Inter observer variability in gcs scoring in a level i trauma centre

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.