The current significance of the FOUR score: A systematic review and critical analysis of the literature

Anestis, Dimitrios M.; Tsitsopoulos, Parmenion P.; Tsonidis, Christos; Foroglou, Nicolas

doi:10.1016/j.jns.2019.116600

Cited by 19 publications

(16 citation statements)

References 126 publications

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“…Quadratic weighted Cohen's kappa (κ w ) values and intraclass correlation coefficients (two-way randomeffects, single rater, consistency ICC) with a confidence interval of 95% were calculated to assess interrater reliability. K w values of 0.40 or less suggest poor agreement, between 0.40 and 0.60 moderate, between 0.60 and 0.80 substantial and higher than 0.80 almost perfect agreement [13,14,29]. As per the ICC, values lower than 0.50 are considered poor, between 0.50 and 0.75 moderate, between 0.75 and 0.90 good, and higher than 0.90 excellent [30].…”

Section: Discussionmentioning

confidence: 99%

“…The Full Outline of Unresponsiveness (FOUR) score seems to be of particular interest, since it is increasingly implemented worldwide and already available in many languages, yet not in Greek [13]. This scale does not include a verbal component (an element that cannot be always reliably assessed), but it contains other important clinical indicators, such as the assessment of the patient's breathing pattern and brainstem reflexes [14].…”

Section: Introductionmentioning

confidence: 99%

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Cross-Cultural Adaptation and Validation of the Greek Version of the “Full Outline of Unresponsiveness Score”: A Prospective Observational Clinimetric Study in Neurosurgical Patients

et al. 2021

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Background: The Full Outline of Unresponsiveness (FOUR) score is a clinical instrument for the assessment of consciousness which is gradually gaining ground in clinical practice, as it incorporates more complete neurological information than the Glasgow Coma Scale (GCS). The main objectives of the current study were the following: (1) translate and cross-culturally adapt the FOUR score into Greek; (2) evaluate its clinimetric properties, including interrater reliability, internal consistency, and construct validity; and (3) evaluate the reliability of assessments among health care professionals with different levels of experience and training. Methods:The FOUR score was initially translated into Greek. Next, patients with neurosurgical pathologies in need of consciousness monitoring were independently assessed with the GCS and FOUR score within one hour by four raters who had different levels of experience and training (two board-certified neurosurgeons, a neurosurgery resident, and a registered nurse). Interrater reliability, internal consistency, and construct validity were evaluated for the scales using weighted Cohen's κ (κ w ) and intraclass correlation coefficients (ICC), Cronbach's α and Spearman's ρ values, respectively. Results: A total of 408 assessments were performed for 99 patients. The interrater reliability was excellent for both the FOUR score (ICC = 0.941) and GCS (ICC = 0.936). The values of κ w exceeded 0.90 for all pairs, suggesting that the FOUR score can be reliably applied by raters with varying experience. Among the scales' components, FOUR score's brainstem and respiratory items showed the lowest, yet high enough (κ w > 0.60), level of agreement. The interrater reliability remained excellent (κ w > 0.85, ICC > 0.90) for all diagnosis and age groups, with a trend toward higher FOUR score values in the most severe cases (ICC = 0.813 vs. 0.723). Both the FOUR score and GCS showed high internal consistency (Cronbach's α > 0.70 for all occasions). The FOUR score correlated strongly with GCS (Spearman's ρ > 0.90 for all raters), suggesting high construct validity.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Cross-Cultural Adaptation and Validation of the Greek Version of the “Full Outline of Unresponsiveness Score”: A Prospective Observational Clinimetric Study in Neurosurgical Patients

et al. 2021

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“…A GCS score of 3 is considered less predictive of outcome [2]. Patients with a GCS of 3 for a prolonged period during their stay in the neuro-ICU are difficult to monitor for subtle changes in their clinical condition [2]. This may occur because a GCS of 3 is frequently associated with iatrogenic causes such as sedation rather than the underlying neurological condition.…”

Section: Impaired Consciousnessmentioning

confidence: 99%

“…The validity of the FOUR score renders it a good predictor of patient outcome. Validity studies have assessed the FOUR score at a specific time point during ICU admission to define the best cut-off between favourable and unfavourable outcome, showing that the FOUR score compares favourably as a predictor [1,2,4,5].…”

Section: Impaired Consciousnessmentioning

confidence: 99%

“…In contrast, the Full Outline of UnResponsiveness (FOUR) score does not rely on verbal assessment and includes a detailed assessment of brainstem function (Table 1) [24]. The FOUR score, introduced in 2005 [ 24], has been extensively tested for validity, reliability, reproducibility and prognostic value, primarily in patients with traumatic brain injury but also in a broader neuro-ICU population [2]. In general, in patients with impaired consciousness, the FOUR score allows a finer gradation of consciousness levels but has, primarily due to the missing verbal sub-score, a disadvantage in patients with only a minimally impaired consciousness.…”

Section: Introductionmentioning

confidence: 99%

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Automated pupillometry and the FOUR score — what is the diagnostic benefit in neurointensive care?

et al. 2020

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Introduction The Glasgow Coma Scale (GCS) and visual inspection of pupillary function are routine measures to monitor patients with impaired consciousness and predict their outcome in the neurointensive care unit (neuro-ICU). Our aim was to compare more recent measures, i.e. FOUR score and automated pupillometry, to standard monitoring with the GCS and visual inspection of pupils. Methods Supervised trained nursing staff examined a consecutive sample of patients admitted to the neuro-ICU of a tertiary referral centre using GCS and FOUR score and assessing pupillary function first by visual inspection and then by automated pupillometry. Clinical outcome was evaluated 6 months after admission using the Glasgow Outcome Scale-Extended. Results Fifty-six consecutive patients (median age 63 years) were assessed a total of 234 times. Of the 36 patients with at least one GCS score of 3, 13 had a favourable outcome. All seven patients with at least one FOUR score of ≤ 3 had an unfavourable outcome, which was best predicted by a low "brainstem" sub-score. Compared to automated pupillometry, visual assessment underestimated pupillary diameters (median difference, 0.4 mm; P = 0.006). Automated pupillometry detected a preserved pupillary light reflex in 10 patients, in whom visual inspection had missed pupillary constriction. Discussion Training of nursing staff to implement frequent monitoring of patients in the neuro-ICU with FOUR score and automated pupillometry is feasible. Both measures provide additional clinical information compared to the GCS and visual assessment of pupillary function, most importantly a more granular classification of patients with low levels of consciousness by the FOUR score. Keywords Consciousness. FOUR. GCS. Automated pupillometry. Prognostic marker This article is part of the Topical Collection on Neurosurgical intensive care

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Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

Ahmadi

Sarveazad

Babahajian

et al. 2022

Eur J Trauma Emerg Surg

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The current significance of the FOUR score: A systematic review and critical analysis of the literature

Cited by 19 publications

References 126 publications

Cross-Cultural Adaptation and Validation of the Greek Version of the “Full Outline of Unresponsiveness Score”: A Prospective Observational Clinimetric Study in Neurosurgical Patients

Cross-Cultural Adaptation and Validation of the Greek Version of the “Full Outline of Unresponsiveness Score”: A Prospective Observational Clinimetric Study in Neurosurgical Patients

Automated pupillometry and the FOUR score — what is the diagnostic benefit in neurointensive care?

Comparison of Glasgow Coma Scale and Full Outline of UnResponsiveness score for prediction of in-hospital mortality in traumatic brain injury patients: a systematic review and meta-analysis

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