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American Journal of Nursing Research. 2019, 7(1), 79-86
DOI: 10.12691/ajnr-7-1-11
Open AccessArticle

Full Outline of Un-Responsiveness Scale (FOUR) Versus Modified Glasgow Coma Scale (GCS) in Predicting Discharge Outcomes of Altered Consciousness Patients

Samah A Shalaby1, , Nagwa A Reda1 and Noha O Emam2

1Critical Care and Emergency Nursing Department, Faculty of Nursing, Alexandria University, Alexandria, Egypt

2Critical Care Department, Assuit University Hospital, Assuit, Egypt

Pub. Date: January 03, 2019

Cite this paper:
Samah A Shalaby, Nagwa A Reda and Noha O Emam. Full Outline of Un-Responsiveness Scale (FOUR) Versus Modified Glasgow Coma Scale (GCS) in Predicting Discharge Outcomes of Altered Consciousness Patients. American Journal of Nursing Research. 2019; 7(1):79-86. doi: 10.12691/ajnr-7-1-11


Objective: Altered consciousness level is common in critically ill patients. Neurological assessment of these patients and their outcomes prediction are challenging for critical nurses. This study aimed to compare between Full Outline of Un-Responsiveness Scale and Modified Glasgow Coma Scale in predicting discharge outcomes in altered consciousness patients. Research Methodology: A descriptive design was followed in this study which was conducted at Trauma Intensive Care, Neurological Intensive Care and Neurosurgery Intensive Care units in Assuit University Hospital. Three tools were utilized to collect the data. Results: Patients' outcomes on discharge were; 3% regained consciousness and discharged to home; around one third regained consciousness and transferred to ward; some of them experienced co-morbidities; and nearly half of them were died after experiencing secondary brain injury. Almost one third of patients who were alive on discharge had physical disabilities and co-morbidities. Conclusions: The components of FOUR score and MGCS had different predictive abilities. FOUR score had higher accuracy prediction of in-hospital outcomes and the prognostic power than MGCS in the first three assessment days. Therefore, this study’s results would be supported by other studies that recruited a larger number of patients with different acuity levels within more hospitals.

altered level of consciousness unconscious patients coma scales FOUR score GCS

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[1]  Palmer, R. and Knight, J., “Assessment of altered conscious level in clinical practice”, British journal of nursing, 15 (22). 1255-9. Dec 2006.
[2]  Blume, C., Del Giudice, R., Wislowska, M., Lechinger, J. and Schabus M. “Across the consciousness continuum-from unresponsive wakefulness to sleep”, Frontiers in human neuroscience, 9. 105-14. Mar. 2015.
[3]  Riker, R. and Fugate, J., “Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium”, Neurocritical care, 21 (2). 27-37. Dec. 2014.
[4]  Wenham, T. and Pittard, A., “Intensive care unit environment”, Continuing Education in Anaesthesia, Critical Care & Pain, 9 (6). 178-83. Dec. 2009.
[5]  Gill, M., Martens, K., Lynch, E., Salih, A. and Green, S., “Interrater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness”, Annals of emergency medicine, 49 (4). 403-7. Apr.2007.
[6]  Bernat, J.L., “The natural history of chronic disorders of consciousness”, Neurology, 75 (3). 206-7. Jul. 2010.
[7]  Owen, A. M., “Disorders of consciousness”, Annals of the New York Academy of Sciences, 1124 (1). 225-38. Mar. 2008.
[8]  Di Perri, C., Stender, J., Laureys, S. and Gosseries, O., “Functional neuroanatomy of disorders of consciousness”, Epilepsy & Behavior, 30. 28-32. Jan. 2014.
[9]  Ting, W. K., Perez Velazquez, J. L. and Cusimano, M. D., “Eye movement measurement in diagnostic assessment of disorders of consciousness”, Frontiers in neurology, 5. 137-9. Jul. 2014.
[10]  Mehta, S., Cook, D., Devlin, J.W., Skrobik, Y., Meade, M., Fergusson, D., Herridge, M., Steinberg, M., Granton, J., Ferguson, N. and Tanios, M., “Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults”, Critical care medicine, 43 (3). 557-66. Mar. 2015.
[11]  Horsting, M. W., Franken, M. D., Meulenbelt, J., van Klei, W. A. and de Lange, D.W., “The etiology and outcome of non-traumatic coma in critical care: a systematic review”, BMC anesthesiology. 15 (1). 65-8. Dec. 2015.
[12]  Kanich, W., Brady, W. J., Huff, J. S., Perron, A. D., Holstege, C., Lindbeck, G. and Carter, C. T., “Altered mental status: evaluation and etiology in the ED”, The American journal of emergency medicine, 20 (7). 613-7. Nov. 2002.
[13]  Teasdale, G. and Jennett, B., “Assessment of coma and impaired consciousness: a practical scale”, The Lancet, 304 (7872). 81-4. Jul. 1974.
[14]  Kornbluth, J. and Bhardwaj, A., “Evaluation of coma: a critical appraisal of popular scoring systems” Neurocritical care, 14 (1). 134-43. Feb. 2011.
[15]  Mercy, A., Thakur, S. R., Yaddanapudi, S. and Bhagat, H., “Can FOUR Score replace GCS for assessing neurological status of critically ill patients-An Indian Study”, Nurse Midwifery Res J, 9 (2). 63-72. Apr. 2013.
[16]  Jalali, R. and Rezaei, M., “A comparison of the Glasgow Coma Scale score with full outline of unresponsiveness scale to predict patients’ traumatic brain injury outcomes in intensive care units”, Critical care research and practice, 2014. 1-4. 2014.
[17]  Pape, T. L., Heinemann, A. W., Kelly, J. P., Hurder, A. G. and Lundgren, S., “A measure of neurobehavioral functioning after coma. Part I: Theory, reliability, and validity of the Disorders of Consciousness Scale”, Journal of Rehabilitation Research & Development, 42(1). 1-18. Jan. 2005.
[18]  Matis, G. and Birbilis, T., “The Glasgow Coma Scale-a brief review Past, present, future”, Acta Neurol Belg. 108 (3). 75-89. Sep. 2008.
[19]  Tatman, A., Warren, A., Williams, A., Powell, J. E. and Whitehouse, W., “Development of a modified paediatric coma scale in intensive care clinical practice”, Archives of Disease in Childhood, 77 (6). 519-21. Dec. 1997.
[20]  Wijdicks, E. F., Bamlet, W. R., Maramattom, B. V., Manno, E. M. and McClelland, R. L., “Validation of a new coma scale: the FOUR score”, Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society. 58 (4). 585-93. Oct. 2005.
[21]  Tadrisi, S. D., Bahari, N., Ebadi, A. and Madani, S. J., “Validity and reliability of coma scale (Four Score) in adult patient hospitalized in critical care units.” Critical Care Nursing, 5 (13). 95-102. 2012.
[22]  Keykha, A., Askari, H., Navidian, A. and Hosseini, B. M., “Ability of Glasgow Coma Scale and Full Outline of Unresponsiveness Score in Measuring Level of Consciousness and Outcome in Patients Receiving Sedation Under Mechanical Ventilation.” Journal of Critical Care Nursing, 10 (1). 10160-6. Feb. 2017.
[23]  Fischer, M., Rüegg, S., Czaplinski, A., Strohmeier, M., Lehmann, A., Tschan, F., Hunziker, P. R. and Marsch, S. C., “Inter-rater reliability of the Full Outline of UnResponsiveness score and the Glasgow Coma Scale in critically ill patients: a prospective observational study”, Critical care, 14 (2). R64. Apr. 2010.
[24]  Cohen, J., “Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population”, Journal of Neuroscience Nursing. 41 (5). 261-7.41. Oct. 2009.
[25]  Stead, L. G., Wijdicks, E. F., Bhagra, A., Kashyap, R., Bellolio, M. F., Nash, D. L., Enduri, S., Schears, R. and William, B., “Validation of a new coma scale, the FOUR score, in the emergency department”, Neurocritical care, 10 (1). 50-4. Feb. 2009.
[26]  Bruno, M. A., Ledoux, D., Lambermont, B., Damas, F., Schnakers, C., Vanhaudenhuyse, A., Gosseries, O. and Laureys, S., “Comparison of the Full Outline of UnResponsiveness and Glasgow Liege Scale/Glasgow Coma Scale in an intensive care unit population”, Neurocritical care, 15 (3). 447-53. Dec. 2011.
[27]  Iyer, V. N., Mandrekar, J. N., Danielson, R. D., Zubkov, A. Y., Elmer, J. L. and Wijdicks, E. F., “Validity of the FOUR score coma scale in the medical intensive care unit”, Mayo Clinic Proceedings, 84 (8). 694-701). Aug. 2009.
[28]  McNett, M. M. and Gianakis, A., “Nursing interventions for critically ill traumatic brain injury patients”, Journal of Neuroscience Nursing, 42 (2). 71-7. Apr. 2010.
[29]  Summers, D., Leonard, A., Wentworth, D., Saver, J. L., Simpson, J., Spilker, J. A., Hock, N., Miller, E. and Mitchell, P. H., “Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association”, Stroke, 40 (8). 2911-44. Aug. 2009.
[30]  Wuchner, S. S., Bakas, T., Adams, G., Buelow, J. and Cohn, J., “Nursing interventions and assessments for aneurysmal subarachnoid hemorrhage patients: a mixed methods study involving practicing nurses”, Journal of Neuroscience Nursing, 44 (4). 177-85. Aug. 2012.
[31]  Watson, D., “The impact of accurate patient assessment on quality of care”, Nursing Times, 102 (6). 34-7. Feb. 2006.
[32]  McHugh, G. S., Engel, D. C., Butcher, I., Steyerberg, E. W., Lu, J., Mushkudiani, N., Hernandez, A. V., Marmarou, A., Maas, A. I. and Murray, G. D., “Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study”, Journal of neurotrauma. 24 (2). 287-93. Feb. 2007.
[33]  Stevens, R. D. and Bhardwaj, A., “Approach to the comatose patient”, Critical care medicine, 34 (1). 31-41. Jan. 2006.
[34]  Ganesh, S., Guernon, A., Chalcraft, L., Harton, B., Smith, B. and Pape, T.L., “Medical comorbidities in disorders of consciousness patients and their association with functional outcomes”, Archives of physical medicine and rehabilitation, 94(10): 1899-907. Oct. 2013.
[35]  Sharshar, T., Citerio, G., Andrews, P. J., Chieregato, A., Latronico, N., Menon, D. K., Puybasset, L., Sandroni, C. and Stevens, R. D., “Neurological examination of critically ill patients: a pragmatic approach. Report of an ESICM expert panel”, Intensive care medicine, 40 (4). 484-95. Apr. 2014.
[36]  Leitgeb, J., Mauritz, W., Brazinova, A., Majdan, M., Janciak, I., Wilbacher, I. and Rusnak, M., “Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury”, European Journal of Trauma and Emergency Surgery, 39 (3). 285-92. Jan. 2913.
[37]  Elliott, M. and Coventry, A., “Critical care: the eight vital signs of patient monitoring”, British Journal of Nursing, 21 (10). 621-5. May. 2012.
[38]  Mena, J. H., Sanchez, A. I., Rubiano, A. M., Peitzman, A. B., Sperry, J. L., Gutierrez, M. I. and Puyana, J. C., “Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13”, The Journal of trauma, 71 (5). 1185. Nov. 2011.
[39]  Singh, B., Murad, M. H., Prokop, L. J., Erwin, P. J., Wang, Z., Mommer, S. K., Mascarenhas, S. S. and Parsaik, A. K., “Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes”, Brain injury, 27 (3). 293-300. Mar. 2013.
[40]  Bordini, A. L., Luiz, T. F., Fernandes, M., Arruda, W. O. and Teive, H. A., “Coma scales: a historical review”, Arquivos de neuro-psiquiatria, 68 (6). 930-7. Dec. 2010.
[41]  Chen, B., Grothe, C. and Schaller, K., “Validation of a new neurological score (FOUR Score) in the assessment of neurosurgical patients with severely impaired consciousness”, Acta neurochirurgica, 155 (11). 2133-9. Nov. 2013.
[42]  Akavipat, P., Sookplung, P., Kaewsingha, P. and Maunsaiyat, P., “Prediction of discharge outcome with the full outline of unresponsiveness (FOUR) score in neurosurgical patients”, Acta Medica Okayama, 65 (3). 205-10. Jun. 2011.
[43]  Murthy, T. V., Bhatia, P., Sandhu, K., Prabhakar, T. and Gogna, R. L., “Secondary brain injury: Prevention and intensive care management”, Indian Journal of Neurotrauma, 2 (01). 7-12. Jun. 2005.
[44]  Puggina, A., da Silva, M., Schnakers, C. and Laureys, S., “Nursing care of patients with disorders of consciousness”, Journal of Neuroscience Nursing, 44 (5). 260-70. Oct. 2012.
[45]  Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M, Peitz, G. J. and Ely, E. W., “Critical care nurses’ role in implementing the “ABCDE bundle” into practice”, Critical care nurse, 32 (2). 35-47. Apr. 2012.
[46]  Sudarsanam, T. D., Jeyaseelan, L., Thomas, K. and John, G., “Predictors of mortality in mechanically ventilated patients”, Postgraduate medical journal, 81 (962). 780-3. Dec. 2005.
[47]  Rimachi, R., Vincent, J. L. and Brimioullem S., “Survival and quality of life after prolonged intensive care unit stay”, Anaesthesia and intensive care. 35 (1). 62-7. Feb. 2007.
[48]  Kim, Y. J., “The impact of time from ED arrival to surgery on mortality and hospital length of stay in patients with traumatic brain injury”, Journal of Emergency Nursing, 37 (4). 328-33. Jul. 2011.
[49]  Esquevin, A., Raoult, H., Ferré, J. C., Ronzière, T., Stamm, A., Perennes, M., Bellou, A. and Gauvrit, J. Y., “Systematic combined noncontrast CT-CT angiography in the management of unexplained nontraumatic coma”, The American journal of emergency medicine, 31 (3). 494-8. Mar. 2013.
[50]  Greer, D. M., Yang, J., Scripko, P.D., Sims, J. R., Cash, S., Kilbride, R., Wu, O., Hafler, J. P., Schoenfeld, D. A. and Furie, K. L., “Clinical examination for outcome prediction in nontraumatic coma”, Critical care medicine. 40 (4). 1150-6. Apr. 2012.