The current significance of the FOUR score: A systematic review and critical analysis of the literature

Background: The Full Outline of Un-Responsiveness Score (FOURs) is a scale for clinical assessment of consciousness that was introduced to overcome disadvantages of the widely accepted Glasgow Coma Scale (GCS). Objective: To carry out a systematic review and critical analysis of the available literature on the clinical application of FOURS and perform a comparison to GCS, in terms of reliability and predictive value. Methods: Initial search retrieved a total of 147 papers. After applying strict inclusion criteria and further article selection to overcome data heterogeneity, a statistical comparison of inter-rater reliability, in-hospital mortality and long-term outcome prediction between the two scales in the adult and pediatric population was done. Results: Even though FOURS is more complicated than GCS, its application remains quite simple. Its reliability, validity and predictive value have been supported by an increasing number of studies, especially in critical care. A statistically significant difference (p = .034) in predicting in-hospital mortality in adults, in favor of FOURs when compared to GCS, was found. However, whether it poses a clinically significant advantage in detecting patients' deterioration and outcome prediction, compared to other scaling systems, remains unclear. Conclusions: Further studies are needed to discern the FOURs' clinical usefulness, especially in patients in noncritical condition, with milder disorders of consciousness.