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Validation of the Full Outline of Unresponsiveness (FOUR) Scale for conscious state in the emergency department: comparison against the Glasgow Coma Scale
  1. J Kevric1,2,
  2. G A Jelinek1,2,
  3. J Knott3,
  4. T J Weiland1,2
  1. 1Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
  2. 2Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, Australia
  3. 3The Royal Melbourne Hospital, Melbourne, Australia
  1. Correspondence to Dr Tracey Weiland, Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, PO Box 2900, Fitzroy, Melbourne, Victoria 3065, Australia; tracey.weiland{at}


Objectives To determine (a) the inter-rater reliability of pairs of emergency doctors' and/or nurses' ratings of the Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness (FOUR) Scale in emergency department (ED) patients, (b) the concurrent validity of the FOUR Scale using the GCS as the reference scale and (c) doctors' and nurses' knowledge and attitudes towards the GCS and FOUR Scale.

Methods A prospective observational study was conducted using staff participants' ratings for a convenience sample of ED patients requiring quantification of conscious state. Participating doctors and nurses attended a formal training session on the correct use of the GCS and FOUR Scale. Pairs of clinicians then independently completed the GCS and FOUR Scale on patients within 5 min of each other.

Results 140 clinicians were recruited and trained in the use of the GCS and FOUR Scale. A total of 217 observations were performed on 203 patients presenting to the ED with various conditions. The inter-rater reliability for the FOUR Scale was greater than that of the GCS (FOUR: к=0.76, p<0.01; GCS: к=0.59, p<0.01). The reliability for both the GCS and the FOUR Scale was poorest within doctor–nurse pairs.

Conclusion The FOUR Scale showed greater reliability than the GCS in ED patients using ED clinicians as raters. A larger study of ED patients is warranted to determine the predictive validity of the FOUR Scale and to further examine the reliability of the scale in various patient populations.

  • Acute medicine-other
  • cardiac care
  • diagnosis
  • cardiac care
  • care systems
  • clinical assessment

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  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the St Vincent's Hospital Melbourne.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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