Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale*

Abstract

Objectives: Estimate the inter-rater reliability of critical care nurses performing a pediatric modification of the Glasgow Coma Scale in a contemporary PICU. Design: Prospective observation study. Setting: Large academic PICU. Patients/Subjects: All 274 nurses with permanent assignments in the PICU were eligible to participate. A subset of 18 nurses were selected as study registered nurses. All PICU patients were eligible to participate. Interventions: None. Measurements and Main Results: PICU nurses were educated and demonstrated proficiency on a pediatric modification of the Glasgow Coma Scale we created to make it more applicable to a diverse PICU population that included patients who are sedated, mechanically ventilated, and/or have developmental disabilities. Each study registered nurse observed a sample of nurses perform the Glasgow Coma Scale, and they independently scored the Glasgow Coma Scale. Patients were categorized as having developmental disabilities if their preillness Pediatric Cerebral Performance Category score was greater than or equal to 3. Fleiss’ Kappa (κ), intraclass correlation coefficient, and percent agreement assessed inter-rater reliability for each Glasgow Coma Scale component (eye, verbal, motor) and age-specific scale (≥ 2 and < 2-yr-old). The overall percent agreement between study registered nurses and nurses was 89% for the eye, 91% for the verbal, and 79% for the motor responses. Inter-rater reliability ranged from good (intraclass correlation coefficient = 0.75) to excellent (intraclass correlation coefficient = 0.96) for testable patients. Agreement on the motor response was significantly lower for children with developmental disabilities (< 2 yr: 59% vs 95%; p = 0.0012 and ≥ 2 yr: 55% vs 91%; p = 0.0012). Agreement was significantly worse for intermediate range Glasgow Coma Scale motor responses compared with responses at the extremes (e.g., motor responses 2, 3, 4 vs 1, 5, 6; p < 0.05). Conclusions: A pediatric modification of the Glasgow Coma Scale performed by trained PICU nurses has excellent inter-rater reliability, although reliability was reduced in patients with developmental disabilities and for intermediate range Glasgow Coma Scale responses. Further research is needed to determine the effectiveness of this Glasgow Coma Scale modification to detect clinical deterioration.

Status 1B designation does not adequately prioritize children with acute‐on‐chronic liver failure for liver transplantation

“…The GCS is a cursory measurement tool with low interrater reliability that was not developed to detect subtleties in encephalopathy and may not be an appropriate tool to identify neurologic failure in children with ACLF. [ 16 ] Furthermore, there are no studies that compare how GCS and hepatic encephalopathy grades correlate in children with liver failure. An additional critique of the status 1B criteria for ACLF is that cardiovascular compromise is not included in the criteria despite high vasopressor requirements being demonstrated in ACLF.…”

Nontraumatic coma in the pediatric intensive care unit: etiology, clinical characteristics and outcome

“…The study was conducted on patients aged 1 month to 17 years who were admitted to our tertiary PICU between March 2015 and November 2019. The modified GCS scoring system was used [3]. The GCS of patients and its relationship with prognosis and etiology were assessed by dividing the study population into three groups depending on the level of consciousness at admission: the first group was comprised of those with a GCS score of 10-12 (mild encephalopathy), the second group had moderate encephalopathy (GCS: 7-9), and the third group had severe encephalopathy (GCS: [14,15,16].…”

“…It is a very serious condition that necessitates immediate medical decision making upon arrival at the pediatric emergency department or pediatric intensive care unit (PICU) [1]. The most common scoring system used for assessment of consciousness is the Glasgow coma scale (GCS), and a modified version of the GCS is used in pediatric patients [2,3]. Pediatric coma is generally defined as having a GCS of < 12 for at least 6 hours [4].…”

Assessment and Treatment of Concussion in the Pediatric Population

“…The individual components are also listed, along with the total score (e.g., E3V3M5, GCS 11). Studies have shown that the pediatric scores have excellent inter-rater reliability 22 (►Table 1).…”