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Wisdom of the caregivers: pooling individual subjective reports to diagnose states of consciousness in brain-injured patients, a monocentric prospective study
  1. Bertrand Hermann1,2,3,4,
  2. Gwen Goudard1,
  3. Karine Courcoux1,
  4. Mélanie Valente2,3,4,5,
  5. Sébastien Labat1,
  6. Lucienne Despois1,
  7. Julie Bourmaleau1,
  8. Louise Richard-Gilis1,2,3,4,
  9. Frédéric Faugeras2,3,4,
  10. Sophie Demeret1,
  11. Jacobo D Sitt2,3,4,
  12. Lionel Naccache1,2,3,4,5,6,
  13. Benjamin Rohaut1,2,3,4,7
    1. 1 Department of Neurology, Neuro ICU, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
    2. 2 Institut du Cerveau et de la Moelle épinière, ICM, PICNIC lab, F-75013, Paris, France
    3. 3 Inserm U 1127, F-75013, Paris, France
    4. 4 CNRS, UMR 7225, F-75013, Paris, France
    5. 5 Department of Neurophysiology, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
    6. 6 Sorbonne Universités, Faculté de Médecine Pitié-Salpêtrière, Paris, France
    7. 7 Division of Critical Care and Hospitalist Neurology, Columbia University, New York City, New York
    1. Correspondence to Dr Benjamin Rohaut; br2529{at}


    Objectives The clinical distinction between vegetative state/unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS) is a key step to elaborate a prognosis and formulate an appropriate medical plan for any patient suffering from disorders of consciousness (DoC). However, this assessment is often challenging and may require specialised expertise. In this study, we hypothesised that pooling subjective reports of the level of consciousness of a given patient across several nursing staff members can be used to clinically detect MCS.

    Setting and participants Patients referred to consciousness assessment were prospectively screened. MCS (target condition) was defined according to the best Coma Recovery Scale-Revised score (CRS-R) obtained from expert physicians (reference standard). ‘DoC-feeling’ score was defined as the median of individual subjective reports pooled from multiple staff members during a week of hospitalisation (index test). Individual ratings were collected at the end of each shift using a 100 mm Visual Analogue Scale, blinded from the reference standard. Diagnostic accuracy was evaluated using area under the receiver operating characteristic curve (AUC), sensitivity and specificity metrics.

    Results 692 ratings performed by 83 nursing staff members were collected from 47 patients. Twenty patients were diagnosed with UWS and 27 with MCS. DoC-feeling scores obtained by pooling all individual ratings obtained for a given patient were significantly greater in patients with MCS than with UWS (59.2 mm (IQR: 27.3–77.3) vs 7.2 mm (IQR: 2.4–11.4); p<0.001) yielding an AUC of 0.92 (95% CI 0.84 to 0.99).

    Conclusions DoC-feeling capitalises on the expertise of nursing staff to evaluate patients’ consciousness. Together with the CRS-R as well as with brain imaging, DoC-feeling might improve diagnostic and prognostic accuracy of patients with DoC.

    • disorders of consciousness
    • diagnosis
    • clinical assessment
    • minimally conscious state
    • group decision making
    • coma recovery scale - revised

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    • Patient consent for publication Not required.

    • BH, GG and KC contributed equally.

    • Contributors Study concept and design: BR, FF, GG, JB, JDS, KC, LD, LN, LR-G, SD and SL. Data collection: BH, GG, KC, LD, MV and SL. Analysis and interpretation of data: BH and BR. Drafting of the manuscript: BH, BR and LN. Critical revision of the manuscript for important intellectual content: BH, BR, JDS, LN and SD. Statistical analysis: BH, BR and LN. Study supervision: BH, BR, GG, KC and MV had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. BH, GG and KC contributed equally to this work.

    • Funding This work was supported by: Amicale des Anciens Internes des Hôpitaux de Paris & Syndicat des Chefs de Cliniques et Assistants des Hôpitaux de Paris (AAIHP—SCCAHP; BR), Assistance Publique—Hôpitaux de Paris (AP-HP; BR and LN), Institut National de la Santé et de la Recherche Médicale (Inserm; BH, JDS and LN), Sorbonne Université (LN), the James S. McDonnell Foundation (LN), Académie des Sciences- Lamonica Prize 2016 (LN) and Philippe Foundation (BR). The research leading to these results has received funding from the program ’Investissements d’avenir' ANR-10- IAIHU-06.

    • Competing interests None declared.

    • Ethics approval The protocol conformed to the Declaration of Helsinki, to the French regulations, and was approved by the local ethic committee (Comité de Protection des Personnes; CPP no 2013-A01385-40; Ile de France 1; Paris, France).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The dataset of this study is available on

    • Collaborators Jérémie Abitbol; Fatiha Ait Yata Azzi; Fatoumata Bah; Francis Bolgert; Sandrine Briand; Sandra Coelho; Alexia Camuzat; Marie-Chantal Colmar; Flora Cherruault; Cecile Chordi; Véronique Cottin; Bintou Coulibaly; Mélanie Dalibard; Athena Demertzi; Estelle Dumarey; Bouchra El Aouni; Atef El Ouarghi; Denis Engemann; Helene Espiand; Cécilia Eltebert; Fabrice Fanhan; Agnès Flament; Marie-Suzelle Fontano; Pascale Fournier; Céline Frammezelle; Alexandra Grinéa; Nouara Harchaoui; Marie Harmancij; Claire Jacqueminet; Charlotte Janvier; Jamila Kebli; Aurélie Lemoal; Kim Louis-Joseph; Brice Lucas; Valérie Maes; Sophie Maillard; Romain Maurel; Madely Petit; Floriane Pépin; Pauline Pérez; Isabelle Picot; Eva Proneur; Federico Raimondo; Manuela Roselmac; Sylviane Saintini; Mélody Seidel; Johan Stender; Yolène Sully; Kelly Tcha; Laura Verbaux; Nicolas Weiss; Kelly Yanganju.

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