Further validation of the FOUR score coma scale by intensive care nurses

The FOUR (Full Outline of UnResponsiveness) score is a new coma scale that consists of 4 components (eye, motor, brainstem, and respiration). The scale was recently validated, but variability among nursing staff has been documented.

We prospectively studied the FOUR score in 80 patients with acute neurologic disease in an intensive care unit (ICU) and compared it with the Glasgow Coma Scale (GCS) using 20 experienced and inexperienced neuroscience ICU nurses and nonneuroscience ICU nurses. Each nurse was trained with the use of video examples and instruction cards. Each patient was rated by 2 nurses, with the order randomly assigned.

The rater agreement was good to excellent with the FOUR score (weighted kappa: eye, 0.84; respiration, 0.92; brainstem, 0.89; and motor, 0.73) and similar to that for the GCS (weighted kappa: eye, 0.85; verbal, 0.89; and motor, 0.74). Greater average experience in years was associated with less disagreement, but the difference was not statistically significant.

The FOUR score provides more neurologic information than the GCS. The FOUR score can be used by any ICU nurses, even those with minimal experience.