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Еvidеnсе Imрlеmеntаtiоn Рlаn аnd Еvаluаtiоn оf реdiаtriс full оutlinе оf unrеsроnsivеnеss sсоrе sсаlе


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Еvidеnсе Imрlеmеntаtiоn Рlаn аnd Еvаluаtiоn of реdiаtriс full outline of unrеsроnsivеnеss sсоrе sсаlе

Summary or brief overview of plan

A plan to implement and evaluate full outline of unresponsiveness (FORM) scoring is provided with the aim of changing practice among healthcare workers who deal with children. This scoring approach is an improvement of the much used Glasgow Coma Scale (GCS) because it is appropriate for those who cannot provide verbal responses regarding their level of consciousness either due to their youth and thus lack of verbal skills, being intubated or being in a vegetative state (Cartwright & Wallace, 2007). Since, the scoring method is new to nursing practice, its adoption in healthcare establishments requires approaches suited for translation of knowledge into practice (Harris, et al., 2015).

Background and literature review

The common approaches of evaluating the consciousness patients with acute neurological problems, those who are comatose and those who have experienced traumatic brain injury have been based on the ability of the patient to respond to light, sound and touch. The Glasgow Coma Scale (GCS) has been widely used to evaluate the level of consciousness (LOC) of patients in many clinical setting with great success (Bruno et al., 2011). However, its effectiveness in evaluating the level of consciousness is compromised for patients with verbal impairments, patients under mechanical ventilation, patients who are intubated and children as well. In addition, this approach is not able to test brainstem reflexes.

The Full Outline of Unresponsiveness Score (FOUR) addresses the shortcomings of GCS by not testing the verbal response and replacing the verbal component with hand gestures thus making it suitable for assessing patients under mechanical ventilation, intubated patients and patients with verbal disability or patients who have not developed verbal skills (Kramer et al., 2012). In addition, FOUR is able to assess the severity of coma and brain injury by testing the reflexes of the brainstem and observing changes in the breathing pattern of a patient, which are not included in GSC. As such, FOUR is able to identify the different stages of herniation, the presence of a vegetative state, and lock-in syndrome as well (Wijdicks, et al., 2005). Further, FOUR enabled accurate prediction of successful extubation of intubated patients who were critically ill (Said, et al., 2016).
Further, FORM is easy to apply, even for novice healthcare workers because it has a uniform scoring format unlike GCS whose scoring varies between test components. Implementation of FORM involves the translation of theory into evidence-based practice, which may have a steep learning curve on those expected to use it in the healthcare setting. As such, to overcome any challenges presented by such translation the knowledge transfer process should be systematic by starting from firstly, understanding knowledge creation and distillation, secondly, going through knowledge diffusion and dissemination, and thirdly, enabling organizational adoption and implementation (Estabrooks, et al., 2006). These stages of knowledge transfer should be viewed through the lens of the creators of new knowledge, in this case, the researcher who provide evidence-based practice. The process of knowledge transfer should start from the findings from the patient safety portfolio, which in this case should be accuracy of diagnosis using scoring tools.

Conceptual models that may be used in the translating research into practice in this case include health education, adult learning, marketing, social influence, and organizational and behavior theories (Farquhar, Stryer & Slutsky, 2002). Specific models include the Promoting Action on Research Implementation in Health Services (PARIHS) model, Rogers’s Diffusion of Innovation model, the Institute for Healthcare Improvement (IHI) model in translation science, the push/pull framework, and the decision-making framework (Farquhar, Stryer & Slutsky, 2002).

Aims of the implementation

Adoption of FORM would improve inter-rater reliability, increase the neurological detail of patient evaluation (Cohen, 2009). In addition, FORM promises good prediction of 3-month outcomes and in-hospital mortality in comatose children (Wijdicks, et al., 2015). Ultimately, the change in practice would improve the accuracy of diagnosis and thus enhance the quality of healthcare and safety of patients in the end.
The outcomes of the new scoring approach would be evaluating using the length of stay in the intensive care unit and hospital, the duration of coma and the comfort of the patient. In addition, the accuracy of in-hospital mortality prediction would inform on the effectiveness of FORM. To this end, the employment of the pediatric overall performance category (POPC) would facilitate the assessment of the long-term outcomes of adopting FORM (Jamal, et al., 2017).

Identification of stakeholders, champions and targets

The stakeholders in the proposed change of practice are the management of healthcare establishments, physicians, nurses, patients, the families of the patients, healthcare trainers in medical schools, healthcare policy makers, and healthcare insurance providers. These stakeholders should be involved in the planning stages because they hold different but pertinent interests in healthcare practice.

However, those who would champion the new practice would be the managers and administrators of healthcare establishments, the chief physician and the chief nurse. They would be involved at the planning, implementation and evaluation stages of the adoption of the new practice. The adoption of the new evaluation approach should target the nurses as the first responders of emergencies and the first healthcare professional in first contact with patients in a healthcare establishment. The nurses would be involved mainly in the implementation phase.

Identification of barriers

The implementation of FORM might be hindered by the management of the healthcare establishments who may fear the financial implications presented by training of the healthcare workers therein and even employing of staff that have expertise in using the assessment approach to serve as trainers and mentors of the rest of the workforce (Houser & Oman, 2010).

The healthcare workers themselves may hinder the plan through resistance. Specifically, they may resist changing from the evaluation approach already in place because they fear change, and the uncertainties and inconveniences that change presents, they may not fathom the value of the new scoring approach, they may be averse to learning,

Scarcity of human resource with expertise in FORM may hinder the implementation plan because it would impair the training of the healthcare workers. Further, lack of finances can impair the hiring of trainers.

Significance of the project

There is need to adopt FORM to address the deficiencies of GCS, which has been considered as the gold standard for a long time and thus improve the assessment of comatose children and children suffering from extensive brain injury. Specifically, the use of GCS on children has not been effective because it relies of verbal responses to inform on brainstem reflexes, which is not workable for young children who are unable to speak. In addition, FORM can better evaluate the success or failure of extubation for children compared to GCS.

Method of knowledge transfer: Planned staging of implementation activities

The proposed method of knowledge transfer would be premised on the Collaborative Model of Knowledge Translation. This approach is dialogic and thus enables collaborative engagement whereby healthcare practitioners would reflect on their current practice and its consequences, and identify what they would do differently by drawing on the knowledge provided by research (Baumbusch et al., 2008). The collaborative nature of this approach enables the involvement of all the stakeholders interested in the health of children, from parents to nurses, insurers, hospital administrators, and healthcare policy makers.

Proposed evaluation

The results derived from employing of the full outline of unresponsiveness (FORM) scoring can be evaluated using the Pediatric Overall Performance Category and Pediatric Cerebral Performance Category (POPC/PCPC) scales and the Functional Status Scale (FSS).

Ethical or resource implications

The ethical issues associated with the adoption of FORM include the determination of the amount of pain to be inflicted onto the patient during the assessment of the level of consciousness. In this case, care should be taken not to provide prolonged extended tactile stimulation that may lead to injuring of nerves in a patient, particularly those who are comatose and children who are unable to speak. In addition, one should avoid being subjective during the assessment process because it would compromise inter-observer and inter-rater agreement, which in run, would complicate the decision making process (Jamal, et al., 2017). However, information obtained from the scores from FORM should be treated with a high level of confidentiality and thus should only be shared with the primary stakeholders directly involved in the healthy wellbeing of the child patient.

The major cost associated with the adoption of FORM is the cost of training the healthcare workers and particularly the nurses in the healthcare establishments. However, this cost can be minimized if a few workers are trained first in a training the trainer program, after which they can train the rest of the workforce at the healthcare setting. This approach may incur lower costs compared to training all workers using an externally hired trainer. In addition, procuring the new test kit, which is in form of test manuals and logbooks, would require expenditure of finances as well. The other cost is the time needed for training, which is difficult to monetize.


The benefits accrued from the adoption of FORM outweigh the cost of implementation of the assessment approach. Specifically, FORM facilitates the accurate diagnosis of the level of consciousness in children who are comatose, have impaired consciousness, and who have extensive brain damage yet they are not able to speak. Accurate diagnosis reduces in-hospital child mortality and helps in the making of evidence-based decisions about the correct interventions to apply, for instance, the need for neurosurgical intervention (Kramer, et al., 2012). In addition, FORM can be employed by nurses who have limited experience in situations related to neuroscience such as intensive care units and the emergency department (Wolf, et al., 2007).

Time line

Training on the use of FORM and to assess the scores obtained take less than an hour. However, the embedding of the scoring approach should be piloted for a week depending on the size of the healthcare establishment and the frequency of patients coming to the emergency department. Overall, a month is sufficient to implement the evidence-based practice and four months to evaluate its outcome considering that FORM promises good prediction of outcomes after 3-month of extubation.


Baumbusch, J. L., Kirkham, S. R., Khan, K. B., McDonald, H., Semeniuk, P., Tan, E., & Anderson, J. M. (2008). Pursuing common agendas: a collaborative model for knowledge translation between research and practice in clinical settings. Research in Nursing & Health31(2), 130-140.

Bruno, M. A., Ledoux, D., Lambermont, B., Damas, F., Schnakers, C., Vanhaudenhuyse, A., … & Laureys, S. (2011). Comparison of the Full Outline of UnResponsiveness and Glasgow Liege Scale/Glasgow Coma Scale in an intensive care unit population. Neurocritical Care15(3), 447-453.

Cartwright, C. C. & Wallace, D. C. (2007). Nursing care of the pediatric neurosurgery patient. Springer.

Cohen, J. (2009). Interrater reliability and predictive validity of the FOUR score coma scale in a pediatric population. Journal of Neuroscience Nursing41(5), 261-267.

Estabrooks, C. A., Thompson, D. S., Lovely, J. J. E., & Hofmeyer, A. (2006). A guide to knowledge translation theory. Journal of Continuing Education in the Health Professions26(1), 25-36.

Farquhar, C. M., Stryer, D., & Slutsky, J. (2002). Translating research into practice: the future ahead. International Journal for Quality in Health Care14(3), 233-249.

Harris, C., Garrubba, M., Allen, K., King, R., Kelly, C., Thiagarajan, M., … & Farjou, D. (2015). Development, implementation and evaluation of an evidence-based program for introduction of new health technologies and clinical practices in a local healthcare setting. BMC Health Services Research15(1), 575.

Houser, J., & Oman, K. S. (2010). Evidence-based practice: An implementation guide for healthcare organizations. Jones & Bartlett Publishers.

Jamal, A., Sankhyan, N., Jayashree, M., Singhi, S., & Singhi, P. (2017). Full Outline of Unresponsiveness score and the Glasgow Coma Scale in prediction of pediatric coma. World Journal of Emergency Medicine8(1), 55.

Kramer, A. A., Wijdicks, E. F., Snavely, V. L., Dunivan, J. R., Naranjo, L. L. S., Bible, S., … & Dickess, S. M. (2012). A multicenter prospective study of interobserver agreement using the Full Outline of Unresponsiveness score coma scale in the intensive care unit. Critical Care Medicine40(9), 2671-2676.

Said, T., Chaari, A., Hakim, K. A., Hamama, D., & Casey, W. F. (2016). Usefulness of full outline of unresponsiveness score to predict extubation failure in intubated critically-ill patients: A pilot study. International Journal of Critical Illness and Injury Science6(4), 172.

Wijdicks, E. F., Bamlet, W. R., Maramattom, B. V., Manno, E. M., & McClelland, R. L. (2005). Validation of a new coma scale: the FOUR score. Annals of Neurology58(4), 585-593.

Wijdicks, E. F., Kramer, A. A., Rohs Jr, T., Hanna, S., Sadaka, F., O’Brien, J., … & Foss, M. (2015). Comparison of the full outline of UnResponsiveness score and the Glasgow Coma Scale in predicting mortality in critically ill patients. Critical Care Medicine43(2), 439-444.

Wolf, C. A., Wijdicks, E. F., Bamlet, W. R., & McClelland, R. L. (2007, April). Further validation of the FOUR score coma scale by intensive care nurses. In Mayo Clinic Proceedings (Vol. 82, No. 4, pp. 435-438). Elsevier.