis, posturing and eye movements, were not inferior to the GCS score in that respect. Age also proved a strong predictor, since elderly patients are more likely to have severe subdural and parenchymal lesions and their clinical severity is accordingly greater.(ABSTRACT TRUNCATED AT 400 WORDS)