Apirada Thongsing, MD
Pediatric Neurology Resident
Montefiore Medical Center, United States
Disclosure information not submitted.
Susan Duberstein, MD
Pediatric Neurology Attending
Children's Hospital at Montefiore, United States
Disclosure information not submitted.
Gracia Mui, MD, MPH
Director of Neurocritical Care
University of Connecticut Health Center, Connecticut, United States
Disclosure information not submitted.
Jaeun Choi, PhD
Biostatistician
Albert Einstein College of Medicine, United States
Disclosure information not submitted.
Title: Development of a Quick Neurological Exam Tool for the Pediatric Intensive Care Unit
Introduction: Serial neurological evaluation of children is important in pediatric critical care. The goal of this study was to design a Quick Neurological Exam (QNE) tool that is reliable, valid, and easy to use in a PICU setting by health care providers who are not specialized in neurology.
Methods: We defined four neurological areas of interest: level of consciousness, communication, motor function, and cranial nerves. These domains are clinically relevant and easy to assess in less than a minute. Each domain has five levels: 0 (worst) to 4 (best) which are then added to calculate a total score (range: 0-16 points). We tested the tool for feasibility and internal validity in patients aged 2-21 years admitted to the PICU with a (primary or secondary) neurological diagnosis. Results were reviewed and revised with stakeholders and a pilot study was performed to test inter-rater reliability. Percent agreement (tolerating a score difference of 1) and weighted and unweighted Cohen's kappa (κw) coefficients (with 95% confidence interval) were calculated.
Results and Conclusions: The QNE tool was validated by a pediatric neurologist describing exam findings using free text in six subjects ranging from normal neurological exam to severely impaired. This narrative was translated into QNE sub-scores by consensus of two attendings (including the examiner) with focus in pediatric neurointensive care. Based on wording used by the pediatric neurologist for the individual levels of sub-scores, the domain descriptions were amended. In a subsequent study, using only this revised scoring tool, the inter-rater reliability was assessed in 18 subjects with 78% agreement between two separate physician raters. The reliability was very good (KW = 0.88, K = 0.17 [-0.04 - 0.38], p = 0.0468). QNE validity was tested by comparing scores determined by neurologists to those of non-specialists. We found 67% agreement and very good correlation (Kw = 0.86, K = 0.42 [0.04 - 0.8], p = 0.004) in the six subjects assessed by a pediatric neurologist and a resident suggesting very good validity. The lower correlation coefficients are attributed to low subject numbers and inexperience with the score. A prospective study is underway to asses for validity, reliability, and non-inferiority among nurses and physicians compared to other tools used in the ICU.