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The Reliability of the Glasgow Coma Scale: a Systematic Review

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The Reliability of the Glasgow Coma Scale: a Systematic Review Intensive Care Med (2016) 42:3–15 DOI 10.1007/s00134-015-4124-3 SYSTEMATIC REVIEW Florence C. M. Reith The reliability of the Glasgow Coma Scale: Ruben Van den Brande Anneliese Synnot a systematic review Russell Gruen Andrew I. R. Maas R. Gruen influence on results considered. Reli- Received: 15 July 2015 Central Clinical School, Monash University, Accepted: 26 October 2015 ability estimates were synthesized Melbourne, Australia Published online: 12 November 2015 narratively. Results: We identified Ó Springer-Verlag Berlin Heidelberg and 52 relevant studies that showed sig- ESICM 2015 R. Gruen Lee Kong Chian School of Medicine, nificant heterogeneity in the type of Take-home message: The overall Nanyang Technological University, reliability estimates used, patients reliability of the GCS is adequate, but can Singapore, Singapore studied, setting and characteristics of be improved by a renewed focus on observers. Methodological quality adequate training and standardization. The A. Synnot methodological quality of reliability studies was good (n = 7), fair (n = 18) or ANZIC-RC, Department of Epidemiology poor (n = 27). In good quality stud- should be improved. and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 ies, kappa values were C0.6 in 85 %, Electronic supplementary material and all intraclass correlation coeffi- The online version of this article Commercial Road, Melbourne, VIC 3004, (doi:10.1007/s00134-015-4124-3) contains Australia cients indicated excellent reliability. supplementary material, which is available Poor quality studies showed lower to authorized users. R. Gruen reliability estimates. Reliability for Central Clinical School, Level 6, The Alfred the GCS components was higher than Centre, 99 Commercial Road, Melbourne, for the sum score. Factors that may VIC 3004, Australia F. C. M. Reith ()) Á influence reliability include education R. Van den Brande Á A. I. R. Maas and training, the level of conscious- Department of Neurosurgery, Antwerp Abstract Introduction: The Glas- ness and type of stimuli used. University Hospital, Wilrijkstraat 10, gow Coma Scale (GCS) provides a Conclusions: Only 13 % of studies 2650 Edegem, Belgium structured method for assessment of were of good quality and inconsis- e-mail: fl[email protected] Tel.: ?3238214401 the level of consciousness. Its derived tency in reported reliability estimates sum score is applied in research and was found. Although the reliability F. C. M. Reith Á R. Van den Brande Á adopted in intensive care unit scoring was adequate in good quality studies, A. I. R. Maas systems. Controversy exists on the further improvement is desirable. University of Antwerp, Edegem, Belgium reliability of the GCS. The aim of this From a methodological perspective, systematic review was to summarize the quality of reliability studies needs A. Synnot evidence on the reliability of the to be improved. From a clinical per- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of GCS. Methods: A literature search spective, a renewed focus on training/ Public Health and Preventive Medicine, was undertaken in MEDLINE, education and standardization of Monash University, Melbourne, Australia EMBASE and CINAHL. Observa- assessment is required. tional studies that assessed the A. Synnot reliability of the GCS, expressed by a Keywords Glasgow Coma Scale Á Cochrane Consumers and Communication statistical measure, were included. Glasgow Coma Score Á Review Group, Centre for Health Methodological quality was evaluated Grading scales Á Reliability Á Communication and Participation, School of Psychology and Public Health, La Trobe with the consensus-based standards Reproducibility of results Á University, Melbourne, Australia for the selection of health measure- Systematic review ment instruments checklist and its 4 Introduction Methods The Glasgow Coma Scale (GCS), introduced in 1974, A protocol for this review was registered on PROSPERO was the first grading scale to offer an objective (ID: CRD42014009488). The focus of the review was assessment of the consciousness of patients [1]. The narrowed to reliability after publication of the protocol, assessment of motor, verbal and eye responses of the but methods were followed as per protocol. We adhered GCS characterizes the level of consciousness. The to reporting and conduct guidance based on the preferred picture provided by these responses enables compar- reporting items for systematic review and meta-analysis ison both between patients and of changes in patients (PRISMA) [17] statement. over time that crucially guides management. The three components can be scored separately or combined in a sum score, ranging from 3 to 15. The sum score was Eligibility criteria initially used in research, but later also in clinical set- tings, even though summation of the three components Studies considered for inclusion were observational incurs loss of information [2]. Both the GCS and the studies, such as cohort studies and case–control studies. sum score are used in the intensive care unit (ICU) in a We excluded case reports, letters, editorials or reviews. broad spectrum of patients with reduced level of con- Studies were included if they used the GCS to verify the sciousness and the sum score is integrated in several level of consciousness, and quantified its reliability by ICU classification systems [3–5]. An approximately any statistical measure. We excluded studies in which linear relationship exists between decreasing sum GCS assessment was not obtained by physical examina- scores and increasing mortality in patients with trau- tion of patients. Studies in which a majority (i.e. [50 %) matic brain injury (TBI) [6], and the motor component of participants were assessed by the pediatric GCS were is a strong predictor of poor outcome in moder- excluded. ate/severe TBI [7]. Reliable scoring is fundamental to the practical utility of the GCS. Conceptually, reliability is the degree to Search strategy which an instrument is free from measurement error [8]. It has an external component (i.e. inter-rater reliability) A systematic literature search was executed from 1974 to which assesses the same subjects by different raters, and January 2015 in MEDLINE, EMBASE and CINAHL. We an internal component (i.e. intra-rater and test–retest developed search strategies using keywords and MeSH reliability), which reflects the degree to which the scale terms on the GCS and its clinimetric properties including yields identical results on different occasions and over reliability, validity, prognostic value and responsiveness time, assuming stable conditions [9]. Reliability is, how- (Table S1). In addition, the reference lists of eligible ever, not an inherent property of a test, but a characteristic articles were screened for further relevant studies and of the scores obtained when applying the test [10]. Esti- relevant systematic reviews scanned for appropriate mates of reliability are influenced by test properties, rater references. characteristics, study settings, heterogeneity of subjects and how subjects are treated, e.g. by intubation and sedation. It is important to identify factors that are Data selection and extraction potentially modifiable in order to improve the applica- bility of the GCS. Citations were downloaded into Covidence (www. The reliability of the GCS has been examined in covidence.org), a software platform that manages the many studies, using a variety of measures, but remains review process. An eligibility checklist was developed in an area of some controversy [11]. Various reports, accordance with the inclusion criteria. Two authors (F.R. specifically in the field of intensive care and emergency and R.V.d.B.) independently reviewed all titles and medicine, have criticized the GCS and questioned its abstracts. Potentially eligible articles were exported into general applicability [12–15]. Many assumptions are, the reference program Zotero (http://zotero.org). At this however, based on limited evidence and mainly reflect stage, the selected articles were screened again to identify personal opinions. No comprehensive systematic review articles relevant to the reliability of the GCS. Articles on the reliability of the GCS and the factors that affect retained were obtained in full text and examined inde- its reliability has been conducted since 1996 [16]. The pendently. Results were compared and disagreements aim of this systematic review is to explore the reliability were resolved by discussion. Data extraction was per- of the GCS and the sum score, to identify influencing formed independently using a standard extraction form. factors and to formulate recommendations for optimiz- The studies were subsequently screened for reporting ing its reliability. factors that could influence the reliability of the GCS. 5 Assessment of methodological quality described that a low DR ranges from 0 to 0.299 whereas a high DR ranges from 0.3 to 0.5. Cronbach’s alpha is the The methodological quality of each study was assessed reliability statistic generally used to quantify internal using the consensus-based standards for the selection of consistency, which refers to the extent to which different health measurement instruments (COSMIN) checklist [8]. items of a scale assess the same construct. Cronbach’s This checklist evaluates studies on measurement proper- alpha values [0.70 are considered adequate and values ties of health measurement instruments. We used domains [0.80 as excellent. Alpha values [0.90 may indicate relevant
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