Clinical assessment of patients with chronic disorders of consciousness by different medical specialists

Abstract

Introduction. Clinical assessment of consciousness in patients coming out of a coma remains a topic of discussion. Monitoring these patients over time is challenging not only because of the slow fluctuations in their neurological status, but also because doctors are not fully aware of the classification of chronic disorders of consciousness (CDC), and how to use the Coma Recovery Scale-revised (CRS-R), which was specifically developed for this group of patients. In practice, most doctors use standard neurological examination to assess consciousness rather than the CRS-R. We have hypothesized that this approach leads to contradictory and poorly standardized results. Materials and methods. We investigated the level of inter-expert reliability in pairs of three medical specialists: neurologists, neurosurgeons and neurocritical care specialists (working in neurocritical care units) in the clinical assessment of consciousness. Their examination findings were compared to the CRS-R scores. Results. The inter-expert reliability was poor in all three specializations when using clinical examination to determine the degree of impaired consciousness in patients with CDC. An average level of IER (Cohen's kappa = 0.46) was found only in the neurosurgeonCRS-R pair. Conclusion. A scale with detailed criteria is different to a standard clinical examination and has a higher level of IER. Moving from subjective evaluation to a standardized CRS-R will enable medical specialists to determine a patients rehabilitation potential and predict disease progression more accurately. Educational programmes, including virtual platforms, should be developed to encompass most of the medical community.

Keywords

• inter-expert reliability
• chronic disorders of consciousness
• coma recovery scale-revised
• scale rating