Serial Neurologic Assessment in Pediatrics (SNAP): A New Tool for Bedside Neurologic Assessment of Critically Ill Children*

Abstract

We developed a tool, Serial Neurologic Assessment in Pediatrics, to screen for neurologic changes in patients, including those who are intubated, are sedated, and/or have developmental disabilities. Our aims were to: 1) determine protocol adherence when performing Serial Neurologic Assessment in Pediatrics, 2) determine the interrater reliability between nurses, and 3) assess the feasibility and acceptability of using Serial Neurologic Assessment in Pediatrics compared with the Glasgow Coma Scale. DESIGN: Mixed-methods, observational cohort. SETTING: Pediatric and neonatal ICUs. SUBJECTS: Critical care nurses and patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Serial Neurologic Assessment in Pediatrics assesses Mental Status, Cranial Nerves, Communication, andMotor Function, with scales for children less than 6 months, greater than or equal to 6 months to less than 2 years, and greater than or equal to 2 years old. We assessed protocol adherence with standardized observations. We assessed the interrater reliability of independent Serial Neurologic Assessment in Pediatrics assessments between pairs of trained nurses by percent-and bias-adjusted kappa and percent agreement. Semistructured interviews with nurses evaluated acceptability and feasibility after nurses used Serial Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale during routine care. Ninety-eight percent of nurses (43/44) had 100% protocol adherence on the standardized checklist. Forty-three nurses performed 387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < 6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability was substantial to near-perfect across all components for each age-based Serial Neurologic Assessment in Pediatrics scale. Percent agreement was independent of developmental disabilities for all Serial Neurologic Assessment in Pediatrics components except Mental Status and lower extremity Motor Function for patients deemed "Able to Participate" with the assessment. Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, compared with Glasgow Coma Scale, was easier to use and clearer in describing the neurologic status of patients who were intubated, were sedated, and/or had developmental disabilities. About 92% of nurses preferred to use Serial Neurologic Assessment in Pediatrics over Glasgow Coma Scale. CONCLUSIONS: When used by critical care nurses, Serial Neurologic Assessment in Pediatrics has excellent protocol adherence, substantial to nearperfect interrater reliability, and is feasible to implement. Further work will determine the sensitivity and specificity for detecting clinically meaningful neurologic decline.

Improving “Neuro Checks” in Neonatal ICU and PICU Is a Serial Neurologic Assessment in Pediatrics*

“…SNAP checks can be performed at admission, recorded over time, and communicated among critical care nurses and practitioners in a clear and concise manner. The perceived contribution of SNAP to nursing assessments was better than the GCS in the study by Kirschen et al (3). If SNAP is proven to be a reliable and valid measure and monitor of neurologic status in the NICU and PICU, SNAP has implications for nursing and critical care practice (13).…”

“…Kirschen et al (3), in their article published in this issue of Pediatric Critical Care Medicine , developed a new standardized screening tool for bedside nurses to score the neurologic status of critically ill patients in the neonatal ICU (NICU) and PICU setting, known as “Serial Neurologic Assessment in Pediatrics” (SNAP). SNAP is a blend of components of the Glasgow Coma Scale (GCS) (4), Full Outline of UnResponsiveness (FOUR) score (5), and pediatric National Institutes of Health Stroke Scale (NIHSS) (6) and has several strengths.…”

“…Compared with the GCS, SNAP emphasizes the importance of a more complete neurologic assessment with an ordinal arrangement of the degree of impairment in mental status, cranial nerves, communication, and motor function and linearity of all components (equal weighting to individual units of the score). Additionally, SNAP includes separate scales for infants (< 6 mo), toddlers (≥ 6 mo to < 2 yr), and children (≥ 2 yr old) (3). Last, SNAP is most akin to the FOUR score, which has shown good validity (7, 8) and correlation with outcome (9) in critically ill adults in medical ICUs.…”

Editor’s Choice Articles for May

“…The idea started with the authors' response to a local need, followed by them developing an evidence-based framework for practice. Now, they share their work, clinical framework, and Robert C. Tasker, MBBS, MD, FRCP [1][2][3] Editor's Choice Articles for May checklist so that other pediatric intensive care practitioners can adapt and use these materials for similar needs. Figures 1 and 2 in the article are a wonderful resource.…”

“…The second article reports a framework for compassionate end-of-life endotracheal extubation at home (2). My third choice describes the feasibility of implementing a new tool for serial neurologic assessment in pediatrics (SNAP) in critically ill patients (3). All three articles (1–3) and related editorial material (4–7) will be freely available for the next two months.…”