title: Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study.
abstract: BACKGROUND
  The Glasgow Coma Scale (GCS) is the most widely used scoring system for comatose patients in intensive care. Limitations of the GCS include the impossibility to assess the verbal score in intubated or aphasic patients, and an inconsistent inter-rater reliability. The FOUR (Full Outline of UnResponsiveness) score, a new coma scale not reliant on verbal response, was recently proposed. The aim of the present study was to compare the inter-rater reliability of the GCS and the FOUR score among unselected patients in general critical care. A further aim was to compare the inter-rater reliability of neurologists with that of intensive care unit (ICU) staff.
  
  
  METHODS
  In this prospective observational study, scoring of GCS and FOUR score was performed by neurologists and ICU staff on 267 consecutive patients admitted to intensive care.
  
  
  RESULTS
  In a total of 437 pair wise ratings the exact inter-rater agreement for the GCS was 71%, and for the FOUR score 82% (P = 0.0016); the inter-rater agreement within a range of +/- 1 score point for the GCS was 90%, and for the FOUR score 92% (P = ns.). The exact inter-rater agreement among neurologists was superior to that among ICU staff for the FOUR score (87% vs. 79%, P = 0.04) but not for the GCS (73% vs. 73%). Neurologists and ICU staff did not significantly differ in the inter-rater agreement within a range of +/- 1 score point for both GCS (88% vs. 93%) and the FOUR score (91% vs. 88%).
  
  
  CONCLUSIONS
  The FOUR score performed better than the GCS for exact inter-rater agreement, but not for the clinically more relevant agreement within the range of +/- 1 score point. Though neurologists outperformed ICU staff with regard to exact inter-rater agreement, the inter-rater agreement of ICU staff within the clinically more relevant range of +/- 1 score point equalled that of the neurologists. The small advantage in inter-rater reliability of the FOUR score is most likely insufficient to replace the GCS, a score with a long tradition in intensive care.
authors.affiliation: Department of Medical Intensive Care, University Hospital, Spitalstrasse, Basel, Switzerland. mfischer@uhbs.ch
authors.forename: Michael
authors.initials: M
authors.lastname: Fischer
authors.forename: Stephan
authors.initials: S
authors.lastname: Rüegg
authors.forename: Adam
authors.initials: A
authors.lastname: Czaplinski
authors.forename: Monika
authors.initials: M
authors.lastname: Strohmeier
authors.forename: Angelika
authors.initials: A
authors.lastname: Lehmann
authors.forename: Franziska
authors.initials: F
authors.lastname: Tschan
authors.forename: Patrick R
authors.initials: PR
authors.lastname: Hunziker
authors.forename: Stephan C
authors.initials: SC
authors.lastname: Marsch
mesh_terms: D000368:Aged; D003128:Coma / Q000145:classification / Q000175:diagnosis; D003244:Consciousness Disorders / Q000145:classification / Q000175:diagnosis*; D016638:Critical Illness / Q000453:epidemiology*; D005260:Female; D015600:Glasgow Coma Scale / Q000592:standards*; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D011446:Prospective Studies; D015203:Reproducibility of Results; D013557:Switzerland / Q000453:epidemiology
references.citation: Am J Crit Care. 2007 Jul;16(4):378-83
references.pmid: 17595370
references.citation: Eur J Emerg Med. 2009 Feb;16(1):29-36
references.pmid: 19106717
references.citation: J Neurosurg. 1984 May;60(5):955-60
references.pmid: 6716164
references.citation: J Neurotrauma. 2007 Feb;24(2):329-37
references.pmid: 17375997
references.citation: J Neurol Neurosurg Psychiatry. 2004 Jan;75(1):161-2
references.pmid: 14707332
references.citation: BMJ. 1997 Feb 22;314(7080):572
references.pmid: 9055718
references.citation: Ann Neurol. 2005 Oct;58(4):585-93
references.pmid: 16178024
references.citation: J Neurosurg. 1988 Nov;69(5):699-706
references.pmid: 3054013
references.citation: Lancet. 1991 Oct 19;338(8773):977-8
references.pmid: 1681344
references.citation: Ann Emerg Med. 2007 Apr;49(4):403-7, 407.e1
references.pmid: 17141146
references.citation: Lancet. 1974 Jul 13;2(7872):81-4
references.pmid: 4136544
references.citation: Ann Emerg Med. 2005 Jan;45(1):37-42
references.pmid: 15635308
references.citation: Mayo Clin Proc. 2007 Apr;82(4):435-8
references.pmid: 17418071
references.citation: JAMA. 2003 Jun 11;289(22):2983-91
references.pmid: 12799407
references.citation: Mayo Clin Proc. 2009 Aug;84(8):694-701
references.pmid: 19648386
references.citation: Biometrics. 1977 Mar;33(1):159-74
references.pmid: 843571