Requirement for hourly Glasgow Coma Scores in the emergency department: process or outcome based?

The lack of hourly Glasgow Coma Score (GCS) documentation in trauma patients while in the emergency department (ED) is frequently cited by American College of Surgeons (ACS) Trauma Center Verification Review Committee site visitors. The basis for this requirement is unclear. We suspected that hourly recording of GCS has no impact on patient outcome.

The trauma registry of a 300-bed ACS-verified, state-designated Level II trauma center was reviewed retrospectively for head trauma patients over 16 years of age. Demographic data, field and ED GCS, presence or absence of hourly GCS in the ED, objective injury scores, complications, discharge status, and hospital length of stay were determined.

A total of 463 patients were identified. Hourly GCS was recorded in the ED in 244 (53%) patients. No significant difference was found in the Trauma and Injury Severity Score or the Abbreviated Injury Score of the head between those who had hourly GCS recorded and those who did not. Patients who had hourly GCS recorded were significantly younger, 42.3 +/- 19.7 years vs 53.9 +/- 24.9 years for those who did not have hourly GCS recorded (P < 0.001). Seventy percent (126/179) of patients involved in a motorcycle or motor vehicle crash had hourly GCS recorded while only 39% (69/175) of patients admitted for falls had hourly GCS (P < 0.001). There were no differences in mortality or complication rates between the groups.

The recording of hourly GCS on head injured patients is reflective of the initial presentation of the patient and not an objective evaluation of the patient. The presence or absence of hourly GCS in the ED was not associated with any increase in complications or mortality. The ACS should reevaluate the requirement for hourly recording of GCS in trauma patients.