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Related Experiment Video

Updated: Jan 26, 2026

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Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale.

Matthew P Kirschen1,2,3, Megan Snyder4, Katherine Smith4

  • 1Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
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Summary

A modified pediatric Glasgow Coma Scale shows excellent reliability among critical care nurses. However, accuracy decreased for children with developmental disabilities and intermediate motor responses, indicating a need for further research.

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Area of Science:

  • Pediatric Critical Care Medicine
  • Neurological Assessment
  • Nursing Practice

Background:

  • The Glasgow Coma Scale (GCS) is a standard neurological assessment tool.
  • Modifications are needed to improve the GCS's applicability in diverse pediatric intensive care unit (PICU) populations, including sedated, ventilated, or developmentally disabled children.
  • Assessing inter-rater reliability is crucial for the consistent application of any modified GCS.

Purpose of the Study:

  • To estimate the inter-rater reliability of a pediatric modification of the Glasgow Coma Scale (GCS) when used by critical care nurses in a pediatric intensive care unit (PICU).
  • To evaluate the GCS modification's performance across different patient subgroups, including those with developmental disabilities.
  • To identify specific components or patient characteristics that may affect the reliability of the modified GCS.

Main Methods:

  • A prospective observational study was conducted in a large academic PICU.
  • A pediatric modification of the GCS was developed and nurses were trained on its use.
  • Inter-rater reliability was assessed using Fleiss' Kappa, intraclass correlation coefficient, and percent agreement among 18 study nurses and other PICU nurses observing patient scores.

Main Results:

  • Overall percent agreement for the modified GCS components was high: 89% for eye, 91% for verbal, and 79% for motor responses.
  • Inter-rater reliability ranged from good (ICC=0.75) to excellent (ICC=0.96) for assessable patients.
  • Agreement on motor responses was significantly lower for children with developmental disabilities (55-59%) compared to those without (91-95%), and worse for intermediate GCS motor scores.

Conclusions:

  • The pediatric GCS modification demonstrates excellent inter-rater reliability among trained PICU nurses.
  • Reliability is reduced in pediatric patients with developmental disabilities and for intermediate motor response scores.
  • Further research is warranted to validate the modified GCS for detecting clinical deterioration in this population.