- Email: [email protected]
Is the Glasgow Coma Scale Score in Children in the Emergency Department Lower During the Night?
RESEARCH
IS
GLASGOW COMA SCALE SCORE IN CHILDREN IN THE EMERGENCY DEPARTMENT LOWER DURING THE NIGHT? THE
Authors: Ramona Onita, David Kirby, and Michael Eisenhut, MD, Luton, United Kingdom
Earn Up to 7.5 CE Hours. See page 459. Introduction: The body clock may, through stimulation of
melatonin secretion, influence the Glasgow Coma Scale (GCS) score. The aim of this study was to investigate whether the time of presentation of children in the emergency department is associated with GCS scores. Methods: We performed a retrospective review of 6,649 records of children presenting to an emergency department, with comparison of patients with GCS scores lower than 15 seen during the daytime and night time regarding diagnosis, disease severity, GCS score, age, sex, and ethnic group. Results: Of 4,034 children seen during the daytime, 25 had GCS scores lower than 15, whereas 34 of 2,592 children seen during the night had GCS scores lower than 15 (P = .005). There were no differences in age, sex, ethnicity, or disease severity between the group of patients seen during the daytime and those seen during
reduced Glasgow Coma Scale (GCS) score may indicate serious brain dysfunction, triggering diagnostic interventions such as cerebral imaging and treatment for suspected encephalitis. If the GCS score drops below 8, airway management by intubation and mechanical ventilation may be initiated. The body clock may, through stimulation of melatonin secretion, influence the GCS score, resulting in a
A
Ramona Onita is Paediatric Specialist Trainee, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. David Kirby is Consultant, Adult & Paediatric Emergency Medicine, Emergency Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. Michael Eisenhut is Consultant Paediatrician, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. For correspondence, write: Michael Eisenhut, MD, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Lewsey Road, Luton, LU4ODZ, United Kingdom; E-mail: [email protected]. J Emerg Nurs 2015;41:404-6. Available online 26 March 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.02.004
404
JOURNAL OF EMERGENCY NURSING
the night. Conditions presenting with reduced GCS scores were seizures (32%), respiratory tract infection (17%), other infections (20%), trauma (13%), and other conditions (18%). Significantly more children with respiratory tract infections and low GCS scores presented during the night (P = .029). Discussion: The presentation of children with low GCS scores was more common during the night. Children with reduced GCS scores and viral respiratory tract infections presented more frequently during the night. Assessment of patients’ level of consciousness during the night needs to discriminate difficulties in eliciting a response due to fatigue from features of cerebral dysfunction. Keywords: Glasgow Coma Scale; Circadian; Night; Nocturnal;
Diurnal
lower score during the night. The aim of this study was to investigate whether the time of presentation of children in the emergency department is associated with GCS scores. The rationale for this retrospective investigation was to establish whether night time, because of fatigue and sleepiness, is associated with lower GCS scores. A spuriously low GCS score may decrease the threshold for inappropriate cerebral imaging. Inappropriate cerebral computed tomograms are commonly obtained in young people, exposing children to radiation, 1 and in young children, sedation may be avoided if the assessment of the level of consciousness is performed appropriately. Methods
We performed a retrospective analysis of 6,649 electronic records of children presenting to the emergency department in Luton & Dunstable University Hospital NHS Foundation Trust, a district general hospital in Luton, United Kingdom, from August to December 2012, with comparison of patients with GCS scores lower than 15 seen during the daytime (7:01 am to 7:00 pm) and night time (7:01 pm to 7:00 am) regarding diagnosis, disease severity (Pediatric Early Warning score 2), GCS score, age, sex, and ethnic group. The project
VOLUME 41 • ISSUE 5
September 2015
Onita et al/RESEARCH
TABLE
Diagnoses of patients (n = 59) with Glasgow Coma Scale scores lower than 15 in relation to time of presentation in emergency department Time of assessment
7:01 am to 7:00 pm (n = 4,034) 7:01 pm to 7:00 am (n = 2,592)
Seizures
Viral respiratory tract infections
Other infections
Trauma
Other conditions
10 (38) 9 (26)
3 (12) a 8 (24)
5 (23) 6 (17)
4 (15) 3 (9)
3 (12) 8 (24)
P = .029 by Fisher exact test for 7:01 am to 7:00 pm versus 7:01 pm to 7:00 am in relation to total number of patients presenting to emergency department.
did not require ethical approval or consent because it fulfilled the criteria set by the National Research Ethics Service of the National Patient Safety Agency for clinical audit, including design and conduct to produce information to inform delivery of best care and evaluation of service delivery against a standard. 3 Institutional review board approval is not required for audit projects. GCS scores are routinely recorded in all patients on arrival by a triage nurse. DATA ANALYSIS
Statistical analysis was conducted using Epi-Info, version 7.0 (Centers for Disease Control and Prevention, Atlanta, GA), for analysis of categorical data by the χ 2 test or by the Fisher exact test if numbers were fewer than 5 in groups. SPSS software, version 18.0 (IBM, Armonk, NY), was used to compare continuous data by the t test for independent samples for data with a parametric distribution and the Mann–Whitney test for data with a nonparametric distribution. Numbers of patients with reduced GCS scores seen during the daytime versus during the night were compared by the χ 2 test. Because of numbers fewer than 5 in some groups, the Fisher exact test was used to compare type of diagnosis, sex, and ethnicity. Age, disease severity, and GCS score of the group seen during the daytime and the group seen during the night were compared using the t test or Mann–Whitney test as appropriate. P b .05 was considered to represent a statistically significant difference.
Results
Of 4,034 children seen during the daytime, 25 had GCS scores lower than 15, whereas 34 of 2,592 children seen during the night had GCS scores lower than 15 (P = .005). There were no differences in age, sex, ethnicity, or disease severity between the group of patients with GCS scores lower than 15 seen during the daytime and those seen during the night. The most common condition in children presenting with reduced GCS scores both during the daytime and during the night (n = 59)
September 2015
VOLUME 41 • ISSUE 5
was seizures (31.6%), followed by a viral respiratory tract infection (16.6%), miscellaneous other infections (20%), trauma (13.3%), and other miscellaneous conditions (18.3%). The only group of diseases with a significant difference in frequency between groups was viral respiratory tract infections. Significantly more children with respiratory tract infections and low GCS scores presented during the night (P = .029, Fisher exact test) (Table). When we compared eye, vocal, or motor responses, there were no significant differences between responses obtained in children seen during the daytime and those in children seen during the night (Figure).
Discussion
This is the first investigation into the association of time of day with GCS score. It is unlikely that the performance of the scorer led to lower scores in more patients during the night. Reduced levels of alertness in children presenting
Score of best response (median, IQR, extremes and outliers)
a
Diagnosis, n (%)
6.00
5.00
4.00
3.00
2.00
1.00
Eye response day
night
Verbal response day
night
Motor response day
night
FIGURE IQR, Interquartile range. Scores for best eye, verbal, and motor responses in children seen in emergency department during daytime (7:01 am to 7:00 pm) and night time (7:01 pm to 7:00 am).
WWW.JENONLINE.ORG
405
RESEARCH/Onita et al
during the night may have reduced the GCS scores and should be investigated as a source of bias in GCS scoring and taken into account during the night in patients in future prospective studies. Future GCS scoring may need to include items discriminating fatigue-related behavior from an illness- or injury-related reduced level of consciousness. Research also needs to establish whether GCS scoring should include a correction factor for fatigue. Viral respiratory tract infections may present with lower GCS scores during the night, which may be related to an enhanced melatonin production of the pineal gland. This melatonin is released in response to the effect of interferon gamma released in viral infections, 4 thereby keeping melatonin levels already increased during the night above levels causing a reduced response. Future studies should examine the influence of fatigue induced by systemic release of inflammatory mediators in all diseases associated with inflammation on the assessment of consciousness level.
significant difference for any of the domains of GCS assessment comparing assessments during the day and night (Figure). Education for nurses and physicians involved in night-time assessment and triage of children and adults should highlight the importance of focusing on specific features of cerebral inflammation, injury, intoxication, or metabolic derangement such as persistent confusion and disorientation. Lack of recognition of caregivers, incomprehensible verbal responses, and focal neurologic signs or seizures may identify children with genuine direct involvement of the brain in the disease process or injury. The GCS score should be viewed in the appropriate context before conclusions are drawn regarding cerebral involvement. Prevention of inappropriately attributing a reduced level of consciousness to cerebral dysfunction may avoid unnecessary investigations and precautionary treatments and thus save costs associated with staff time, as well as use of scanners and consumables, and avoid potential harm to patients from radiation and medication.
Limitations
We did not have information on the degree of fatigue of patients seen in the emergency department to enable a correlation with GCS scores because this is not routinely recorded. The Epworth Sleepiness Scale 5 is only applicable to older children and adults and could not be retrospectively applied to our data but may be applied in future studies in older children and adults investigating this topic. Implications for Emergency Nurses
The implications for emergency nursing practice are that during the night, triage nurses should assess the extent to which fatigue may influence the GCS score. A distinguishing feature between a fatigue-induced reduced response and a reduced response due to cerebral dysfunction that can be used by the assessor is an improved GCS score with a repeat assessment within a short period (minutes). If the reduced GCS score is associated with fatigue, then after arousal by the first assessment, a repetition of this assessment will yield an improved GCS score. A further distinguishing feature will be the quality of the GCS response once the child is awake, which may lead to progressively improved scores as the assessment proceeds through the domains of the GCS (eye, motor, or verbal response). Against the latter being a useful discriminator is the fact that we did not find a
406
JOURNAL OF EMERGENCY NURSING
Conclusions
The presentation of children with low GCS scores was more common during the night. Children with reduced GCS scores and respiratory tract infections presented more frequently during the night. Assessment of patients’ level of consciousness during the night should discriminate difficulties in eliciting a response due to fatigue (ie, due to endogenous hormonal effects) from specific features of cerebral dysfunction. Reassessment of the GCS score after arousal might provide a more accurate decision-making tool for further investigations and management. REFERENCES 1. Oikarinen H, Meriläinen S, Pääkkö E, Karttunen A, Nieminen MT, Tervonen O. Unjustified CT examinations in young patients. Eur Radiol. 2009;19(5):1161-1165. 2. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006;21(3):271-278. 3. National Research Ethics Service. NHS Health Research Authority. http://nres.nhs.uk/. Accessed January 1, 2015. 4. Withyachumnarnkul B, Nonaka KO, Santana C, Attia AM, Reiter RJ. Interferon-gamma modulates melatonin production in rat pineal glands in organ culture. J Interferon Res. 1990;10(4):403-411. 5. Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6):540-545.
VOLUME 41 • ISSUE 5
September 2015
IS
GLASGOW COMA SCALE SCORE IN CHILDREN IN THE EMERGENCY DEPARTMENT LOWER DURING THE NIGHT? THE
Authors: Ramona Onita, David Kirby, and Michael Eisenhut, MD, Luton, United Kingdom
Earn Up to 7.5 CE Hours. See page 459. Introduction: The body clock may, through stimulation of
melatonin secretion, influence the Glasgow Coma Scale (GCS) score. The aim of this study was to investigate whether the time of presentation of children in the emergency department is associated with GCS scores. Methods: We performed a retrospective review of 6,649 records of children presenting to an emergency department, with comparison of patients with GCS scores lower than 15 seen during the daytime and night time regarding diagnosis, disease severity, GCS score, age, sex, and ethnic group. Results: Of 4,034 children seen during the daytime, 25 had GCS scores lower than 15, whereas 34 of 2,592 children seen during the night had GCS scores lower than 15 (P = .005). There were no differences in age, sex, ethnicity, or disease severity between the group of patients seen during the daytime and those seen during
reduced Glasgow Coma Scale (GCS) score may indicate serious brain dysfunction, triggering diagnostic interventions such as cerebral imaging and treatment for suspected encephalitis. If the GCS score drops below 8, airway management by intubation and mechanical ventilation may be initiated. The body clock may, through stimulation of melatonin secretion, influence the GCS score, resulting in a
A
Ramona Onita is Paediatric Specialist Trainee, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. David Kirby is Consultant, Adult & Paediatric Emergency Medicine, Emergency Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. Michael Eisenhut is Consultant Paediatrician, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, United Kingdom. For correspondence, write: Michael Eisenhut, MD, Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Lewsey Road, Luton, LU4ODZ, United Kingdom; E-mail: [email protected]. J Emerg Nurs 2015;41:404-6. Available online 26 March 2015 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.02.004
404
JOURNAL OF EMERGENCY NURSING
the night. Conditions presenting with reduced GCS scores were seizures (32%), respiratory tract infection (17%), other infections (20%), trauma (13%), and other conditions (18%). Significantly more children with respiratory tract infections and low GCS scores presented during the night (P = .029). Discussion: The presentation of children with low GCS scores was more common during the night. Children with reduced GCS scores and viral respiratory tract infections presented more frequently during the night. Assessment of patients’ level of consciousness during the night needs to discriminate difficulties in eliciting a response due to fatigue from features of cerebral dysfunction. Keywords: Glasgow Coma Scale; Circadian; Night; Nocturnal;
Diurnal
lower score during the night. The aim of this study was to investigate whether the time of presentation of children in the emergency department is associated with GCS scores. The rationale for this retrospective investigation was to establish whether night time, because of fatigue and sleepiness, is associated with lower GCS scores. A spuriously low GCS score may decrease the threshold for inappropriate cerebral imaging. Inappropriate cerebral computed tomograms are commonly obtained in young people, exposing children to radiation, 1 and in young children, sedation may be avoided if the assessment of the level of consciousness is performed appropriately. Methods
We performed a retrospective analysis of 6,649 electronic records of children presenting to the emergency department in Luton & Dunstable University Hospital NHS Foundation Trust, a district general hospital in Luton, United Kingdom, from August to December 2012, with comparison of patients with GCS scores lower than 15 seen during the daytime (7:01 am to 7:00 pm) and night time (7:01 pm to 7:00 am) regarding diagnosis, disease severity (Pediatric Early Warning score 2), GCS score, age, sex, and ethnic group. The project
VOLUME 41 • ISSUE 5
September 2015
Onita et al/RESEARCH
TABLE
Diagnoses of patients (n = 59) with Glasgow Coma Scale scores lower than 15 in relation to time of presentation in emergency department Time of assessment
7:01 am to 7:00 pm (n = 4,034) 7:01 pm to 7:00 am (n = 2,592)
Seizures
Viral respiratory tract infections
Other infections
Trauma
Other conditions
10 (38) 9 (26)
3 (12) a 8 (24)
5 (23) 6 (17)
4 (15) 3 (9)
3 (12) 8 (24)
P = .029 by Fisher exact test for 7:01 am to 7:00 pm versus 7:01 pm to 7:00 am in relation to total number of patients presenting to emergency department.
did not require ethical approval or consent because it fulfilled the criteria set by the National Research Ethics Service of the National Patient Safety Agency for clinical audit, including design and conduct to produce information to inform delivery of best care and evaluation of service delivery against a standard. 3 Institutional review board approval is not required for audit projects. GCS scores are routinely recorded in all patients on arrival by a triage nurse. DATA ANALYSIS
Statistical analysis was conducted using Epi-Info, version 7.0 (Centers for Disease Control and Prevention, Atlanta, GA), for analysis of categorical data by the χ 2 test or by the Fisher exact test if numbers were fewer than 5 in groups. SPSS software, version 18.0 (IBM, Armonk, NY), was used to compare continuous data by the t test for independent samples for data with a parametric distribution and the Mann–Whitney test for data with a nonparametric distribution. Numbers of patients with reduced GCS scores seen during the daytime versus during the night were compared by the χ 2 test. Because of numbers fewer than 5 in some groups, the Fisher exact test was used to compare type of diagnosis, sex, and ethnicity. Age, disease severity, and GCS score of the group seen during the daytime and the group seen during the night were compared using the t test or Mann–Whitney test as appropriate. P b .05 was considered to represent a statistically significant difference.
Results
Of 4,034 children seen during the daytime, 25 had GCS scores lower than 15, whereas 34 of 2,592 children seen during the night had GCS scores lower than 15 (P = .005). There were no differences in age, sex, ethnicity, or disease severity between the group of patients with GCS scores lower than 15 seen during the daytime and those seen during the night. The most common condition in children presenting with reduced GCS scores both during the daytime and during the night (n = 59)
September 2015
VOLUME 41 • ISSUE 5
was seizures (31.6%), followed by a viral respiratory tract infection (16.6%), miscellaneous other infections (20%), trauma (13.3%), and other miscellaneous conditions (18.3%). The only group of diseases with a significant difference in frequency between groups was viral respiratory tract infections. Significantly more children with respiratory tract infections and low GCS scores presented during the night (P = .029, Fisher exact test) (Table). When we compared eye, vocal, or motor responses, there were no significant differences between responses obtained in children seen during the daytime and those in children seen during the night (Figure).
Discussion
This is the first investigation into the association of time of day with GCS score. It is unlikely that the performance of the scorer led to lower scores in more patients during the night. Reduced levels of alertness in children presenting
Score of best response (median, IQR, extremes and outliers)
a
Diagnosis, n (%)
6.00
5.00
4.00
3.00
2.00
1.00
Eye response day
night
Verbal response day
night
Motor response day
night
FIGURE IQR, Interquartile range. Scores for best eye, verbal, and motor responses in children seen in emergency department during daytime (7:01 am to 7:00 pm) and night time (7:01 pm to 7:00 am).
WWW.JENONLINE.ORG
405
RESEARCH/Onita et al
during the night may have reduced the GCS scores and should be investigated as a source of bias in GCS scoring and taken into account during the night in patients in future prospective studies. Future GCS scoring may need to include items discriminating fatigue-related behavior from an illness- or injury-related reduced level of consciousness. Research also needs to establish whether GCS scoring should include a correction factor for fatigue. Viral respiratory tract infections may present with lower GCS scores during the night, which may be related to an enhanced melatonin production of the pineal gland. This melatonin is released in response to the effect of interferon gamma released in viral infections, 4 thereby keeping melatonin levels already increased during the night above levels causing a reduced response. Future studies should examine the influence of fatigue induced by systemic release of inflammatory mediators in all diseases associated with inflammation on the assessment of consciousness level.
significant difference for any of the domains of GCS assessment comparing assessments during the day and night (Figure). Education for nurses and physicians involved in night-time assessment and triage of children and adults should highlight the importance of focusing on specific features of cerebral inflammation, injury, intoxication, or metabolic derangement such as persistent confusion and disorientation. Lack of recognition of caregivers, incomprehensible verbal responses, and focal neurologic signs or seizures may identify children with genuine direct involvement of the brain in the disease process or injury. The GCS score should be viewed in the appropriate context before conclusions are drawn regarding cerebral involvement. Prevention of inappropriately attributing a reduced level of consciousness to cerebral dysfunction may avoid unnecessary investigations and precautionary treatments and thus save costs associated with staff time, as well as use of scanners and consumables, and avoid potential harm to patients from radiation and medication.
Limitations
We did not have information on the degree of fatigue of patients seen in the emergency department to enable a correlation with GCS scores because this is not routinely recorded. The Epworth Sleepiness Scale 5 is only applicable to older children and adults and could not be retrospectively applied to our data but may be applied in future studies in older children and adults investigating this topic. Implications for Emergency Nurses
The implications for emergency nursing practice are that during the night, triage nurses should assess the extent to which fatigue may influence the GCS score. A distinguishing feature between a fatigue-induced reduced response and a reduced response due to cerebral dysfunction that can be used by the assessor is an improved GCS score with a repeat assessment within a short period (minutes). If the reduced GCS score is associated with fatigue, then after arousal by the first assessment, a repetition of this assessment will yield an improved GCS score. A further distinguishing feature will be the quality of the GCS response once the child is awake, which may lead to progressively improved scores as the assessment proceeds through the domains of the GCS (eye, motor, or verbal response). Against the latter being a useful discriminator is the fact that we did not find a
406
JOURNAL OF EMERGENCY NURSING
Conclusions
The presentation of children with low GCS scores was more common during the night. Children with reduced GCS scores and respiratory tract infections presented more frequently during the night. Assessment of patients’ level of consciousness during the night should discriminate difficulties in eliciting a response due to fatigue (ie, due to endogenous hormonal effects) from specific features of cerebral dysfunction. Reassessment of the GCS score after arousal might provide a more accurate decision-making tool for further investigations and management. REFERENCES 1. Oikarinen H, Meriläinen S, Pääkkö E, Karttunen A, Nieminen MT, Tervonen O. Unjustified CT examinations in young patients. Eur Radiol. 2009;19(5):1161-1165. 2. Duncan H, Hutchison J, Parshuram CS. The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children. J Crit Care. 2006;21(3):271-278. 3. National Research Ethics Service. NHS Health Research Authority. http://nres.nhs.uk/. Accessed January 1, 2015. 4. Withyachumnarnkul B, Nonaka KO, Santana C, Attia AM, Reiter RJ. Interferon-gamma modulates melatonin production in rat pineal glands in organ culture. J Interferon Res. 1990;10(4):403-411. 5. Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14(6):540-545.
VOLUME 41 • ISSUE 5
September 2015