inter observer variability in gcs scoring in a level i trauma centre
TRANSCRIPT
Vivek Tandon, Deepak Agrawal
Dept of Neurosurgery. JPNATC AIIMS – New Delhi
Inter-observer variability in GCS scoring in a Level I Trauma Centre
Do we now need GCS independent protocols?
IntroductionFrykberg and Tepas showed in mass casualty
CNS injury is frequent and specially in terrorist bombings.
Head injury being the most common cause – 71% for immediate and 52% for the late fatality.
GCS charting is an integral part of assessment in the ER by any physician/ surgeon.
HI Protocols are usually implemented in ER based on the initial GCS
GCS effectivenessMotor component of GCS and systolic blood
pressure are the strongest physiological predictors of severe injury.
Sensitivity and specificity of GCS score less than 6 were 72.6 % and 96.2%. AND for systolic BP of < 80 mm were 30.4 and 99.2%.
Objective This study was to assess whether there was
any interobserver variability in GCS recording by doctors & nurses during the initial management of patient in the ER and ICU/ward
Materials and methodsOnly those patients which were admitted under
neurosurgery through casualty were studied. We analyzed the GCS score awarded to the
patient by the resident doctor (emergency team) in casualty, by the neurosurgeon in casualty and by the neurosurgeon at the time of admission in ward /ICU / or before operating. GCS scores awarded by the nursing staff were also studied.
No. of years of post MBBS experience for doctors and no. of years of service was also analyzed.
Results Total no. of patients
100
GCS score - <8 24
GCS score - <9 - 13
32
GCS score - 14 - 15 44
ResultsTotal no. of patients with discrepancy
42 %
Discrepancy in score =1
15 35%
Discrepancy in score =2
11 26%
Discrepency in score =3
9 22%
Discrepency in score = >4
7 17%
results
26
22
ResultsScoring discrepancies
Scoring difference in eye score
15
Scoring difference in verbal score
28
Scoring difference in motor score
24
Results continued
Mean year of experience of JR
Difference in score , compared with S/R neurosurgery
%
less than 1 year 25 59.5%
More than one year 17 40.5%
DiscussionIf There is variability in GCS recording patients
with severe HI may be labeled as moderate HI or vice-versa
Protocols for HI management are usually developed based on the GCS assessment.
At JPNATC GCS independent protocol for cervical spine & HI screening has been developed where all pts of suspected HI irrespective of GCS undergo CT of head & Cx spine (upto C7)
Conclusions GCS scoring can not be a gold standard for
assessing the level of consciousness in patients with significant brain injury.
There is need to devise simpler and GCS independent protocols for triage.
In spite of proper training there remains significant inter-observer variability in GCS recordings even among neurosurgeons.