Implementation of the FOUR Scale Versus the Glasgow Coma Scale in Neurological Assessment of Intubated Adult ICU Patients: An Evidence-Based Practice Project

Abstract

Background: Accurate neurological assessment is essential for prognosis and timely clinical decision-making in critically ill patients. The Glasgow Coma Scale (GCS) is widely used; however, its reliance on eye, verbal, and motor responses limits its applicability in intubated and neurologically impaired patients. Non-testable components are conventionally scored as one rather than zero, potentially underestimating true neurological function. The Full Outline of Un-Responsiveness (FOUR) scale was developed to overcome these limitations by assessing eye response, motor response, brainstem reflexes, and respiratory pattern.

Objective: To implement the FOUR scale in adult intensive care unit (ICU) patients and evaluate its perceived accuracy, usefulness and satisfaction compared with the GCS.

Methods: This evidence-based practice project conducted in two ICU units of a private tertiary care hospital in Islamabad, Pakistan. Five postgraduate residents and seven nurses in the intervention unit received structured training on FOUR scale implementation, while the control unit continued routine neurological assessment using the GCS. Fifteen adult intubated patients with neurological impairment were assessed over a four-week implementation period from mid-July to August 2025. Clinician-reported accuracy, perceived usefulness and satisfaction of the assessment tools were evaluated post-implementation.

Results:  Following the four-week implementation period, clinicians in the intervention unit reported higher perceived accuracy, increased satisfaction and greater perceived usefulness of the FOUR scale compared with routine neurological assessment using the GCS. Mean clinician satisfaction scores were higher for the FOUR scale (4.6 ± 0.5) than for the GCS (3.2 ± 0.7). Inter-rater reliability was also greater with the FOUR scale (κ = 0.82) compared with the GCS (κ = 0.65), indicating stronger agreement in neurological assessment among clinicians. Qualitative feedback further highlighted improved clarity in neurological assessment and enhanced communication regarding patient status and prognosis, particularly for intubated patients.

Conclusion: The FOUR scale was perceived as a more useful neurological assessment tool than the GCS for adult ICU patients with intubation or neurological impairment. Thus, the project supports integrating the FOUR scale into routine ICU practice and nursing education to improve neurological monitoring in critically ill adults.