Full Outline of UnResponsiveness score versus Glasgow Coma Scale in critically ill patients with altered sensorium: A comparison of inter-observer variability and outcomes

BACKGROUND AND AIMS: Glasgow Coma scale (GCS), the most widely used tool for evaluation of the level of consciousness has various limitations. The Full Outline of UnResponsiveness (FOUR) score is a possible alternative. The present study was designed to examine the inter-rater reliability and outcome predictability of these scores in the Intensive Care Unit (ICU). METHODS: The GCS and FOUR scores of 111 adult patients with altered sensorium, admitted to the ICU, were assessed as early as possible after admission by the Senior Resident (SR), Junior Resident (JR) and Staff Nurse (SN) of ICU. The outcomes measured survival and modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) of the patients at discharge. RESULTS: The inter-observer agreement was measured using the kappa ('k') statistic. For GCS it was higher (k = 0.472 to 0.555) than FOUR score (k = 0.352 to 0.448). A higher 'k' score in either score was recorded between SR and JR. Linear regression analysis showed no significant association of either score with the duration of ICU stay or mechanical ventilation. Survival in ICU was correlated with both GCS and FOUR scores on logistic regression. GOS and mRS were correlated with either GCS or FOUR scores on ordinal regression. CONCLUSION: The inter-observer agreement with FOUR score was not superior to GCS in this study, possibly due to lack of familiarity with the FOUR score. Both the scores were statistically correlated with the rate of survival.