Neurology/original researchInterrater Reliability of 3 Simplified Neurologic Scales Applied to Adults Presenting to the Emergency Department With Altered Levels of Consciousness
Introduction
Patients presenting to the emergency department (ED) with altered levels of consciousness of traumatic and nontraumatic cause require careful assessment and continuous monitoring. Historically, a variety of neurologic scales has been used to monitor these patients, including the Glasgow Coma Scale (GCS),1 Advanced Trauma Life Support AVPU (Alert, responds to Verbal stimuli, responds to Painful stimuli, Unresponsive) scale,2 ACDU (Alert, Confused, Drowsy, Unresponsive) scale,3 and Swedish Reaction Level Scale.4 With the exception of the GCS, most of these have never undergone prospective assessment to ensure reliability and validity but have rather been adapted for use either because of institutional preference or ease of application. The GCS has recently been found to exhibit only moderate interrater reliability when tested in the ED setting in patients with altered levels of consciousness from traumatic and nontraumatic causes.5
Recently Gill et al6 proposed a statistically derived scale, the Simplified Motor Scale (SMS), as a potential replacement for the GCS. The SMS was found to perform as well as the GCS at predicting 4 clinical outcomes after traumatic brain injury in 8,000 patients. Although these findings pointed toward the potential of the SMS to replace the more complex GCS, the SMS would require prospective validation in a new sample of patients with altered levels of consciousness from traumatic and nontraumatic causes before clinical application.
In this study, we chose to test the interrater reliability of the AVPU scale, ACDU scale, and SMS prospectively when applied to patients presenting to the ED with altered levels of consciousness from traumatic and nontraumatic causes. If found to demonstrate improved interrater reliability when compared with the GCS in the clinical setting, 1 or more of these alternative scales could replace this more complex neurologic scale for the assessment of patients with altered levels of consciousness in the ED.
Section snippets
Study Design and Setting
This prospective, observational study examined the interrater reliability of the GCS, its 3 components, and the SMS, AVPU, and ACDU scales when measured by 2 attending-level physicians within 5 minutes in adults (17 years of age or older) presenting to our ED with altered levels of consciousness. Enrollment took place during a 14-month study period in our ED, which is a Level I trauma center with a census of 69,000 patients per year. Convenience sampling took place during an even distribution
Results
Enrollment was initiated in 126 patients by 20 emergency physicians, with 6 patients being excluded from the final analysis because of lack of complete data recorded on their prospective data form. We analyzed the data from the remaining 120 patients (52% men, 48% women), from whom we obtained a total of 240 paired readings. The median subject age was 58 years (range 18 to 89 years) (Table 2).
The 3 scales with the best interrater agreement in terms of percent agreements and κ values were the
Limitations
Because we chose not to exclude intubated patients from the study, it is possible that the interrater agreement of all scores were inflated. Most intubated patients had been given hypnotic and paralytic drugs as part of the rapid sequence intubation protocol, and therefore their scores could have been artificially and uniformly GCS=3, AVPU=0, ACDU=0, and SMS=0. Because there is no universal agreement about the assignment of neurologic scores to intubated patients, we chose not to instruct our
Discussion
In this study, we found that the SMS (2=obeys commands, 1=localizes pain, 0= withdrawal to pain or less response) outperformed other proposed simplified neurologic scales when tested prospectively for interrater reliability in ED patients presenting with altered mental status of nontraumatic (76%) and traumatic (23%) causes. For purposes of comparison, we also tested interrater reliability of the components of the GCS and total GCS score for each patient, and although the GCS components
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Supervising editor: E. John Gallagher, MD
Author contributions: MG and SG conceived of the study idea. MG, KM, ELL, and AS compiled the study data. MG and SG performed the data analyses, and all authors contributed to the writing and revision of the paper. MG takes responsibility for the paper as a whole.
Funding and support: The authors report this study did not receive any outside funding or support.
Available online June 6, 2006.
Reprints not available from the authors.