Assessment of a standardized quick neurologic examination (QNE) tool for reliability and validity in the PICU setting.

Common practices to perform serial neurologic exams in the PICUs include pupillary response and the Glasgow Coma Scale (GCS) or Full Outline of Un-Responsiveness (FOUR) score, with shortcomings in assessing more subtle cerebral dysfunction.

The new QNE tool evaluates four neurologic domains: level of consciousness, communication, motor function and cranial nerves. Each domain is scored from 0 (worst) to 4 (best), with total scores ranging from 0-16. PICU patients aged 2-21 years with a neurologic diagnosis were evaluated by different raters (RN, resident and attending). Agreement (tolerating a total score difference of 1-2) and weighted and unweighted Cohen’s kappa (??_w, ??) coefficients were calculated. Scores were stratified into “upper” (12-16), “middle” (6-11) and “lower” (0-5). Validity was determined by comparison of categories between neurologists and non-specialists. Simple linear regression was used to compare QNE with FOUR and GCS scores.

23 subjects were assessed in total with different combinations of raters. The agreement between nurse and physician raters was 68% (tolerance =1) and 86% (tolerance = 2, n = 22). The inter-rater reliability was excellent (??_w = 0.92, ?? = 0.24 [0.08 – 0.4], p = 0.004). When assessing for “upper”, “middle” and “lower” category, the agreement was 83% (zero tolerance). We found 70% agreement and good correlation (??_w = 0.4, ?? = 0.27 [-0.28 – 0.82], p=0.236) in the 10 subjects assessed by a pediatric neurologist and a resident, suggesting good validity. The FOUR and GCS scores that were collected at the same time by the raters correlated well with the QNE scores (R-squared: 0.744 and 0.877, respectively).

The QNE tool has excellent reliability and good validity. It will likely improve appropriate neurologic assessment and communication between different providers in the PICU setting.