Acute Crit Care.  2024 Aug;39(3):408-419. 10.4266/acc.2024.00570.

The Glasgow Coma Scale and Full Outline of Unresponsiveness score evaluation to predict patient outcomes with neurological illnesses in intensive care units in West Bank: a prospective cross-sectional study

• Omar WM
• Khader IRA
• Hani SB
• ALBashtawy M

• KMID: 2563530
• DOI: http://doi.org/10.4266/acc.2024.00570

Abstract

Background
Determining the clinical neurological state of the patient is essential for making decisions and forecasting results. The Glasgow Coma Scale and the Full Outline of Unresponsiveness (FOUR) Scale are commonly used tools for measuring behavioral consciousness. This study aims to compare scales among patients with neurological disorders in intensive care units (ICUs) in the West Bank.
Methods
A prospective cross-sectional design was employed. All patients admitted to ICUs who met inclusion criteria were involved in this study. Data were collected from from An-Najah National University, Al-Watani, and Rafedia Hospital. Both tools were used to collect data.
Results
A total of 84 patients were assessed, 69.0% of the patients were male, and the average length of stay was 6.4 days. The mean score on the Glasgow Coma scale was 11.2 on admission 11.6 after 48 hours, and 12.2 on discharge. The mean FOUR Scale score was 12.2 on admission, 12.4 after 48 hours, and 12.5 at discharge.
Conclusions
This study indicates that both the Glasgow Coma Scale and the FOUR scale are effective in predicting outcomes for neurologically deteriorated critically ill patients. However, the FOUR scale proved to be more reliable when assessing outcomes in ICU patients.

Keyword

intensive clinical units; Full Outline of Unresponsiveness scale; Glasgow Coma Scale; neurological assessment; unresponsiveness patients

Figure

• 

  Figure 1. Flowchart of the Patient Selection Process for the Study on Neurological Disorders in intensive care units (ICUs) in the West Bank. NNUH: An-Najah National University Hospital.

• 

  Figure 2. Area under the curve of Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) scales in predicting intensive care unit neurological patient’s mortality. ROC: receiver operating characteristic.

• 

  Figure 3. Survival analysis curve of neurological intensive care unit (ICU) study participants.

Reference

1. Cooksley T, Rose S, Holland M. A systematic approach to the unconscious patient. Clin Med (Lond). 2018; 18:88–92.

2. Abdo WF, Broerse CI, Grady BP, Wertenbroek AA, Vijlbrief O, Buise MP, et al. Prolonged unconsciousness following severe COVID-19. Neurology. 2021; 96:e1437–42.

3. Abira DK. A comparison of the Glasgow Coma Scale with full outline of unresponsiveness scale in prediction of patient outcomes in the critical care unit at Kenyatta National Hospital. [dissertation]. University of Nairobi;2020.

4. Demirbilek H, Vuralli D, Haris B, Hussain K. Managing severe hypoglycaemia in patients with diabetes: current challenges and emerging therapies. Diabetes Metab Syndr Obes. 2023; 16:259–73.

5. Marino MH, Whyte J. Treatment trials in disorders of consciousness: challenges and future directions. Brain Sci. 2022; 12:569.

6. Wiberg S, Hassager C, Stammet P, Winther-Jensen M, Thomsen JH, Erlinge D, et al. Single versus serial measurements of neuron-specific enolase and prediction of poor neurological outcome in persistently unconscious patients after out-of-hospital cardiac arrest: a TTM-Trial Substudy. PLoS One. 2017; 12:e0168894.

7. Ramazani J, Hosseini M. Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in medical intensive care unit. Ann Card Anaesth. 2019; 22:143–8.

8. Reith FC, Van den Brande R, Synnot A, Gruen R, Maas AI. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med. 2016; 42:3–15.

9. Kornbluth J, Bhardwaj A. Evaluation of coma: a critical appraisal of popular scoring systems. Neurocrit Care. 2011; 14:134–43.

10. Foo CC, Loan JJM, Brennan PM. The relationship of the FOUR score to patient outcome: a systematic review. J Neurotrauma. 2019; 36:2469–83.

11. Anestis DM, Tsitsopoulos PP, Tsonidis CA, Foroglou N. The current significance of the FOUR score: a systematic review and critical analysis of the literature. J Neurol Sci. 2020; 409:116600.

12. Jain S, Iverson LM. Glasgow coma scale. StatPearls Publishing;2024.

13. Wahlster S, Wijdicks EF, Patel PV, Greer DM, Hemphill JC 3rd, Carone M, et al. Brain death declaration: practices and perceptions worldwide. Neurology. 2015; 84:1870–9.

14. Kanwal NA, Inayat AM, Zarnigar AJ, Anjum SA, Anjum NA, Latif WA. Knowledge & practice of GCS among nurses working at ICU: cross sectional study. Pak J Med Health Sci. 2022; 16:131–3.

15. Jalali R, Rezaei M. A comparison of the Glasgow Coma Scale score with full outline of unresponsiveness scale to predict patients’ traumatic brain injury outcomes in intensive care units. Crit Care Res Pract. 2014; 2014:289803.

16. Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005; 58:585–93.

17. Almojuela A, Zeiler FA, Hasen M, Honey CM. P.059: A systematically conducted review of the Full Outline of UnResponsiveness (FOUR) score and its use in outcome prediction. Can J Neurol Sci. 2018; 45(s2):S31.

18. Dwivedi A, Singh NK, Mehta A, Singh AK, Chaudhary PK. A comparative study to evaluate prognostic value of Glasgow Coma Score and Full Outline of Unresponsiveness Scale to predict the outcome of unconscious child in the paediatric intensive care unit. J Med Evid. 2003; 4:207–12.

19. Abdallah A, Demaerschalk BM, Kimweri D, Aden AA, Zhang N, Butterfield R, et al. A comparison of the Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) scores in predicting mortality among patients with reduced level of consciousness in Uganda. Neurocrit Care. 2020; 32:734–41.

20. Hassan AA, Ahmed H, Kandeel NA. Evidence related to predictive scales for trauma patients' outcome: literature review. Mansoura Nurs J. 2022; 9:163–76.

21. Alhassan A, Fuseini AG, Musah A. Knowledge of the Glasgow Coma Scale among nurses in a tertiary hospital in Ghana. Nurs Res Pract. 2019; 2019:5829028.

22. Aleid A, Alzahrani BS, Alameer MH, Alhassan AJ, Alahmed I. Bilateral spontaneous resolution of traumatic epidural hematoma: a case report and literature review. Cureus. 2023; 15:e39379.

23. Bayraktar YS, Sahinoglu M, Cicekci F, Kara I, Karabagli H, Duman A, et al. Comparison of Glasgow Coma Scale and Full Outline of Unresponsiveness (FOUR) score: a prospective study. Turk Neurosurg. 2019; 29:285–8.

24. Bailey CS, Fisher CG, Dvorak MF. Type II error in the spine surgical literature. Spine (Phila Pa 1976). 2004; 29:1146–9.

25. Israel GD. Determining sample size. University of Florida Cooperative Extension Service, Institute of Food and Agriculture Sciences. EDIS;1992.

26. Basak D, Chatterjee S, Attergrim J, Sharma MR, Soni KD, Verma S, et al. Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: a multicentre prospective cohort study. Injury. 2023; 54:93–9.

27. Amirtharaj AD, Balachandran S, Gujjar AR, Arulappan J, Jaypal SK. Comparison of Full Outline of Unresponsiveness (FOUR) and Glasgow Coma Scale (GCS) in determining outcome among patients in critical care units: a prospective study. Int J Nutr Pharm Neurol Dis. 2023; 13:145–51.

28. Yan X, Xiao L, Liao M, Huang J, He Z, Yan T. The validity, reliability and feasibility of four instruments for assessing the consciousness of stroke patients in a neurological intensive care unit compared. BMC Med Res Methodol. 2022; 22:102.

29. Qasem Surrati AM, Mohammedsaeed W, Shikieri AB. Cardiovascular risk awareness and calculated 10-year risk among female employees at Taibah University 2019. Front Public Health. 2021; 9:658243.

30. Özçelik EE, Celik S. Comparison of the Turkish versions of the Glasgow coma scale and four score used by intensive care nurses for neurological evaluation. J Clin Nurs. 2022; 31:1397–406.

31. Bani Hani S, Ahmad M. Effective prediction of mortality by heart disease among women in Jordan using the chi-squared automatic interaction detection model: retrospective validation study. JMIR Cardio. 2023; 7:e48795.

32. Wilberforce C, Odero W, Menya D. Commercial bicyclist injuries in Kisumu City, Kenya: an epidemiology of a neglected problem. Int J Innov Sci Res. 2015; 14:228–35.

33. Erkabu SG, Agedie Y, Mihretu DD, Semere A, Alemu YM. Ischemic and hemorrhagic stroke in Bahir Dar, Ethiopia: a retrospective hospital-based study. J Stroke Cerebrovasc Dis. 2018; 27:1533–8.

34. Vaisi raygani AA, Darabi M, Jalali R, Beiki O, Abdi A. Investigating RTS, TRISS, GCS, and FOUR as measures for predicting the mortality in trauma patients: a prospective study. J Emerg Med Trauma Acute Care. 2023; 2023:1:2.

35. Olsen HT, Nedergaard HK, Strøm T, Oxlund J, Wian KA, Ytrebø LM, et al. Nonsedation or light sedation in critically ill, mechanically ventilated patients. N Engl J Med. 2020; 382:1103–11.

36. Mortensen CB, Kjær MN, Egerod I. Caring for non-sedated mechanically ventilated patients in ICU: a qualitative study comparing perspectives of expert and competent nurses. Intensive Crit Care Nurs. 2019; 52:35–41.

37. Abd Elrazek Baraka A, Shalaby SA. Effect of training sessions about Full Outline of Un-Responsiveness scale compared to Glasgow Coma Scale on nurses’ performance, perception and its reliability. Egypt J Health Care. 2021; 12:54–72.

38. Sepahvand E, Jalali R, Mirzaei M, Ebrahimzadeh F, Ahmadi M, Amraii E. Glasgow Coma Scale versus Full Outline of UnResponsiveness Scale for prediction of outcomes in patients with traumatic brain injury in the intensive care unit. Turk Neurosurg. 2016; 26:720–4.