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Intensive Care Medicine
Published in: Intensive Care Medicine 1/2016

01-01-2016 | Systematic Review

The reliability of the Glasgow Coma Scale: a systematic review

Authors: Florence C. M. Reith, Ruben Van den Brande, Anneliese Synnot, Russell Gruen, Andrew I. R. Maas

Published in: Intensive Care Medicine | Issue 1/2016

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Abstract

Introduction

The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS.

Methods

A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively.

Results

We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85 %, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used.

Conclusions

Only 13 % of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
Appendix
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Literature
1.
Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84CrossRefPubMed
2.
Koziol J, Hacke W (1990) Multivariate data reduction by principal components with application to neurological scoring instruments. J Neurol 237:461–464CrossRefPubMed
3.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829CrossRefPubMed
4.
Vincent JL, Moreno R, Takala J et al (1996) The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710CrossRefPubMed
5.
Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963CrossRefPubMed
6.
7.
Murray GD, Butcher I, McHugh GS et al (2007) Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:329–337CrossRefPubMed
8.
9.
10.
Sun S (2011) Meta-analysis of Cohen’s kappa. Health Serv Outcomes Res Methodol 11:145–163CrossRef
11.
12.
Green SM (2011) Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med 58:427–430CrossRefPubMed
13.
14.
Wijdicks EFM (2006) Clinical scales for comatose patients: the Glasgow Coma Scale in historical context and the new FOUR Score. Rev Neurol Dis 3:109–117PubMed
15.
16.
Prasad K (1996) The Glasgow Coma Scale: a critical appraisal of its clinimetric properties. J Clin Epidemiol 49:755–763CrossRefPubMed
17.
18.
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMed
19.
20.
Fleiss J (1986) The design and analysis of clinical experiments. Wiley, New York
21.
Teasdale G, Knill-Jones R, van der Sande J (1978) Observer variability in assessing impaired consciousness and coma. J Neurol Neurosurg Psychiatry 41:603–610PubMedCentralCrossRefPubMed
22.
Heron R, Davie A, Gillies R, Courtney M (2001) Interrater reliability of the Glasgow Coma Scale scoring among nurses in sub-specialties of critical care. Aust Crit Care 14:100–105CrossRefPubMed
23.
Nunnally JC, Bernstein IH (1994) Psychometric theory, 3rd edn. McGraw-Hill, New York
24.
Menegazzi JJ, Davis EA, Sucov AN, Paris PM (1993) Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma 34:46–48CrossRefPubMed
25.
Hollander JE, Go S, Lowery DW et al (2003) Inter-rater reliability of criteria used in assessing blunt head injury patients for intracranial injuries. Acad Emerg Med 10:830–835CrossRefPubMed
26.
Kho ME, McDonald E, Stratford PW, Cook DJ (2007) Interrater reliability of APACHE II scores for medical-surgical intensive care patients: a prospective blinded study. Am J Crit Care 16:378–383PubMed
27.
Wenner JB, Norena M, Khan N et al (2009) Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II Score, and predicted probability of mortality in an electronic intensive care unit database. J Crit Care 24:401–407CrossRefPubMed
28.
Chen LM, Martin CM, Morrison TL, Sibbald WJ (1999) Interobserver variability in data collection of the APACHE II score in teaching and community hospitals. Crit Care Med 27:1999–2004CrossRefPubMed
29.
Diringer MN, Edwards DF (1997) Does modification of the Innsbruck and the Glasgow Coma Scales improve their ability to predict functional outcome? Arch Neurol 54:606–611CrossRefPubMed
30.
Sadaka F, Patel D, Lakshmanan R (2012) The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 16:95–101CrossRefPubMed
31.
Gill MR, Reiley DG, Green SM (2004) Inter-rater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med 43:215–223CrossRefPubMed
32.
33.
Juarez VJ, Lyons M (1995) Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs 27:283–286CrossRefPubMed
34.
Rowley G, Fielding K (1991) Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet 337:535–538CrossRefPubMed
35.
Fielding K, Rowley G (1990) Reliability of assessments by skilled observers using the Glasgow Coma Scale. Aust J Adv Nurs 7:13–17PubMed
36.
Gill M, Martens K, Lynch EL et al (2007) Inter-rater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness. Ann Emerg Med 49:403–407CrossRefPubMed
37.
Koch D, Linn S (2000) The Glasgow Coma Scale and the challenge of clinimetrics. Int Med J 7:51–60
38.
39.
McHugh ML (2012) Interrater reliability: the kappa statistic. Biochem Medica 22:276–282CrossRef
40.
Heard K, Bebarta VS (2004) Reliability of the Glasgow Coma Scale for the emergency department evaluation of poisoned patients. Hum Exp Toxicol 23:197–200CrossRefPubMed
41.
Le Roux P, Menon DK, Citerio G et al (2014) Consensus summary statement of the international multidisciplinary consensus conference on multimodality monitoring in neurocritical care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Intensive Care Med 40(9):1189–1209. doi:10.​1007/​s00134-014-3369-6 CrossRefPubMed
42.
Livingston BM, Mackenzie SJ, MacKirdy FN, Howie JC (2000) Should the pre-sedation Glasgow Coma Scale value be used when calculating acute physiology and chronic health evaluation scores for sedated patients? Scottish Intensive Care Society Audit Group. Crit Care Med 28:389–394CrossRefPubMed
43.
Rutledge R, Lentz CW, Fakhry S, Hunt J (1996) Appropriate use of the Glasgow Coma Scale in intubated patients: a linear regression prediction of the Glasgow Verbal Score from the Glasgow Eye and Motor scores. J Trauma 41:514–522CrossRefPubMed
44.
45.
46.
Zhao X (2011) When to use Cohen’s k, if Ever?. International Communication Association 2011 Conference, Boston, pp 1–30
47.
Braakman R, Avezaat CJ, Maas AI et al (1977) Inter observer agreement in the assessment of the motor response of the Glasgow coma scale. Clin Neurol Neurosurg 80:100–106CrossRefPubMed
48.
Rimel RW, Jane JA, Edlich RF (1979) An injury severity scale for comprehensive management of central nervous system trauma. JACEP 8:64–67CrossRefPubMed
49.
Lindsay KW, Teasdale GM, Knill-Jones RP (1983) Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg 58:57–62CrossRefPubMed
50.
Stanczak DE, White JG 3rd, Gouview WD et al (1984) Assessment of level of consciousness following severe neurological insult. A comparison of the psychometric qualities of the Glasgow Coma Scale and the comprehensive level of Consciousness Scale. J Neurosurg 60:955–960. doi:10.​3171/​jns.​1984.​60.​5.​0955 CrossRefPubMed
51.
52.
Starmark JE, Stalhammar D, Holmgren E, Rosander B (1988) A comparison of the Glasgow Coma Scale and the Reaction Level Scale (RLS85). J Neurosurg 69:699–706CrossRefPubMed
53.
Tesseris J, Pantazidis N, Routsi C, Fragoulakis D (1991) A comparative study of the Reaction Level Scale (RLS85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (modified) (E2CS(M)). Acta Neurochir Wien 110:65–76CrossRefPubMed
54.
Ellis A, Cavanagh SJ (1992) Aspects of neurosurgical assessment using the Glasgow Coma Scale. Intensive Crit Care Nurs 8:94–99CrossRefPubMed
55.
Oshiro EM, Walter KA, Piantadosi S et al (1997) A new subarachnoid hemorrhage grading system based on the Glasgow Coma Scale: a comparison with the Hunt and Hess and World Federation of Neurological Surgeons Scales in a clinical series. Neurosurgery 41:140–147CrossRefPubMed
56.
Crossman J, Bankes M, Bhan A, Crockard HA (1998) The Glasgow Coma Score: reliable evidence? Injury 29:435–437CrossRefPubMed
57.
Wijdicks EF, Kokmen E, O’Brien PC (1998) Measurement of impaired consciousness in the neurological intensive care unit: a new test. J Neurol Neurosurg Psychiatry 64:117–119PubMedCentralCrossRefPubMed
58.
Lane PL, Baez AA, Brabson T et al (2002) Effectiveness of a Glasgow Coma Scale instructional video for EMS providers. Prehosp Disaster Med 17:142–146PubMed
59.
Ely EW, Truman B, Shintani A et al (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289:2983–2991CrossRefPubMed
60.
Wijdicks EF, Bamlet WR, Maramattom BV et al (2005) Validation of a new Coma Scale: the FOUR score. Ann Neurol 58:585–593CrossRefPubMed
61.
Holdgate A, Ching N, Angonese L (2006) Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness. Emerg Med Australas 18:379–384CrossRefPubMed
62.
Baez AA, Giraldez EM, De Pena JM (2007) Precision and reliability of the Glasgow Coma Scale score among a cohort of Latin American prehospital emergency care providers. Prehosp Disaster Med 22:230–232CrossRefPubMed
63.
Kerby JD, MacLennan PA, Burton JN et al (2007) Agreement between prehospital and emergency department Glasgow Coma Scores. J Trauma 63:1026–1031CrossRefPubMed
64.
Wolf CA, Wijdicks EF, Bamlet WR, McClelland RL (2007) Further validation of the FOUR Score Coma Scale by intensive care nurses. Mayo Clin Proc 82:435–438CrossRefPubMed
65.
Nassar AP Jr, Neto RCP, de Figueiredo WB, Park M (2008) Validity, reliability and applicability of Portuguese versions of Sedation-Agitation Scales among critically ill patients. Sao Paulo Med J 126:215–219CrossRef
66.
Akavipat P (2009) Endorsement of the FOUR Score for consciousness assessment in neurosurgical patients. Neurol Med Chir Tokyo 49:565–571CrossRefPubMed
67.
68.
Ryu WHA, Feinstein A, Colantonio A et al (2009) Early identification and incidence of mild TBI in Ontario. Can J Neurol Sci 36:429–435CrossRefPubMed
69.
Stead LG, Wijdicks EF, Bhagra A et al (2009) Validation of a new Coma Scale, the FOUR Score, in the emergency department. Neurocrit Care 10:50–54CrossRefPubMed
70.
Fischer M, Ruegg S, Czaplinski A et al (2010) Inter-rater reliability of the Full Outline of Unresponsiveness Score and the Glasgow Coma Scale in critically ill patients: a prospective observational study. Crit Care 14:R64PubMedCentralCrossRefPubMed
71.
Idrovo L, Fuentes B, Medina J et al (2010) Validation of the FOUR Score (Spanish Version) in acute stroke: an interobserver variability study. Eur Neurol 63:364–369CrossRefPubMed
72.
Necioglu Orken D, Kocaman Sagduyu A, Sirin H et al (2010) Reliability of the Turkish version of a new Coma Scale: FOUR Score. Balk Med J 27:28–31
73.
Ashkenazy S, DeKeyser-Ganz F (2011) Assessment of the reliability and validity of the Comfort Scale for adult intensive care patients. Heart Lung 40:e44–e51CrossRefPubMed
74.
Bruno MA, Ledoux D, Lambermont B et al (2011) Comparison of the FOUR and Glasgow Liege Scale/Glasgow Coma Scale in an intensive care unit population. Neurocrit Care 15:447–453CrossRefPubMed
75.
Gujjar AR, Nandagopal R, Jacob PC et al (2011) FOUR Score–a new Coma Score: inter-observer reliability and relation to outcome in critically ill medical patients. Eur J Neurol 18:441
76.
Kevric J, Jelinek GA, Knott J, Weiland TJ (2011) Validation of the Full Outline of Unresponsiveness (FOUR) Scale for conscious state in the emergency department: comparison against the Glasgow Coma Scale. Emerg Med J 28:486–490CrossRefPubMed
77.
Namiki J, Yamazaki M, Funabiki T, Hori S (2011) Inaccuracy and misjudged factors of Glasgow Coma Scale scores when assessed by inexperienced physicians. Clin Neurol Neurosurg 113:393–398CrossRefPubMed
78.
Patel D, Sadaka F, Lakshmanan R (2011) The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 15:S238
79.
Takahashi C, Okudera H, Origasa H et al (2011) A simple and useful coma scale for patients with neurologic emergencies: the Emergency Coma Scale. Am J Emerg Med 29:196–202CrossRefPubMed
80.
Winship C, Williams B, Boyle M (2011) Assessment of the Glasgow Coma Scale: a pilot study examining the accuracy of paramedic undergraduates. Australas J Paramed 10:11
81.
Marcati E, Ricci S, Casalena A et al (2012) Validation of the Italian version of a new Coma Scale: the Four Score. Intern Emerg Med 7:145–152CrossRefPubMed
82.
Winship C, Williams B, Boyle MJ (2012) Should an alternative to the Glasgow Coma Scale be taught to paramedic students? Emerg Med J 30:e19CrossRefPubMed
83.
Benítez-Rosario MA, Castillo-Padrós M, Garrido-Bernet B et al (2013) Appropriateness and reliability testing of the modified richmond Agitation-Sedation Scale in Spanish patients with advanced cancer. J Pain Symptom Manag 45:1112–1119CrossRef
84.
Dinh MM, Oliver M, Bein K et al (2013) Level of agreement between prehospital and emergency department vital signs in trauma patients. Emerg Med Australas 25:457–463PubMed
85.
Gujjar AR, Jacob PC, Nandhagopal R et al (2013) FOUR score and Glasgow Coma Scale in medical patients with altered sensorium: interrater reliability and relation to outcome. J Crit Care 28(316):e1–e8PubMed
Metadata
Title
The reliability of the Glasgow Coma Scale: a systematic review
Authors
Florence C. M. Reith
Ruben Van den Brande
Anneliese Synnot
Russell Gruen
Andrew I. R. Maas
Publication date
01-01-2016
Publisher
Springer Berlin Heidelberg
Published in
Intensive Care Medicine / Issue 1/2016
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-015-4124-3

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