The endorsement of the four score for consciousness assessment in neurosurgical patients

Abstract

Background: Glasgow Coma Scale (GCS) has been accepted for neurological assessment but it has some pitfalls during the assessment, e.g. not included brainstem indicators, obscured verbal response by intubation, etc. The FOUR (Full Outline of UnResponsiveness) score which evaluated eye response, motor response, brainstem reflexes and respiration has been developed but it has not been validated in neurosurgical patients. The study is aimed to endorse the FOUR score to GCS in practical environment. Material and methods: Awake, drowsy, stuporous, comatose patients were studied. Four evaluator groups; 2 expert clinicians (EC), 2 novice clinicians (NC), 2 experienced nurses (EN), 2 apprenticed nurses (AN) assessed 64 patients to assure each rater group reliability. Then, thirty six were evaluated by 1 EC and 1 from the others randomly to test the difference of both total scores by Wilcoxon’s signed rank test. Spearman’s correlation was used to find the correlation between both scores from 68 patients evaluated by EC. The estimation of FOUR score cut points were estimated and validated by weighted kappa (k) compared with the GCS to establish the risk prognosis. Score feasibility was analyzed by nonparametric test. Results: Intraclass correlation in each group was over 0.9 and there were no difference between the scoring from expert and inexperienced raters (p>0.05). The scores’ correlation was good (r=0.78). The low, intermediate and high risk prognostic groups were ranged 0-7, 8-14 and 15-16 by FOUR score with k=0.92. The feasibility of FOUR score was lower than the GCS (p<0.01). Conclusion: The FOUR score is reliable and valid for consciousness evaluation with some consequences in practicability. The extensive implementation would make it more familiar.