Validation of the Chinese version of the FOUR score in the assessment of neurosurgical patients with different level of consciousness.

Xiaomei Zhang,Juan Peng,Fangyao Chen,Yingying Deng,Xiaoyan Wang,Binghui Qiu,Hongzhen Zhou,Ying Zhou

doi:10.1186/s12883-015-0508-9

Abstract

BackgroundThe Glasgow Coma Scale (GCS) is currently the most widely used scoring system for comatose patients. A decade ago, the Full Outline of Unresponsiveness (FOUR) score was devised to better capture four functional aspects of consciousness (eye, motor responses, brainstem reflexes, and respiration). This study aimed to validate the Chinese version of the FOUR score in patients with different levels of consciousness.MethodsThe study had two phases: (1) translation of the FOUR score, and (2) assessment of its reliability and validity. The Chinese version of the FOUR score was developed according to a standardized protocol. One hundred-twenty consecutive patients with acute brain damage, admitted to Nanfang Hospital (Southern Medical University, Guangdong, China) from November 2014 to February 2015, were enrolled. The inter-rater agreement for the FOUR score and GCS was evaluated using intraclass correlation coefficient (ICC). Receiver operating characteristic (ROC) curves were established to determine the scales’ abilities to predict outcome.ResultsThe rater agreement was excellent both for FOUR (ICC = 0.970; p < 0.001) and GCS (ICC = 0.958; p < 0.001). The FOUR score yielded an excellent test-retest reliability (ICC = 0.930; p < 0.001). Spearman’s correlation coefficients between GCS and the FOUR score were high: r = 0.932, first rating; r = 0.887, second rating (all p < 0.001). Areas under the curve (AUC) for mortality were 0.834 (95 % CI, 0.740–0.928) and 0.815 (95 % CI, 0.723–0.908) for the FOUR score and GCS, respectively.ConclusionsThe Chinese version of the FOUR score is a reliable scale for evaluating the level of consciousness in patients with acute brain injury.

Highlights

The Glasgow Coma Scale (GCS) is currently the most widely used scoring system for comatose patients
For the Full Outline of Unresponsiveness (FOUR) score, the maximum grade of 16 was the most represented among the patients, corroborating the results obtained for motor response, respiration, and brain stem response; the majority of patients had an eye sub-score of 0
This study demonstrated that the Chinese version of the FOUR score has a good concurrent validity, a high degree of internal consistency, and a good inter-rater reliability among medical staff, and is at least as good as the GCS

Summary

Introduction

The Glasgow Coma Scale (GCS) is currently the most widely used scoring system for comatose patients. A decade ago, the Full Outline of Unresponsiveness (FOUR) score was devised to better capture four functional aspects of consciousness (eye, motor responses, brainstem reflexes, and respiration). The Glasgow Coma Scale (GCS) is a widely used tool to measure objectively the patient’s level of consciousness (LOC) in the clinical setting. A novel coma scaling system, the Full Outline of Un-Responsiveness (FOUR) score was developed by the Mayo Clinic in 2005 [3]. It evaluates four functional categories: eye response, motor response, brainstem reflexes, and respiration pattern (including mechanical ventilation). Previous studies compared the FOUR score to the GCS score and showed that they were comparable [10,11,12,13,14]

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