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Don't guess the GCS: a systems-based approach to safer neurological assessment in the emergency department
Enda Hession1, Cian Broderick2, James Foley2
1Department of Emergency Medicine, University Hospital Galway, Galway, Ireland. endahession@rcsi.com.
Background:
The Glasgow Coma Scale (GCS) is a fundamental tool in emergency neurological assessment, yet its accuracy is frequently compromised by cognitive load and reliance on recall. This quality improvement project aimed to assess the accuracy, speed, and clinician confidence in GCS scoring and to evaluate the impact of a low-cost visual aid and educational intervention.
Methods:
A baseline survey assessed GCS use, confidence, and reliance on visual aids among 30 emergency department (ED) staff. A subgroup of 20 staff then completed ten clinical vignettes with and without visual aids, measuring accuracy and time to completion. An educational package and standardised GCS posters were introduced, followed by three Plan-Do-Study-Act (PDSA) cycles assessing real-time scoring accuracy during live resuscitation room care.
Results:
Of surveyed staff, 80% calculated GCS daily, though 47% did so without aids. Confidence increased from 77% without aids to 93% with aids. In vignette testing, accuracy improved from 24 to 48% (p = 0.18), while mean completion time decreased from 44 to 33 s (p = 0.001). PDSA cycles demonstrated sustained real-time improvement in scoring accuracy (80%, 100%, 86%).
Conclusion:
This intervention improved the accuracy and efficiency of GCS assessments in a high-acuity ED setting. A simple cognitive aid, embedded within a patient safety culture, can reduce error and support safer neurological assessment.
