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Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review
Comparative Effectiveness Reviews, No. 182
Investigators: Roger Chou, MD, Annette M Totten, PhD, Miranda Pappas, MA, Nancy Carney, PhD, Spencer Dandy, BS, Sara Grusing, BA, Rongwei Fu, PhD, Ngoc Wasson, MPH, and Craig Newgard, MD, MPH, FACEP.
Author Information and AffiliationsStructured Abstract
Objectives:
To assess the predictive utility, reliability, and ease of use of the total Glasgow Coma Scale (tGCS) versus the motor component of the Glasgow Coma Scale (mGCS) for field triage of trauma, and effects on clinical decisionmaking and clinical outcomes.
Data sources:
MEDLINE®, CINAHL®, PsycINFO®, HaPI (Health and Psychosocial Instruments), the Cochrane Databases (January 1995 through June 2016), and reference lists.
Study selection:
Studies on predictive utility of the tGCS versus the mGCS or Simplified Motor Scale (SMS), randomized trials and cohort studies on effects of the tGCS versus the mGCS on rates of over- or under-triage, and studies on interrater reliability and ease of use.
Data extraction:
One investigator abstracted study characteristics and results; a second checked data for accuracy. Two investigators independently applied prespecified criteria to rate study quality. Data on discrimination were pooled using a random effects model. The strength of evidence was graded using published methods.
Results:
Thirty-two studies met inclusion criteria; 24 studies addressed predictive utility and 10 addressed interrater reliability or ease of use. No study assessed comparative effects on over- or under-triage or clinical outcomes. For in-hospital mortality, the tGCS is associated with slightly greater discrimination than the mGCS (pooled mean difference in area under the receiver operating characteristic curve [AUROC], 0.015; 95% confidence interval [CI], 0.009 to 0.022; I2 = 85%; 12 studies; strength of evidence [SOE]: Moderate) or the SMS (pooled mean difference in AUROC, 0.030; 95% CI, 0.024 to 0.036; I2 = 0%; 5 studies; SOE: Moderate). This means that for every 100 trauma patients, the tGCS correctly discriminates 1 to 3 more cases of in-hospital mortality from cases without in-hospital mortality than the mGCS or SMS. The tGCS is also associated with greater discrimination than the mGCS or SMS for receipt of neurosurgical interventions, severe brain injury, and emergency intubation (differences in AUROC from 0.03 to 0.05; SOE: Moderate). Differences in discrimination between mGCS and SMS were very small.
Findings were robust in sensitivity and subgroup analyses. Differences among the tGCS, mGCS, and SMS in diagnostic accuracy (sensitivity, specificity) using standard thresholds were small, based on limited evidence (SOE: Low). Evidence was insufficient to determine if there were differences between the tGCS and the mGCS in interrater reliability (SOE: Insufficient). Three studies found that the tGCS was associated with lower proportions of correct scores than the mGCS; differences ranged from 6 percent to 27 percent (SOE: Low).
Limitations:
Evidence on comparative predictive utility was primarily restricted to effects on discrimination. All predictive utility studies were retrospective, and mGCS and SMS were taken from tGCS rather than independently assessed. Most studies had methodological limitations. We included only English-language studies and were limited in our ability to assess publication bias. Studies on ease of use focused on scoring of video or written patient scenarios.
Conclusions:
The tGCS is associated with slightly greater discrimination than the mGCS or SMS for in-hospital mortality, receipt of neurosurgical interventions, severe brain injury, and emergency intubation. The clinical significance of small differences in discrimination is likely to be small and could be offset by factors such as convenience and ease of use. Research is needed to understand how use of the tGCS versus the mGCS or SMS impacts clinical outcomes and risk of over- or under-triage.
Contents
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Scope Development
- Literature Search Strategy
- Study Selection
- Data Abstraction and Data Management
- Assessment of Methodological Risk of Bias of Individual Studies
- Assessing Research Applicability
- Data Synthesis and Rating the Body of Evidence
- Grading the Body of Evidence for Each Key Question
- External Review
- Results
- Results of Literature Search
- Key Question 1. In patients with known or suspected trauma, what is the predictive utility of the total Glasgow Coma Scale (tGCS) compared with the motor component of the GCS (mGCS) score for predicting in-hospital mortality, morbidity, Injury Severity Score (ISS) of 16 or greater, head Abbreviated Injury Scale (AIS) score greater than 2 (AIS-2005) or greater than 3 (AIS-1998), presence of intracranial hemorrhage, and utilization indicators of severe injury (e.g., receipt of intracranial monitoring within 48 hours of admission, receipt of a neurosurgical intervention within 12 hours of admission, or early intubation [in the field or immediately upon presentation to the emergency department (ED)])?
- Key Question 1a. How does predictive utility vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medications in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?
- Key Question 2. In patients with known or suspected trauma, what are the comparative effects of the tGCS compared with the mGCS on over- and under-triage (e.g., proportion of patients in whom initial emergency medical services transport is to a higher or lower than appropriate level of care, or proportion transferred to a higher or lower level of care)?
- Key Question 2a. How do effects on over- and under-triage vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?
- Key Question 3. In patients with known or suspected trauma, what is the comparative effectiveness of the tGCS compared with the mGCS on clinical outcomes (e.g., in-hospital mortality, morbidity, quality of life)?
- Key Question 3a. How do effects on clinical outcomes vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?
- Key Question 4. In patients with known or suspected trauma, what is the comparative reliability (e.g., interrater and intrarater kappa) and ease of use (e.g., time to complete, amount of missing data, user reported satisfaction) of the tGCS compared with the mGCS score?
- Key Question 4a. How do comparative reliability and ease of use vary according to patient age or other patient characteristics (e.g., TBI vs. unspecified or other trauma, systolic blood pressure, level of intoxication, type of trauma, intubation or receipt of medication in the field), the training and background of the person administering the instrument, and the timing/setting of assessment (i.e., in the field vs. upon presentation to the ED or urban vs. rural location)?
- Discussion
- References
- Abbreviations and Acronyms
- Appendix A. Search Strategies
- Appendix B. Inclusion and Exclusion Criteria
- Appendix C. List of Included Studies
- Appendix D. List of Excluded Studies
- Appendix E. Risk of Bias Criteria
- Appendix F. Strength of Evidence Domains and Definitions
- Appendix G. Strength of Evidence Table
- Appendix H. Head-to-Head Studies for Predictive Utility
- Appendix I. Indirect Studies for Predictive Utility
- Appendix J. Studies of Reliability and Ease of Use
- Appendix K. Quality Assessment of Studies of Predictive Utility
- Appendix L. Quality Assessments of Studies of Reliability and Ease of Use
Suggested citation:
Chou R, Totten AM, Pappas M, Carney N, Dandy S, Grusing S, Fu R, Wasson N, Newgard C. Glasgow Coma Scale for Field Triage of Trauma: A Systematic Review. Comparative Effectiveness Review No.182. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No.16(17)-EHC041-EF. Rockville, MD: Agency for Healthcare Research and Quality; January 2017. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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