SEVERITY - ARCHIVE

GCS (GLASGOW COMA SCALE) - ARCHIVE

Definition

Glasgow Coma Scale while subject is in care of the Emergency Medical Service.

  1. On admission to Model System emergency department
  2. Highest score recorded in the 24 hours following *first EMS contact
  3. Lowest score recorded in the 24 hours following *first EMS contact

Form

[X] Form 1
[ ] Form 2

Source

  • Form 1 - Abstraction (acute record)

Details

Highest and lowest GCS scores should be recorded for all three responses (eyes, verbal, and motor) at once.

Highest and Lowest scores recorded in the 24 hours following first EMS contact include the Model System EMS and ED admission scores if recorded.

If only 1 GCS is recorded, use that score for all three assessments. If patient is in barbiturate coma or paralyzed by use of Pavalin at the time of assessment, record individual items as 7 and total as 77. The coma or paralysis must be induced by medical personnel and not by patient.

Only code “chemically induced coma” with neuromuscular blocking agents or barbiturates.

If patient is intubated at the time of assessment, record the verbal score as 8 and the total score as 88. For the purposes of analysis, these cases will not be included unless specified for recoding during analysis.

If patient is intubated and in chemically-induced coma or paralysis, code 8 for verbal response and 7’s for eye opening, motor response and total GCS.

Utilize the highest and lowest motor score on the GCS as a guide for determining the highest and lowest GCS scores recorded in the 24 hours following *first EMS contact.

GCS scores recorded when the patient is chemically paralyzed should not be included as the highest or lowest GCS scores.

GCS scores recorded when the patient is intubated can be included as the highest or lowest GCS scores by using the motor score or the Becker conversion score .

Reference

Teasdale G, Jennett B (1976) Assessment and Prognosis of Coma After Head Injury, Acta Neurochir 34, 45-55.

Variables

Form Type

Variable

ID

Question

History

Form 1

GCSEyeHi

3465

GCS Eye Opening High

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSEyeLo

3466

GCS Eye Opening Low

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSMotHi

3467

GCS Motor High

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSMotLo

3468

GCS Motor Low

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSTotHi

3469

GCS Total ED High

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSTotLo

3470

GCS Total ED Low

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSVerHi

3471

GCS Verbal High

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

GCSVerLo

3472

GCS Verbal Low

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Codes and Values

ID 3465

For Form: [Form 1]
For Variables: [GCSEyeHi]

Code

Description

1

None

2

To Pain

3

To Voice

4

Spontaneous

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

9

Unknown Eye Opening Response

ID 3466

For Form: [Form 1]
For Variables: [GCSEyeLo]

Code

Description

1

None

2

To Pain

3

To Voice

4

Spontaneous

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

9

Unknown Eye Opening Response

ID 3467

For Form: [Form 1]
For Variables: [GCSMotHi]

Code

Description

1

None

2

Extension to Pain

3

Flexion to Pain

4

Withdraws from Pain

5

Localizes Pain

6

Obeys Commands

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

9

Unknown Motor Response

ID 3468

For Form: [Form 1]
For Variables: [GCSMotLo]

Code

Description

1

None

2

Extension to Pain

3

Flexion to Pain

4

Withdraws from Pain

5

Localizes Pain

6

Obeys Commands

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

9

Unknown Motor Response

ID 3469

For Form: [Form 1]
For Variables: [GCSTotHi]

Code

Description

77

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

88

Patient Intubated at time of Scoring

99

Unknown Total GCS Score

ID 3470

For Form: [Form 1]
For Variables: [GCSTotLo]

Code

Description

77

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

88

Patient Intubated at time of Scoring

99

Unknown Total GCS Score

ID 3471

For Form: [Form 1]
For Variables: [GCSVerHi]

Code

Description

1

None

2

Incomprehensible Sounds

3

Inappropriate Speech

4

Confused

5

Oriented

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

8

Patient Intubated at time of Scoring

9

Unknown Verbal Response

ID 3472

For Form: [Form 1]
For Variables: [GCSVerLo]

Code

Description

1

None

2

Incomprehensible Sounds

3

Inappropriate Speech

4

Confused

5

Oriented

7

Patient Chemically Paralyzed ( Or in chemically-induced coma for treatment purposes;*sedated )

8

Patient Intubated at time of Scoring

9

Unknown Verbal Response

History

Date

Description

1994-02-01

Added NOTE : to clarify which GCS scores to use.

1995-01-01

Dropped 88 and 8=Not applicable codes.

1995-07-01

Added NOTE : highest/lowest now collected within 24 hours of injury; this includes EMS and initial ED score.

1995-07-01

Added CODES : 7 for individual items and 77 for total = chemically induced coma or paralysis. Added
code T=intubated for verbal item and TT=intubated for total. Dropped eye swelling and intubation
items.

1996-04-01

Changed CODES : for patient intubated from "T" and "TT" to "8" and "88".

1999-04-01

Added NOTE : regarding determining highest and lowest GCS scores when patient is chemically paralyzed and/or intubated.

1999-07-01

Added NOTE : revised definition for highest and lowest scores to be within 24 hours following first EMS contact.

1999-10-01

Added NOTE : which stated for highest and lowest score can use model system EMS and ED GCS.

2003-01-01

Deleted NOTE : “highest score” and “lowest score” for all GCS variables and all related instructions.

PUPILLARY RESPONSE - ARCHIVE

Definition

This variable describes pupillary response to light stimulation at time of the initial neurological evaluation following injury (System Admission) and the worst results during the first 24 hrs. after injury.

Form

[X] Form 1
[ ] Form 2

Source

  • Abstraction (acute record)

Details

Document left (OS) and right (OD) pupils separately. Worst scores for each eye may be from different exams during the first 24-hour period after injury.

Worst score within the first 24 hours post-injury can include Model System ED, but not any EMS data.

If only one reading is available within the first 24 hours post injury, use it as the initial and worst score.

Variables

Form Type

Variable

ID

Question

History

Form 1

PupilInitL

3505

Pupillary Response - Initial Eye Left

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

PupilInitR

3506

Pupillary Response - Initial Eye Right

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

PupilWorstL

3507

Pupillary Response - Worst Eye Left

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

PupilWorstR

3508

Pupillary Response - Worst Eye Right

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Codes and Values

ID 3505

For Form: [Form 1]
For Variables: [PupilInitL]

Code

Description

1

Brisk or Normal Reaction (BR) +

2

Sluggish Reaction (SR) +

3

No Reaction (NR)

7

Not Applicable: Closed by swelling

8

Not Applicable: Eye absent or blind

9

Unknown ( Or eye sutured closed )

ID 3506

For Form: [Form 1]
For Variables: [PupilInitR]

Code

Description

1

Brisk or Normal Reaction (BR) +

2

Sluggish Reaction (SR) +

3

No Reaction (NR)

7

Not Applicable: Closed by swelling

8

Not Applicable: Eye absent or blind

9

Unknown ( Or eye sutured closed )

ID 3507

For Form: [Form 1]
For Variables: [PupilWorstL]

Code

Description

1

Brisk or Normal Reaction (BR) +

2

Sluggish Reaction (SR) +

3

No Reaction (NR)

7

Not Applicable: Closed by swelling

8

Not Applicable: Eye absent or blind

9

Unknown ( Or eye sutured closed )

ID 3508

For Form: [Form 1]
For Variables: [PupilWorstR]

Code

Description

1

Brisk or Normal Reaction (BR) +

2

Sluggish Reaction (SR) +

3

No Reaction (NR)

7

Not Applicable: Closed by swelling

8

Not Applicable: Eye absent or blind

9

Unknown ( Or eye sutured closed )

History

Date

Description

1999-04-01

Changed CODE : to unknown code "(or eye suture closed)"

2001-10-01

Changed CODE : "4 - Closed by swelling" to "7 - Closed by swelling" to avoid misinterpretation of "4" as a scale score.

2002-01-01

Changed CODE : added "N/A" to code "7" and code "8" to further clarify that it is not in the hierarchy.

RANCHO - ARCHIVE

Definition

Rancho Los Amigos Scale is completed at the following times: a)Within 72 hours following admission to inpatient rehabilitation, and b) Discharge from inpatient rehabilitation.

Form

[X] Form 1
[ ] Form 2

Source

  • Abstraction (rehab record)

Details

If Rancho Level assessment is not completed within the 72 hour windows, they should still reflect the patients’ status within that time period. If this is not possible and the assessments are done out of the 72 hour window, use code 9. Every effort should be made to obtain the Rancho level, however, if not assessed, use code 9. Do not leave blanks.

Variables

Form Type

Variable

ID

Question

History

Form 1

RanchoA

3513

Rancho Los Amigo Scale Rehab Admission

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

RanchoD

3514

Rancho Los Amigo Scale Rehab Discharge

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Codes and Values

ID 3513

For Form: [Form 1]
For Variables: [RanchoA]

Code

Description

1

Level I No Response ( Patient does not respond to external stimuli and appears asleep )

2

Level II Generalized Response ( Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses )

3

Level III Localized Response ( Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action )

4

Level IV Confused, Agitated Response ( Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no short term recall, attention is short and nonselective )

5

Level V Confused, Inappropriate, Nonagitated Response ( Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. )

6

Level VI Confused, Appropriate Response ( Patient gives context appropriate, goal directed responses, dependent upon external input for direction. There is carry over for relearned, but not for new tasks, and recent memory problems persist )

7

Level VII Automatic, Appropriate Response ( Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. )

8

Level VIII Purposeful, Appropriate Response ( Patient orients and responds to the environment, but abstract reasoning abilities are decreased relative to premorbid levels )

9

Unknown ( Or assessment done outside of 72 hour window )

ID 3514

For Form: [Form 1]
For Variables: [RanchoD]

Code

Description

1

Level I No Response ( Patient does not respond to external stimuli and appears asleep )

2

Level II Generalized Response ( Patient reacts to external stimuli in nonspecific, inconsistent, and nonpurposeful manner with stereotypic and limited responses )

3

Level III Localized Response ( Patient responds specifically and inconsistently with delays to stimuli, but may follow simple commands for motor action )

4

Level IV Confused, Agitated Response ( Patient exhibits bizarre, nonpurposeful, incoherent or inappropriate behaviors, has no short term recall, attention is short and nonselective )

5

Level V Confused, Inappropriate, Nonagitated Response ( Patient gives random, fragmented, and nonpurposeful responses to complex or unstructured stimuli. Simple commands are followed consistently, memory and selective attention are impaired, and new information is not retained. )

6

Level VI Confused, Appropriate Response ( Patient gives context appropriate, goal directed responses, dependent upon external input for direction. There is carry over for relearned, but not for new tasks, and recent memory problems persist )

7

Level VII Automatic, Appropriate Response ( Patient behaves appropriately in familiar settings, performs daily routines automatically, and shows carry over for new learning at lower than normal rates. Patient initiates social interactions, but judgment remains impaired. )

8

Level VIII Purposeful, Appropriate Response ( Patient orients and responds to the environment, but abstract reasoning abilities are decreased relative to premorbid levels )

9

Unknown ( Or assessment done outside of 72 hour window )

History

Date

Description

1994-02-01

Deleted NOTE : references to Level I data collection and Acute discharge assessment.

1994-02-01

Deleted CODES : Dates of assessment and "88 - N/A" code.

1994-09-13

Added CODE : "99 - Unknown".

1999-10-01

Changed CODE : "99 - Unknown" to "9 - Unknown".

RTS - ARCHIVE

Definition

Revised Trauma Score while subject is in care of Emergency Medical Service.

Respiratory Rate – code actual rate per minute (use 3 characters)

Systolic Blood Pressure – code actual blood pressure (use 3 characters)

Form

[X] Form 1
[ ] Form 2

Source

*Form 1 - Abstraction (acute record)

Details

Computer will calculate Revised Trauma Score from these data and the EMS GCS.

If patient was brought to the hospital by some method other than EMS, code 999 for Systolic Blood Pressure and Respiratory Rate.

If data is available from more than one EMS, use first available EMS data.

If a range rather than a single score is given for Respiratory Rate or Systolic Blood Pressure, enter the RAW SCORE that (a) produces the worst code, using the coding equivalents below, and (b) is closest to the midpoint of the range. (“Worst code”= numerically lowest code.) See the EXAMPLE.

If respiratory rate is between 10 and 29, Respiratory Score=4. If respiratory rate is 30 or above, Respiratory Score=3. If respiratory rate is between 6 and 9, Respiratory Score=2. If respiratory rate is between 1 and 5, Respiratory Score=l. If respiratory rate is 0, Respiratory Score=0. If systolic blood pressure is 90 or above, Systolic Blood Pressure Score=4. If systolic blood pressure is between 76 and 89, Systolic Blood Pressure Score=3. If systolic blood pressure is between 50 and 75, Systolic Blood Pressure Score=2. If systolic blood pressure is between 1 and 49, Systolic Blood Pressure Score= 1. If systolic blood pressure is 0, Systolic Blood Pressure Score=0.

EXAMPLE:

Scoring when a single rate (rather than range of rates) is provided:

At admission to ED, patient had a respiratory rate of 30/minute and a systolic blood pressure of 80mmHg. a. Respiratory rate 030 c. Systolic blood pressure 080

Determining a single rate when a range of rates is provided:

At admission to ED, patient had a respiratory rate of between 8 and 12 per minute.

First step: Determine which scores within the range produce the worst code. a. Use the respiratory rate coding equivalences (in NOTES) to determine the code equivalences for the scores within with range. -> Within the range 8-12, the scores 8 and 9 equal code “2” (see line 3 of the coding equivalences) -> Within the range 8-12, the scores 10, 11, and 12 equal code “4” (see line 1 of the coding equivalences) b. Determine which of these codes is the worst code. -> “2” is lower than “4”, so “2” is the worst code. c. Identify the score or scores that equal the worst code. -> Scores 8 and 9 equal “2”, the worst code. (If only one score equals the worst code, enter that score. Do the additional steps below only if more than one score equals the worst code.) Second step: Having determined which scores equal the worst code, identify which one of these scores is closest to the midpoint of the range. Enter that score into the database. a. Identify the midpoint of the range. -> The range is 8-12, which includes 8,9,10,11,12. The midpoint score (the middle score) is 10. b. Identify which of the scores that equal the worst code is nearest to the midpoint. -> 8 and 9 equal the worst code. 9 is closer to 10 (the midpoint) than is 8. c. Enter “9” into the database

Variables

Form Type

Variable

ID

Question

History

Form 1

RTSEMSBP

3527

ED Revised Trauma Score - Systolic Blood Pressure

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Form 1

RTSEMSRep

3528

ED Revised Trauma Score - Respiratory Rate

1989-10-01 - Variable Added
2003-01-01 - Variable Removed

Codes and Values

ID 3527

For Form: [Form 1]
For Variables: [RTSEMSBP]

Code

Description

888

Unmeasurable

999

Unknown or No EMS

ID 3528

For Form: [Form 1]
For Variables: [RTSEMSRep]

Code

Description

888

Unmeasurable: Bagged

999

Unknown or No EMS

History

No history found for the Domain.