title: Comparison of mental-status scales for predicting mortality on the general wards.
abstract: BACKGROUND
  Altered mental status is a significant predictor of mortality in inpatients. Several scales exist to characterize mental status, including the AVPU (Alert, responds to Voice, responds to Pain, Unresponsive) scale, which is used in many early-warning scores in the general-ward setting. The use of the Glasgow Coma Scale (GCS) and Richmond Agitation Sedation Scale (RASS) is not well established in this population.
  
  
  OBJECTIVE
  To compare the accuracies of AVPU, GCS, and RASS for predicting inpatient mortality.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Single, urban, academic medical center.
  
  
  METHODS
  Adult inpatients on the general wards.
  
  
  METHODS
  Nurses recorded GCS and RASS on consecutive adult hospitalizations. AVPU was extracted from the eye subscale of the GCS. We compared the accuracies of each scale for predicting in-hospital mortality within 24 hours of a mental-status observation using area under the receiver operating characteristic curves (AUC).
  
  
  RESULTS
  There were 295,974 paired observations of GCS and RASS obtained from 26,873 admissions; 417 (1.6%) resulted in in-hospital death. GCS and RASS more accurately predicted mortality than AVPU (AUC 0.80 and 0.82, respectively, vs 0.73; P < 0.001 for both comparisons). Simultaneous use of GCS and RASS produced an AUC of 0.85 (95% confidence interval: 0.82-0.87, P < 0.001 when compared to all 3 scales).
  
  
  CONCLUSIONS
  In ward patients, both GCS and RASS were significantly more accurate predictors of mortality than AVPU. In addition, combining GCS and RASS was more accurate than any scale alone. Routine tracking of GCS and/or RASS on general wards may improve the accuracy of detecting clinical deterioration.
authors.affiliation: Section of Hospital Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Zadravecz
authors.affiliation: Pritzker School of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Linda
authors.initials: L
authors.lastname: Tien
authors.affiliation: Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Robertson-Dick
authors.affiliation: Section of Hospital Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Trevor C
authors.initials: TC
authors.lastname: Yuen
authors.affiliation: Section of Hospital Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Nicole M
authors.initials: NM
authors.lastname: Twu
authors.affiliation: Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Matthew M
authors.initials: MM
authors.lastname: Churpek
authors.affiliation: Section of Hospital Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Dana P
authors.initials: DP
authors.lastname: Edelson
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D016638:Critical Illness; D005260:Female; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D057209:Hospital Rapid Response Team; D006757:Hospital Units; D006801:Humans; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods*; D012189:Retrospective Studies