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Abstract Since its development in 1974, the Glasgow Coma Scale(GCS) has been the gold standard
for assessing the patients Level Of Consciousness(LOC) and acute changes in neurological status. Despite its
widespread use, the GCS has many limitations that are well documented. The Full Outline of
UnResponsiveness(FOUR) score is a new coma scale that was recently validated as a proposed alternative to
GCS. The main purpose of the study was to assess the reliability of the FOUR score in critically ill patients of
main ICU of PGIMER, Chandgiarh. In this study, scoring of GCS and FOUR score were performed by anesthetists
and nurses on 21 patients. In a total of 100 pair-wise ratings, the inter-rater agreement for both the FOUR score
(k = 0.65) and the GCS (k = 0.66) was good among nurse anesthetist pair. The internal consistency for both
the FOUR score ( = 0.97) and the GCS scale ( = 0.94) was excellent. A good correlation was found between
the FOUR score and the GCS ( = 0.94, p = 0.001). The predictive validity of the FOUR score [Area under the
receiver operating curve(AUROC)= 0.8] is slightly higher than the GCS (AUROC = 0.76) in this population.
But the results could not be concluded with the availability of very limited number of patients. Majority of the
raters strongly agreed that the FOUR score can be used as an alternative to the GCS scale, though there is no
significant difference in the raters opinion about both the scales. The study suggests that the new FOUR score
has precise clinical acumen in detecting subtle changes in neurological status as the GCS scale. Inclusion of
assessment of brainstem function along with the assessment of cortex function adds value to the new tool.
Keywords Introduction
Glasgow Coma Scale (GCS), Full Outline of
Consciousness is a state of general
UnResponsiveness score (FOUR),
Unconsciousness awareness of oneself and the environment
and includes the ability to orient towards new
Correspondance at stimuli.1 Despite advances in technology, a
thorough clinical assessment is still the key
Anita Mercy to identify subtle changes in a patients
MSc. Nursing 2nd yrs student (Oncology Nursing) neurological status and is fundamental to the
National Institute of Nursing Education (NINE), management of neuroscience patients. To
PGIMER, Chandigarh provide quality patient care, the bedside nurse
must therefore be able to accurately and
the GCS
Inter-rater agreement of the FOUR 2.50
R Sq Linear = 0.871
Table. 2: Kappa values for the inter-rater agreement of the FOUR score N = 100
Kappa value (k)
Rater Pair Total Eye Motor Brainste Respiration
n Score response response reflexes Score
Score Score Score
Nurse Nurse 29 0.47 0.58 0.74 0.74 0.90
Nurse Doctor 41 0.65 0.70 0.64 0.86 0.78
Doctor- Doctor 30 0.48 0.69 0.59 0.78 0.32 `
Overall 100 0.55 0.67 0.66 0.80 0.69
Table. 3: Kappa values for the inter-rater agreement of the GCS score N = 100
Kappa value (k)
Rater Pair n Total Eye response Motor response ROC Curve
ICU mortality status prediction using the FOUR score was analyzed using ROC curve
0.0
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
Reference Line
FOUR score
Figure 2. Predictive value of the GCS and the FOUR score for ICU Mortality
The descriptive statistics of the raters score can be used as an alternative to GCS.
opinion about the practical feasibility of the Very few among both the raters group
FOUR score is shown in table. 5. Among 31 were disagreeing that FOUR score can be used
raters, 20(64.5%) agreed to the statement that as an alternative to GCS. Most of the raters
FOUR score is reliable, 20(64.5%) agreed to expressed that they find difficulty in eliciting
the statement that FOUR score is easy to use, withdrawal response to pain and often face
13(41.9%) agreed to the statement that FOUR confusion between withdrawal response to
score is reproducible, 20(64.5%)agreed to the pain and flexion response to pain in GCS.
statement that FOUR score gives more clinical Some of them verbalized difficulty in
information, 16(51.6%) agreed to the assessing the motor component of GCS in
statement that FOUR score takes less time to quadriplegic patients. Raters felt that the
perform & 13(41.9%) agreed & 10(32.3%) addition of brain stem reflexes in FOUR score
strongly agreed to the statement that FOUR would give them more clinical information.