British Journal of Neuroscience Nursing

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The Glasgow Coma Scale 40 years on:
a review of its practical use
questioned its ability to meet the standards of modern
evidence-based medicine (Green, 2011).
The widespread use of the GCS has perhaps led to
non-standardised practices and inappropriate use in
certain settings. An exact understanding of its relevance and use, terminology and the method used to
elicit responses is essential for health professionals to
use the GCS appropriately and reliably in clinical
practice. Variations and non-standardised practice
have potentially serious clinical implications for
patient safety.
Aim
The purpose of this paper is to review the use of the
GCS in clinical practice 40 years after its creation.
The paper aims to highlight and clarify some of the
subjective and confusing aspects of GCS use, with a
particular focus on the use of painful stimulus.
Siobhan McLernon
The Glasgow Coma Scale (GCS) was originally devised by Teasdale and Jennett in 1974 to objectively determine the level of impaired
consciousness in a wide range of disorders. The
central edict of the GCS was that it could be quickly
and simply used by a wide range of health
professionals, enabling reliable repeated bedside
assessment. It was also intended to enable early
detection of a deterioration in consciousness level,
which is often the earliest and most sensitive indicator
of a change in neurological status (Hickey, 2009).
Another aim was to improve communication between
practitioners caring for patients with altered levels of
consciousness (Teasdale and Jennett, 1974).
Prior to the development of the GCS, unstructured
terms and general descriptions were used to describe
patients’ consciousness levels, such as ‘semi-comatose’,
‘stuporose’ ‘obtunded’ and ‘decerebrate’. These
descriptions resulted in confusion, loss of information
and diffculties in communication between health
professionals (Matis and Birbilis, 2008).
The GCS has been adopted worldwide and has
gained validated ubiquitous use in many clinical
conditions, such as overdose (Livingstone et al, 2000),
infection (Holdgate et al, 2006), drowning (Bratton
et al, 1994) and cardiac arrest (Schefold et al, 2009). It
forms the basis of the World Federation of
Neurological Surgeons (WFNS) grading scale for
subarachnoid haemorrhage (SAH) (Ogungbo, 2003)
and is incorporated into several clinical guidelines to
optimise the care and triage of patients following
traumatic brain injury (TBI) (Brain Trauma
Foundation, 2007; National Institute for Health and
Care Excellence (NICE), 2014).
Over recent decades some criticisms surrounding
the GCS and its clinical applicability and reliability
have appeared in the literature. It has been suggested
that its ease of use opens it up to misinterpretation
and misapplication (Addison and Crawford, 1999).
Concerns regarding inaccuracy in GCS scoring in daily
practice have been raised that threaten to diminish its
clinical value (Zuercher et al, 2009; Middleton, 2012).
Several authors have argued that the GCS contains
multiple subjective elements, particularly around the
application of painful stimuli and motor response
(Gill et al, 2007; Barlow, 2012). These criticisms have
Abstract
This year sees the celebration of the 40th anniversary of the Glasgow Coma
Scale (GCS), which is as relevant in clinical decision making now as it was
40 years ago. The GCS was originally devised in 1974 as a simple bedside
tool to improve clarity and consistency in communication about patients
with impaired consciousness in a wide range of disorders. Impaired
consciousness is an expression of dysfunction of the brain as a whole. Over
the decades there has been increasing evidence of variation in the
consistency of GCS assessment in clinical practice. Education and experience
in the use of the GCS are important factors that have been shown to
improve the reliability and accuracy of GCS scoring. The use of different
examination techniques, especially the application of painful stimulation,
contributes to inconsistency. A standardised approach is required for safe
therapeutic clinical decision making and clear communication between
health professionals. Novel approaches to education are required to
standardise practice, and explicit guidelines aimed at improving its overall
application in clinical practice are needed.
Key Words Glasgow Coma Scale, GCS, consciousness, brain injuries
Author Siobhan McLernon, Senior Lecturer, London Southbank University
Correspondence mclernt@lsbu.ac.uk
Accepted 30 June 2014
This article has been subject to double-blind peer review.
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emergency departments accurately and reliably identify
the small number of patients who will go on to have
serious acute complications.
Further work by Gill et al (2004; 2005; 2007) reported
low-to-moderate IR reliability when performing the
GCS in patients with impaired consciousness in A&E
settings. These studies also identifed that the motor
response rating to painful stimuli was problematic in
relation to IR reliability and accuracy. These fndings
concur with Teasdale et al’s (1978) earlier work and
perhaps indicate that the use of painful stimulus
remains the most subjective and confusing aspect of
the GCS’s performance.
It remains unclear whether the GCS has adequate
IR reliability as there is a lack of consistency in the
research base (Baker, 2008; Zuercher et al, 2009).
There is not a single ‘absolute’ value for the IR reliability of the GCS and, as discussed earlier, it may be high
or low. However, of most relevance are the factors that
influence the GCS’s reliability, how prevalent they are
in practice and what can be done to promote good
practice. Clinical decisions need to be based on other
clinical and radiological fndings in conjunction with
the GCS. Neurological assessment should also include
vital signs, pupillary response and limb movements.
Effects of experience and education
on GCS performance
Lack of experience and education have been found to
contribute to inaccurate scoring of the GCS in a
variety of settings (Waterhouse, 2008; Zuercher et al,
2009; Mattar et al, 2013). Teasdale and Jennett’s
(1974) early work found that exposing observers to a
training flm on rating patients’ responses reduced
disagreement rates from 20% to 3%. They concluded
that the GCS required clearly defnable criteria to
ensure reliable rating. Subsequent studies have concluded that there is a need for education in the use of
the GCS to improve IR reliability and that experience
in the use of the scale reduces variability (Teasdale
et al, 1978; Dewey et al, 1999; O’Farrell and Zou,
2008; Waterhouse, 2008).
Rowley and Fielding’s (1991) landmark study found
that the reliability of the GCS increased with experience
and that inexperience was associated with a high rate
of errors when using the GCS. Nurses with varying
amounts of experience and from several clinical settings
have also been found to have a lack of knowledge
regarding the underpinning pathophysiology of the
three components of the GCS (Waterhouse, 2008). It is
unclear whether knowledge of relevant pathophysiology
improves overall performance of GCS assessment and
this is perhaps an area for future research.
It is imperative that the GCS has adequate reliability
to ensure patient safety and inform diagnostic and
therapeutic clinical decision making. High variability
of the GCS and its overall score may lead to underor over-treatment. Incorrectly low GCS scores may
Factors that affect the performance of the GCS are
discussed and recommendations for future use and
development are presented.
Literature review
A literature search was conducted in the MEDLINE,
CINAHL, Scopus and Cochrane library databases for
articles dating from 1974 to January 2014. Medical
subject headings (MeSH) terms used in the search
were ‘Glasgow Coma Scale’, ‘GCS’, ‘consciousness’
and ‘brain injuries’ together with ‘education’, ‘assessment’ and ‘inter-rater reliability’. An internet search
for recent policy and guidance documentation was
also conducted, and Google Scholar was also
searched. The reference lists of relevant GCS articles
were hand-searched for further relevant papers.
Inter-rater reliability and accuracy
of GCS scoring
The GCS should demonstrate high levels of agreement
and consistency of scoring between observers
(Teasdale and Jennett, 1974; Baker, 2008). Agreement
between observers is known as inter-rater (IR) or
inter-observer reliability. Reliability relates to consistency between observers but also consistency between
scores (Baker, 2008). Inter-rater reliability for coma
scales is generally presented as a weighted kappa
value. This is a measure of agreement between two or
more observers accounting for variability based on
chance alone (Kornbluth and Bhardwaj, 2011). A
value of 1 indicates good agreement and a value of 0
indicates agreement by chance alone. Therefore the
higher the kappa score the better the reliability. Good
IR reliability reduces the risk of error and enhances
patient safety.
Teasdale et al’s (1978) original work described IR
reliability in terms of a ‘disagreement rate’ as the
kappa statistic was not in existence. The work
demonstrated good IR reliability between experienced
observers. However, observations of motor responses
elicited by supraorbital painful stimulus were not
always reliable among the observers. Subsequent
studies have demonstrated reliability to be high
(Heard and Bebarta, 2004: Holdgate et al, 2006) to
low (Gill et al, 2007) with kappa indices in the range
of 0.32 to 0.85 when including a variety of observers
in several settings.
Studies conducted in accident and emergency
(A&E) departments have revealed highly variable IR
reliability (Kelly et al, 2004; Kerby et al, 2007). High
error rates have been found in patients with ‘intermediate’ levels of consciousness (i.e. GCS scores of
9–12) (Rowley and Fielding, 1991; Kerby et al, 2007).
This fnding has clinical signifcance as patients in this
category with fluctuating levels of consciousness are
perhaps the most vulnerable—they are already
compromised and are therefore more likely to deteriorate (Jennett, 2002). It is therefore imperative that
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lead to unnecessary clinical decisions being made,
such as unnecessary referral and imaging (Zuercher
et al, 2009). At worst, under-treatment may lead to
undetected clinical deterioration, which may have lifethreatening consequences. GCS assessments must be
reproducible at a single point in time, and changes in
the patient’s condition reported in a timely fashion.
Knowledge gained through education and previous
neurosurgical experience have been found to be statistically signifcant with regard to nurses’ accuracy and
ability to perform assessment of consciousness when
using the GCS (Heron et al, 2001; Chan et al, 2013;
Mattar et al, 2013). Continuing education of health
professionals is essential to improve knowledge and
understanding of GCS assessment in clinical practice
as well as standardisation across different clinical
settings (Teasdale et al, 2014). Broad-reaching novel
approaches to education, such as web-based animations and algorithms on how to perform the GCS,
may also enhance its use.
Painful stimuli
Over time the indications for applying ‘peripheral’ vs
‘central’ painful stimuli to elicit a particular response
have become obscured (Price, 2002). The confusion
appears to be around when and where to use painful
stimuli. Variations of both the description of motor
responses and the methods used to elicit them have
appeared in the literature (Price, 2002; Holdgate et al,
2006). The aim of applying painful stimuli is to assess
the level of consciousness of a patient who is in an
altered state (Waterhouse, 2009). Only two sections of
the GCS observation chart potentially require the
application of painful stimulus: the eye opening
section (application of peripheral stimuli) and the
best motor response section (application of central
peripheral stimuli in the frst instance).
Central or peripheral sites refer to parts of the body
only, as all painful stimulus is initially transmitted
peripherally via spinal and cranial nerves to the
central nervous system (Purves et al, 2008). Various
locations have been used to apply painful stimuli,
such as in the use of ear lobe pressure (Barlow, 2012),
jaw margin pressure (Waterhouse, 2005; Palmer and
Knight, 2006) and sternal rub (Iacono and Lyons,
2005; Holdgate et al, 2006; Palmer and Knight, 2006).
However, the use of these locations should be avoided
(Teasdale and Jennett, 1974; Addison and Crawford,
1999). Variability in the application of painful stimuli
is a cause for concern as it may compromise the
reliability of the scale.
During the assessment of eye opening, if the patient
does not eye open spontaneously or to speech then
painful stimuli must be used. Central painful stimuli
such as supraorbital ridge pressure should be avoided
as they can cause reflex screwing up of the eyelids.
Peripheral painful stimulus should therefore be used
to ascertain eye opening to pain. This was originally
performed by applying pressure with a pen or pencil
to the fngertip (i.e. nailbed) (Teasdale and Jennett,
1974; Teasdale, 1975). However, concerns were raised
that nailbed pressure can damage the nail, nailbed
and underlying matrix, particularly when performed
at frequent intervals (Price, 2002; Waterhouse, 2005).
Experienced nurses have also reported that applying
regular painful stimuli to patients can be an emotional
and distressing experience for them even if they understand its necessity (Bartlett, 2000). More recently,
application of pressure with a pen or pencil to the
lateral outer aspect of the third or fourth digit has been
advocated as this causes less local damage and elicits
the same response (Waterhouse, 2008). Pressure should
be applied with gradually increasing intensity for up to
a maximum of 10–15 seconds and then released. If the
patient is able to open his/her eyes to pain, this demonstrates the integrity of the spinal pathways to the
reticular formation (Waterhouse, 2008). Local pathology
may cause the patient to be unable to open their eyes,
therefore the enforced closure of the eye can be recorded
as C (=eyes closed) on the chart.
If the patient cannot obey commands and is unable
to eye open spontaneously or to speech it is at this
point that the observer would go on to assess best
motor response. The word ‘best’ refers to the best
level of upper limb response shown at the time of
assessment and is a reflection of the integrity of the
brain as a whole (Middleton, 2012). To decide whether
the best motor response is localising, a ‘central
peripheral’ painful stimulus (i.e. applied to the head
or neck) is required (Teasdale et al, 1978).
Supraorbital nerve pressure is often diffcult to apply
as fnding the exact location requires expertise. It is
also contraindicated in the case of signifcant periorbital injury (Teasdale and Jennett, 1974). A suitable
alternative is pinching the upper outer border of the
trapezius muscle (neck), as this stimulus is transmitted
via cervical sensory nerves, i.e. the spinal accessory
nerve (cranial nerve XI) (Teasdale and Jennett, 1974;
Barlow, 2012). The patient should raise one hand
above the clavicle to the site of stimulation in an
attempt to remove the stimulus, and this is recorded
as localising. If the patient opens his/her eyes and
moves his/her arms, there is no need to use peripheral
painful stimulus (Waterhouse, 2009). However, if they
do not then application of peripheral painful stimuli
allows the assessment of specifc limb function, such
as normal and abnormal flexion and extension to
pain. A normal flexion response is characterised by
rapid flexion of the elbow, often accompanied by lifting the elbow clear of the body. An abnormal flexion
response is characterised by elbow flexion accompanied by a spastic flexion of the wrist (Barlow, 2012).
An extension response is indicated by extension of the
elbow accompanied by pronation of the forearm
(Waterhouse, 2005). The upper limb with the best
response (right/left) should be documented clearly.
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In brainstem death, a spinal reflex may still be
present and cause the legs to flex in response to pain
applied locally. It is for this reason and because the
upper limbs show a wide range of responses that best
upper limb response should always be documented
(Teasdale et al, 1978). To ensure consistency the nurse
taking over the patient’s care at handover should
observe how the GCS assessment was obtained and
documented (Waterhouse, 2005). It is imperative that
the method and location of painful stimulation used
to elicit patient responses is maintained until a maximum response is elicited so that the signifcance of
the response is correctly interpreted (Barlow, 2012).
Inconsistencies in application are perhaps a result of
imprecise, variable or absent defnitions.
Changes in GCS assessment act as a clinical
indication for important clinical decision making,
such as the need for medical review, when to seek
neurosurgical opinion and when to intubate and
ventilate a patient prior to transfer (NICE, 2014). It is
therefore of utmost importance that every aspect of
GCS assessment is conducted in a systematic and
standardised manner by competent health professionals
to avoid under- or over-treating patients and to ensure
patient safety. The practice of applying painful stimuli
to patients who have hemiplegic limbs who are aware
and awake and are no longer in the acute phase of
neurological illness should be discouraged.
Practical considerations
Responsiveness may fluctuate in the hours after acute
injury or disease and so the GCS should be assessed
as early as possible post-resuscitation to provide a
baseline and for the early detection of clinical
deterioration (Jennett, 2002; NICE, 2014).
The GCS score is the numerical equivalent of the
GCS and was designed for research and audit purposes
as well as the development of guidelines (Barlow,
2012). The GCS score is not intended to be used to
describe individual patients in a clinical situation.
Sometimes the score cannot be calculated accurately
as one or more of the individual components of the
GCS are not measurable (e.g. if the patient has a tracheostomy the verbal response cannot be assessed).
Additionally, using the GCS score rather than the
scale may lead to a loss of useful information and
diminished clinical usefulness (Teoh et al, 2000). A
description of individual patients in the case notes,
during handovers and in referrals should always be
made in words using the GCS (e.g. a patient scoring
13/15 should be documented as E4,V4,M5 (Jennett,
2002; Barlow, 2012; NICE, 2014).
The timing and frequency of observations should
be adjusted based on the following criteria: the risk of
complications, the patient’s condition, how much time
has passed since the injury or neurosurgical procedure
and how much change is observed. The patient’s
response indicates the level of cerebral functioning
and must be graphed as the GCS is a measure of
trend and change not a static or exact level of consciousness (Middleton, 2012). Changes in the overall
trend demonstrated by a series of regular observations
provide a powerful clinical reflection of neurological
state, which may act as a trigger for medical review
and possible intervention (NICE, 2014).
Experienced observers may identify subtle changes
in the patient (Waterhouse, 2005). An increase in the
stimulus needed to elicit the same response may indicate a reduction in the level of cerebral functioning,
which may not alter the GCS score at the time of
assessment. However, this subtle change usually
requires an increase in the frequency of assessment
and must be documented (Palmer and Knight, 2006).
GCS assessment should therefore be performed by
knowledgeable and experienced health professionals
in a systematic and standardised way to ensure that
changes in the patient’s neurological state are detected
rapidly and accurately.
Limitations
One of the most frequently documented limitations
of the GCS is its inability to assess verbal response in
endotracheally intubated patients with analgesia and
sedation (Brunker, 2006; Green, 2011; Kornbluth and
Bhardwaj, 2011). Patients with severe TBI (GCS 8 or
less) require airway management via endotracheal
intubation (NICE, 2014). TBI management makes
GCS assessment challenging as patients often require
analgesia, sedation and short-acting neuromuscular
blockade to facilitate ventilation and ongoing management. GCS assessment is therefore inappropriate
for this group of patients (Teasdale and Murray,
2000). In the intensive care setting, assessments such
as pupillary response, intracranial pressure trends and
multimodal monitoring techniques are used to assess
for increasing severity of cerebral injuries during the
acute phase (Tisdall and Smith, 2007). However, it is
often still possible to assess ‘best’ motor response
when analgesia and sedation are reduced or discontinued. This has prognostic signifcance for mortality
(Healey et al, 2003; Zuercher et al, 2009). Assessment
of sedated head-injured patients using the GCS
involves disturbing them and often involves inflicting
pain. Clinicians need to question daily and on an
individual basis the clinical need to carry out GCS
assessment in this group of patients to avoid
unnecessary and unjustifed use (Brunker, 2006).
A language barrier is common in clinical settings,
and can make verbal response diffcult to assess
(Teasdale, 1975). However, this can normally be
overcome by involving the family where possible as
well as by using non-verbal methods of communication such as writing to ascertain whether the patient
understands and can interpret what is being asked.
Dysphasia reflects focal damage to one of the
speech centres and can sometimes make it diffcult to
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distinguish between confusion and disturbances in
speech function (Hickey, 2009). Existing speech disturbances prior to injury should be established and
documented. Regardless of the aetiology and nature
of dysphasia it is important to document ‘D’ in the
most appropriate section of the GCS so that any deterioration in speech can be detected (Waterhouse,
2005). Documentation must include the rationale for
choosing a particular section in the verbal component
and this must be clearly communicated at handover
and in the case notes. Patients with dementia, underlying chronic neurological disorders or learning
disabilities also challenge GCS assessment as the preinjury baseline may be less than 15. This should be
established as soon as possible and taken into account
during assessment (NICE, 2014).
In an attempt to address some of the limitations of
the GCS, several alternative scoring systems have
been proposed (Kornbluth and Bhardwaj, 2011). The
Full Outline of Unresponsiveness (FOUR) scale has
gained most prominence as a suitable replacement to
the GCS for patients in the intensive care setting
following the acute phase of neurological injury or
disease (Wijdicks et al, 2005; Bruno et al, 2011).
However, further research is required to determine the
predictive validity and reliability of the scale in a
variety of patient populations. Despite the GCS’s
limitations it remains the tool of choice in clinical
practice worldwide. Consensus on methods to address
its limitations will maintain its role in clinical practice
and research in the future (Teasdale et al, 2014).
Conclusion and recommendations
for future practice
The GCS is a quick and simple tool for assessing
impairment of consciousness during the acute phase
of neurological injury or disease. Its incorporation
into clinical guidelines recognises its correlation to the
extent of damage and the risk of complications.
Inconsistency in the use of the GCS in clinical practice, particularly around the application of painful
stimuli, indicates that further education is required.
The quality assurance of adequate IR reliability is
important as considerable variations have been
reported, particularly in the A&E setting. There is a
general consensus in the literature that education and
experience improve reliability among observers and
improve the accuracy of GCS scoring. Observers
performing the GCS assessment must therefore be
adequately trained and competent to ensure accurate
and reliable assessment.
The GCS is not an appropriate tool for use in
chronic neurological conditions. Health professionals
must therefore ensure that they are using the right
tool for the right patient and the correct injury state
at the right time.
Novel approaches to education are required on an
ongoing basis to maintain skills in the assessment of
consciousness, particularly in acute care settings where
patients are at risk of clinical deterioration. There is a
growing need for explicit standardised guidelines and
precise defnitions on how and when to perform the
GCS assessment in clinical practice. These guidelines
would aim to resolve current inconsistencies and
variability in practice as well as improve IR reliability
and patient safety. BJNN
Acknowledgments
I would like to thank Professor Sir Graham Teasdale for his help and
support in the preparation of this paper.
Declaration of interests
This work had no external sources of funding. The author has no
conflicts of interest to declare.
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Key Points
■ A standardised approach is required for safe therapeutic clinical decision
making and clear communication between health professionals.
■ After 40 years, the Glascow Coma Scale (GCS) remains clinically relevant
and is used ubiquitously worldwide for early detection of a deterioration
in consciousness level.
■ Variations and discrepancies still exist in the application of painful
stimulus and this is an area for continued education.
■ Experience and knowledge gained through education improve nurses’
accuracy and ability in performing GCS assessment.
■ Educational interventions and guidelines in using the GCS are essential to
improve knowledge and understanding of GCS assessment in clinical
practice. Broad-reaching novel approaches to education such as webbased animations and algorithms on how to perform the GCS may also
enhance its use.
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Call for peer reviewers
The British Journal of Neuroscience Nursing is very grateful for the advice provided
by its pool of dedicated volunteer peer reviewers and always appreciates new offers
from experienced clinicians and academics interested in helping out.
If you would like to be considered for the peer review team, please send a brief CV and details of your particular areas of
expertise or interest to the Editor, Craig Nicholson: craig.nicholson@markallengroup.com
Guidelines for reviewers are available.
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