Press releases

Expertise caregivers helps improve patient diagnosis in altered state of consciousness


Hospital teams Pitié-Salpêtrière Hospital AP-HP, Inserm and the Institute of the brain and spinal cord – AP-HP / CNRS / Inserm / University-Sorbonne showed appreciation caregivers (nurses and nursing auxiliaries) for the state of consciousness of patients represented a real added value to medical and electrophysiological exams and conventional brain imaging diagnostics. This work, published in the journal The British Medical Journal Open, apply the principle of “collective intelligence” (or “wisdom of the crowds”).

The waning of severe brain injury, initially a coma patient can progress to altered state of consciousness such as vegetative or minimally conscious state. The determination of the level of consciousness is important both to better assess the patient’s condition, to explain to his family, and also because of the prognostic value of that information.

However it is sometimes difficult to establish and then requires an approach called “multimodal” combining clinical expertise and neuroimaging. The recent international recommendations stress in particular the need to repeat clinical evaluations using a specific scale (the “Coma Recovery Scale – Revised”), and the utility of complement by specialized brain imaging examinations (EEG, evoked potentials cognitive, PET scans and functional MRI).

It is in this context that researchers from Inserm, a medical team of the neurological intensive care hospital Pitié-Salpêtrière AP-HP, led by Dr. Sophie Demeret and a team of the neurophysiology department clinic Pitié-Salpêtrière hospital AP-HP and laboratory “PICNIB lab” at the Institute of the brain and spinal cord led by Prof. Lionel Naccache, professor of physiology at Sorbonne University, wanted to add to this multimodal approach an additional source of information on the principle of “collective intelligence” (or “wisdom of the crowds”): the expertise of the medical staff is constantly in contact with patients throughout their hospital stay.

The tool, called “DoC-feeling” (DoC for Disorders of Consciousness) using a visual analog scale (as used for pain assessment) to collect the subjective perception vis-à-vis the status of carers awareness of the patient quickly and easily. The synthesis of all the measurements taken over a week and provides a “collective” score between 0 and 100.

Forty-nine patients hospitalized for expert evaluation of the level of consciousness in the neurological intensive care unit of the hospital of the Pitié-Salpêtrière AP-HP were included in a year and a half. Nearly 700 evaluations by more than 80 carers were collected. The study, supervised by two referent nurses and supported by health managers, has shown that the median value of individual assessments by caregivers was closely correlated with depth specialized clinical assessments. Another advantage is that this approach allowed to significantly increase the number of patient observations, the state of consciousness may fluctuate over time.

The teams conclude that this approach, in addition to the medical clinic assessment and examinations electrophysiological and brain imaging, should improve the diagnostic accuracy of patients’ state of consciousness. This work puts more and before the interest of the collective intelligence and a collaborative approach to a complex known clinical question.

“This work initiated by two nurses in neurological intensive care hospital Pitié-Salpêtrière AP-HP: Gwen Goudard and Karine Courcoux, which involved more than 80 carers over a period of more than a year, demonstrates extraordinary motivation and the enormous potential of research in allied unity, “ says Dr. Benjamin Rohaut who oversaw the study. He added : “The support of service managers, Louise Richard Gili and Julie Bourmaleau and the help of Dr. Bertrand Hermann, Inserm researcher at the PICNIC-lab for data analysis and writing of the article, were key assets for conducting the study to completion. “


Wisdom of the caregivers: pooling individual subjective reports to diagnose states of consciousness in brain-injured patients, a monocentric prospective study.
Hermann B*, Goudard G*, Courcoux K*, Valente M, Labat S, Despois L, Bourmaleau J, Richard-Gilis L, Faugeras F, Demeret S, Sitt JD, Naccache L & Rohaut B. 

The British medical journal