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A Pediatric FOUR Score Coma Scale: Interrater Reliability and Predictive Validity

Czaikowski, Brianna L.; Liang, Hong; Stewart, C. Todd

Journal of Neuroscience Nursing: April 2014 - Volume 46 - Issue 2 - p 79–87
doi: 10.1097/JNN.0000000000000041
Article

ABSTRACT: The Full Outline of UnResponsiveness (FOUR) Score is a coma scale that consists of four components (eye and motor response, brainstem reflexes, and respiration). It was originally validated among the adult population and recently in a pediatric population. To enhance clinical assessment of pediatric intensive care unit patients, including those intubated and/or sedated, at our children’s hospital, we modified the FOUR Score Scale for this population. This modified scale would provide many of the same advantages as the original, such as interrater reliability, simplicity, and elimination of the verbal component that is not compatible with the Glasgow Coma Scale (GCS), creating a more valuable neurological assessment tool for the nursing community. Our goal was to potentially provide greater information than the formally used GCS when assessing critically ill, neurologically impaired patients, including those sedated and/or intubated. Experienced pediatric intensive care unit nurses were trained as “expert raters.” Two different nurses assessed each subject using the Pediatric FOUR Score Scale (PFSS), GCS, and Richmond Agitation Sedation Scale at three different time points. Data were compared with the Pediatric Cerebral Performance Category (PCPC) assessed by another nurse. Our hypothesis was that the PFSS and PCPC should highly correlate and the GCS and PCPC should correlate lower. Study results show that the PFSS is excellent for interrater reliability for trained nurse–rater pairs and prediction of poor outcome and in-hospital mortality, under various situations, but there were no statistically significant differences between the PFSS and the GCS. However, the PFSS does have the potential to provide greater neurological assessment in the intubated and/or sedated patient based on the outcomes of our study.

Questions or comments about this article may be directed to Brianna L. Czaikowski, RN, at czaikowski.brianna@ministryhealth.org. She is a Registered Nurse in the Pediatric Intensive Care Unit, Ministry St. Joseph’s Hospital, Marshfield, WI.

Hong Liang, PhD, is a Biostatistician in the Biomedical Informatics Research Center, Marshfield Clinic Research Foundation, Marshfield, WI.

C. Todd Stewart, MD, was the Vice President and a Pediatric Intensivist at Marshfield Clinic/Ministry St. Joseph’s Hospital, Marshfield, WI.

This study was funded by the Marshfield Clinic’s physician research funds and the Marshfield Clinic Research Foundation’s disease specific funds.

The authors declare no conflicts of interest.

© 2014 American Association of Neuroscience Nurses