The Glasgow Coma Scale, Outreach & MEWS

1. The Glasgow Coma Scale, Outreach & MEWS Oriana, Nicky & Lyndsay 1st February 2007

2. The Glasgow Coma Scale • Tool for assessing all patients at potential risk of neurological deterioration • 2 aspects of consciousness: - arousal - cognition • Physiology

3. Responses & scoring • Best eye response - max score 4 • Best verbal response - max score 5 • Best motor response - max score 6 • GCS of 8 or less - severe injury • GCS of 9 – 12 - moderate injury • GCS of 13 – 15 - minor injury

4. Best eye response • Eyes opening spontaneously = 4 • Eyes opening to verbal command = 3 • Eyes opening to pain = 2 • No eyes opening = 1

5. Best verbal response • Orientated = 5 • Confused = 4 • Inappropriate words = 3 • Incomprehensible sounds = 2 • No verbal response = 1

6. Simon Hope • Pre-hospital care recorded GCS of 15 = minor injury • A&E – Score recorded as 14 at 0200 • GCS score decreased to 13 at 0400 • Best verbal response = confused • Sp02 90% • Decreased oxygen supply to brain - RAS

7. Problems with GCS • Misunderstood • Misused • General nurses vs ‘neuroscience’ nurses • Research of 3rd year nursing students • Implications for practice

8. Motor Response : • Sensory input & translation into motor • response within the brain. i.e. motor and sensory function • Total score: 6

9. Score 6 – Obeys commands: • Highest level of motor response • Accurate response to instruction (twice) • eg: raise eyebrows, stick out tongue, squeeze and let go. Score 5 - Localising pain: • Response to pain stimulus - moves hand to the point of stimulation 1. Sternal rub (Shah 1999, NS) 3 stimuli recommended by the National Neuroscience Benchmarking Group:- • Supra orbital pressure • Jaw margin pressure • Trapezius squeeze

10. Supra Orbital Notch:

11. Jaw Margin Pressure:

12. Trapezius Squeeze:

13. Score 4 - Withdrawal from Pain: • Normal flexion in response to central pain stimuli, but failing to locate source of pain. • Pulls limb away from painful stimulus.

14. Decorticate posturing: which occurs due to a block in motor pathway between cerebral cortex and brain stem Slower response Flexing upper arm & rotating of wrist & thumb through fingers Score 3 - Flexion to Pain:

15. Decerebrate posturing: occurs due to blockage/damage within brainstem. Straightening of elbow & internal rotation of shoulder and wrist; leg extension with toes pointing downwards Score 2 - Extension to Pain:

16. Score 1- No Motor Response: • Brain incapable of processing any sensory input & motor activity • Rigid to all pain stimuli • Check not unresponsive due to local disease / injury!! Neurological examination of limbs: • pattern & power of movement = identify site and severity of brain damage

17. SIMON HOPE • Motor Responses: - localised pain, score 5 (MEWS) - level of consciousness, score 2 (PAR) • Responded to pain stimuli by move hand to point of stimulation - towards the chin, across the midline in an obvious and coordinated attempt to remove the source of pain (Waterhouse 2005). • Higher brain center recognition of pain and response to remove the source.

18. OUTREACH TEAM: • Comprehensive Critical Care Review (DH 2000) recommendation. • PART (Patient At Risk Team) • MEWS (Modified Early Warning System) • R-MEWS (Reading-Modified Early Warning System) • 3 essential objectives: 1. avoid admissions 2. enable discharge 3. share critical care skills

19. RBBH - critical care outreach service: • 24/7 • 8 specialist nurses with intensive care backgrounds • Specialist service ensures critical ill pts, across the whole hospital, are identified and treated quickly and effectively – medication change or admission to ICU/ITU. • R-MEWS: is the RBH’s own version of the ‘track and trigger system’ (a standard assessment for all adult acute inpatients in a trust) • Commended in the British Medical Association's A to Z of 'Doctors Making a Difference' for developing R-MEWS.

20. SIMON HOPE Why were the outreach team only called out 2hrs after deterioration clearly identified by early warning score? NICE (2003) guidelines: aimed at A&E:- • GCS < 15 (impaired consciousness):- assessed immediately by a trained member of staff (e.g. triage nurse). • GCS < or = 8:- early involvement of an anaesthetist or critical care physician to provide appropriate airway management, and to assist with resuscitation. • GCS <15 = 30min obs till recovery of max score.

21. Modified Early Warning System(MEWS) • Morgan et al developed an EWSS in 1997 • Similar to PAR = Patients At Risk (outreach services) • MEWS - an assessment tool using a score system for routine observations of vital signs • Enables staff to detect early signs of physiological deterioration – theoretically avoiding ICU admission • A system which is appropriate for bedside assessment on the ward because it is versatile, quick and easy to use and simply collates results (Subbe et al 2001).

22. MEWS • Quantifies a patient’s physiological condition by assigning a score (0,1,2,3) to each set of physiological parameters - 0: patient needs can be met by the usual ward care - 1: are at risk of deterioration - 2: require detailed observation and/or support of 1 failing organ - 3: require advanced respiratory support and/or have multiple organ failure

23. Example MEWS Chart Simon’s vital sign recordings: Resps = 30 increased to 36: score = 3 Pulse = 120 increased to 145: score = 3 BP = 100/60 dropped to 90/50: score = 1 TOTAL MEWS SCORE = 7 (+)

24. References (MEWS presentation) • Groom P (2001) Critical care and outreach teams – a prayer answered? Nursing Times 97(34) • Oakey RJ, Slade V (2006) Physiological observation track and trigger system. Nursing Standard 20(27) p48-54 • Palmer R (2004) Using an early warning system in a medical assessment unit. Nursing Times 100(48) p34-35 • Quarterman CPJ, Thomas AN, McKenna M, McNamee R (2004) Use of patient information systems to audit the introduction of modified early warning systems. Journal of Evaluation in Clinical Practice 11(2) p133-138 • Watson D (2006) The impact of accurate patient assessment on quality of care. Nursing Times 102(6) p34-37

25. References - GCS • Shoqirat, N (2006) Nursing students’ understanding of the Glasgow Coma Scale. Nursing Standard, 20,30, 41-47 • Waterhouse, C (2005) The Glasgow Coma Scale and other neurological observations. Nursing Standard, 19. 33. 56-64