00130478-202105000-00006 Serial Neurologic Assessment in Pediatrics (SNAP) : A New Tool For Bedside Neurologic Assessment of Critically Ill Children

Serial Neurologic Assessment in Pediatrics
(SNAP): A New Tool for Bedside Neurologic

Assessment of Critically Ill Children*
Matthew P. Kirschen, MD, PhD1–3
OBJECTIVES: We developed a tool, Serial Neurologic Assessment in Katherine A. Smith, MPH, BSN,
Pediatrics, to screen for neurologic changes in patients, including those who RN, CPN4
are intubated, are sedated, and/or have developmental disabilities. Our aims
Megan Snyder, MSN, RN,
were to: 1) determine protocol adherence when performing Serial Neurologic
ACCNS-P, CCRN4
Assessment in Pediatrics, 2) determine the interrater reliability between nurses,
and 3) assess the feasibility and acceptability of using Serial Neurologic Bingqing Zhang, MPH1
Assessment in Pediatrics compared with the Glasgow Coma Scale. John Flibotte, MD3,5
DESIGN: Mixed-methods, observational cohort. Lauren Heimall, MSN, RNC-NIC,
C-NNIC, PCNS-BC4
SETTING: Pediatric and neonatal ICUs.
Katrina Budzynski, PT, DPT, PCS6
SUBJECTS: Critical care nurses and patients.
Ryan DeLeo, MS, OTR/L7
INTERVENTIONS: None.
Jackelyn Cona, MS, CCC/SLP8
MEASUREMENTS AND MAIN RESULTS: Serial Neurologic Assessment
in Pediatrics assesses Mental Status, Cranial Nerves, Communication, and Claire Bocage, BA9
Motor Function, with scales for children less than 6 months, greater than or Lynn Hur, BA9
equal to 6 months to less than 2 years, and greater than or equal to 2 years Madeline Winters, RN1
old. We assessed protocol adherence with standardized observations. We Richard Hanna, MS1
assessed the interrater reliability of independent Serial Neurologic Assessment
Janell L. Mensinger, PhD10
in Pediatrics assessments between pairs of trained nurses by percent- and
bias- adjusted kappa and percent agreement. Semistructured interviews Jimmy Huh, MD1,3
with nurses evaluated acceptability and feasibility after nurses used Serial Shih-Shan Lang, MD11
Neurologic Assessment in Pediatrics concurrently with Glasgow Coma Scale Frances K. Barg, PhD9
during routine care. Ninety-eight percent of nurses (43/44) had 100% pro- Judy A. Shea, PhD12
tocol adherence on the standardized checklist. Forty-three nurses performed
387 paired Serial Neurologic Assessment in Pediatrics assessments (149 < Rebecca Ichord, MD2,3
6 mo; 91 ≥ 6 mo to < 2 yr, and 147 ≥ 2 yr) on 299 patients. Interrater reliability Robert A. Berg, MD1,3
was substantial to near-perfect across all components for each age-based Joshua M. Levine, MD2
Serial Neurologic Assessment in Pediatrics scale. Percent agreement was in- Vinay Nadkarni, MD1,3
dependent of developmental disabilities for all Serial Neurologic Assessment
Alexis Topjian, MD, MSCE1,3
in Pediatrics components except Mental Status and lower extremity Motor
Function for patients deemed “Able to Participate” with the assessment.
Nurses reported that they felt Serial Neurologic Assessment in Pediatrics, com-
pared with Glasgow Coma Scale, was easier to use and clearer in describing
the neurologic status of patients who were intubated, were sedated, and/or
had developmental disabilities. About 92% of nurses preferred to use Serial
Neurologic Assessment in Pediatrics over Glasgow Coma Scale.
CONCLUSIONS: When used by critical care nurses, Serial Neurologic
Assessment in Pediatrics has excellent protocol adherence, substantial to near- *See also p. 512.
perfect interrater reliability, and is feasible to implement. Further work will deter-
Copyright © 2021 by the Society of
mine the sensitivity and specificity for detecting clinically meaningful neurologic Critical Care Medicine and the World
decline. Federation of Pediatric Intensive and
KEY WORDS: acute brain injury; Glasgow Coma Scale; neurologic Critical Care Societies
assessments
DOI: 10.1097/PCC.0000000000002675
Pediatric Critical Care Medicine www.pccmjournal.org 483

Copyright © 2021 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.
Unauthorized reproduction of this article is prohibited
Kirschen et al
A
mong the more than 400,000 children admit- sedation, and/or baseline developmental disabilities.
ted to PICUs annually, brain injury is the In this study, we aimed to: 1) determine protocol ad-
most common cause of death, with mortality herence when performing SNAP, 2) determine the
rates up to six times greater than the general PICU interrater reliability (IRR) between the nurses, and 3)
population (1–5). Children with neurologic diagno- assess the feasibility and acceptability of using SNAP
ses are admitted to the PICU more frequently than compared with the GCS in a critical care environment.
other hospitalized children and have longer hospital
stays with greater hospital costs (2). Up to 10% of MATERIALS AND METHODS
children admitted to PICUs are discharged with new Subjects
neurologic deficits (6, 7). These acquired functional
deficits affect not only the 20% of patients admitted Nurses. We recruited nurses with permanent assign-
with acute brain injury but also patients with non- ments in the PICU or neonatal ICU (NICU) with a
neurologic critical illness (6, 7). goal recruitment of 24 nurses from each unit. Nurses
Bedside nurses in the PICU perform a modified received a gift card for their participation.
neurologic examination (referred to as a neurologic Patients. All patients greater than or equal to -37
assessment) on patients at regular intervals to eval- weeks corrected gestational age who were admitted to
uate for changes in a patient’s neurologic examina- the PICU or NICU were eligible. We included NICU
tion that may represent an acute pathologic decline nurses and patients to ensure adequate enrollment of
in brain function. However, the components of patients less than 6 months old.
these modified neurologic examinations (e.g., con-
sciousness, cranial nerves, communication, and Ethical Considerations
the sensorimotor system), examination frequency,
This study was approved by the Institutional Review
and communication of neurologic deterioration are
Board at Children’s Hospital of Philadelphia. Nurses
highly variable (8). The Glasgow Coma Scale (GCS)
provided informed consent, and a waiver of consent was
is used in 80% of PICUs as a component of this neu-
granted for patients since neurologic assessments were
rologic assessment, but has significant limitations
performed in conjunction with standard clinical care.
and may be an inappropriate tool in contemporary
PICU populations with patients who are intubated, SNAP Development
are sedated, and/or have preexisting developmental
disabilities (9–15). Two-thirds of pediatric intensiv- We convened a multidisciplinary team of experts to
ists think their PICU’s current nursing neurologic design SNAP. This team included physicians in critical
assessment practices are suboptimal to monitor the care, neurosurgery, and neurology, pediatric and neo-
neurologic health of their critically ill patients (8). natal critical care nurses, and physical, occupational,
Unrecognized changes in a patient’s neurologic ex- and speech/language therapists. We used existing vali-
amination may lead to irreversible brain injury or dated coma scales including the GCS, Full Outline of
death. UnResponsiveness score, and the pediatric National
To address these concerns, we designed a new neu- Institutions of Health Stroke Scale to inform SNAP’s
rologic assessment tool, Serial Neurologic Assessment design (16–18). SNAP components include Mental
in Pediatrics (SNAP), to standardize the modified neu- Status, Cranial Nerves, Communication, and Motor
rologic examination performed by bedside nurses at Function—components of the neurologic examina-
regular intervals to facilitate the detection of clinical tion we felt were most clinically relevant for a bedside
changes in an individual patient’s neurologic exam- screening assessment. We developed SNAP scales for
ination. These clinical changes, when communicated children less than 6 months (infant), greater than or
to the provider team, may lead to more in-depth neu- equal to 6 months to less than 2 years (toddler), and
rologic assessments, further diagnostic evaluation, or greater than or equal to 2 years old (child) based on
therapeutic intervention for the patient. SNAP includes developmental abilities (Figs. 1–3; and Appendix 1,
scoring options to assess the neurologic examina- http://links.lww.com/PCC/B681). Modifications were
tion of patients with artificial airways, pharmacologic made after pilot testing.
484 www.pccmjournal.org May 2021 • Volume 22 • Number 5

Feature Articles
Mental Status assesses both the degree of stimula- This study had three parts conducted in parallel. In
tion required to obtain eye opening and the patient’s part 1, we assessed protocol adherence by determining
ability to fixate and track, prioritizing the latter. whether nurses performed SNAP in the standard-
Cranial Nerves assess the pupillary light reflex. Cough ized manner taught during training. A study nurse
and gag reflexes are assessed when pupillary reflexes observed each nurse performing SNAP and completed
are absent. We generated separate Communication a standardized checklist to evaluate adherence to each
scales for patients with natural and artificial airways, SNAP component. Observations were done for all
with both scales assessing receptive and expressive nurses in both the first and last weeks of the study to
language. In this way, patients with artificial airways ensure adherence over time.
were not penalized and could still achieve a maximal In part 2, we assessed IRR between the pairs of trained
score. We created separate Motor Function scales for nurses. Nurses only assessed patients in the unit where
patients who could participate in the examination and they provided clinical care. We used a purposive sampling
those who could not, either due to medication effects, strategy to enroll patients. Two nurses independently and
acute brain injury, or preexisting developmental dis- sequentially performed SNAP. SNAP assessments were per-
abilities. Motor Function was graded on a functional formed in conjunction with routine nursing assessments to
scale, rather than by confrontational resistance test- avoid unnecessarily disturbing patients. PICU nurses com-
ing, to optimize the ability to detect clinically mean- pleted at least 20 paired assessments using all three SNAP
ingful changes. Since communication capabilities for age-specific scales, and NICU nurses completed at least 10
infants less than 6 months old with natural or artificial paired assessments using only the infant SNAP scale. An
airways are similar, the type of airway was not sepa- experienced pair of nurses was defined as both nurses hav-
rated for this aged scale. Similarly, Motor Function for ing completed at least five SNAP assessments. For patients
infants was not separated by ability to participate with greater than 6 months old, nurses determined the patient’s
the assessment. Each component includes a nontest- preillness Pediatric Cerebral Performance Category
able option for situations, where the examination was (PCPC) score to assess whether the patient had baseline
physically unattainable (e.g., neuromuscular blockade, developmental disabilities (20). This was done by medical
extremity immobilization, or severe edema precluding record review and discussions with the bedside nurse and
eye opening). families. Patients who had preillness PCPC scores greater
than or equal to 3 (moderate dysfunction) were considered
to have a functional developmental disability.
Study Procedures
In part 3, nurses performed SNAP in conjunction
At the time of this study, the standard PICU nursing with their routine neurologic assessments during clinical
neurologic assessment was the pediatric modifica- care. Nurses were instructed to use SNAP on at least 20
tion of the GCS at 40, cranial nerve assessment with different patients over a several week period, after which
pupillary, cough, and gag reflexes, and four-extrem- nurses participated in a semistructured interview with a
ity motor strength graded on the Medical Research trained study nurse. The interview explored each nurse’s
Council scale (14, 15, 19). Nurses performed this perception about the feasibility and acceptability of SNAP
GCS-based assessment hourly for patients with acute through open-ended responses and the comparison of
brain injury or deemed at high risk for acute brain SNAP with their current clinical neurologic assessment
injury, and every 4 hours for patients with low risk of via a Likert scale (Appendix 2, http://links.lww.com/
brain injury. Nursing neurologic assessments in the PCC/B682). Interviews were recorded, transcribed, dei-
NICU were less standardized and limited to quali- dentified, and entered into NVivo 12.0 for coding and
tative descriptions of activity, tone, pupillary reac- analysis. Working with the investigators, research coor-
tivity, and fontanelle fullness. dinators in the Mixed Methods Research Laboratory
All participating nurses received 15–30 minutes of developed a codebook based on a close reading of the
in-person SNAP training by a study nurse and study first five transcripts. Each code was operationalized and
physician (board certified in pediatric critical care decision rules for their application were included. Two
medicine and child neurology), including step-by-step research coordinators coded the transcripts and used
instructions on how to perform each component. the IRR function in NVivo to assess agreement between

Kirschen et al
Figure 1. Serial Neurologic Assessment in Pediatrics (SNAP) scale for infants ≥37 weeks gestation to < 6 mo old (corrected gestational age).
Figure 2. Serial Neurologic Assessment in Pediatrics (SNAP) scale for toddlers ≥ 6 mo to < 2 yr.
Figure 3. Serial Neurologic Assessment in Pediatrics (SNAP) scale for children ≥ 2 yr old.
the coders. Coding proceeded until strong IRR, κ = 0.93 assessment of each patient for each age scale. The
(weighted by source size), was achieved. Codes were strength of agreement for PABAK and PABAK-OS
summarized and examined for patterns resulting in were interpreted as: less than or equal to 0 = poor,
themes about the data. 0.01–0.20 = slight, 0.21–0.40 = fair, 0.41–0.60 =
moderate, 0.61–0.80 = substantial, and 0.81–1 = al-
Statistical Analysis most perfect (21). For Motor Function, right and left
Patients’ characteristics were summarized by fre- extremities were combined. Percent agreement cal-
quencies and percentages. IRR for the primary anal- culations were also derived from patients who were
ysis was determined for each SNAP component using scored as testable using all assessments. We used per-
prevalence- and bias- adjusted kappa (PABAK) and cent agreement in a secondary analysis to compare
its ordinal scale version (PABAK-OS) using the index IRR across scales, between “Natural” versus “Artificial

Feature Articles
Airway” and “Able” versus “Unable to Participate” median of 23 (21–26) and each NICU nurse completed
subscales, and by grouping variables including NICU a median of 11 (10–12) assessments. Eighty percent of
versus PICU nurses, experienced versus inexperi- patients (239/299) were assessed once, 15% (45/299)
enced nurses, and patients with versus without de- were assessed twice, and 5% (15/299) were assessed
velopmental disabilities. We used marginal models greater than or equal to three times.
(generalized estimating equation [GEE] approach) IRR for whether a patient was testable or nontestable
with binomial distribution, identity link function, was almost perfect across all scales (Supplementary
and exchangeable working correlation matrix to Table 2, http://links.lww.com/PCC/B684; and
account for multiple assessment for some patients Supplementary Table 3, http://links.lww.com/PCC/
(22). We report the marginal absolute difference with B685). For testable patients, IRR was substantial to near-
95% CIs for percent agreement. When the model did perfect across all components of each age-based SNAP
not converge, we specified Poisson distribution in- scale (Table 1). Percent agreement for SNAP compo-
stead for the GEE model (22). We defined acceptable nents was not different between the age-based scales,
percent agreement as greater than or equal to 80% except for Mental Status that had less agreement for the
(23). To preserve adequate power for identifying po- infant scale compared with the toddler scales (80% vs
tentially significant differences in percent agreement 93%, –12% [–21% to –3%]) (Supplementary Table 4,
for subscales and groups, we did not apply familywise http://links.lww.com/PCC/B686). The majority of
error corrections. The analysis of percent agreement disagreements (18/28, 64%) between the nurses for
was conducted using SAS Version 9.4 (SAS Institute, infants on the Mental Status component were between
Cary, NC), PABAK using R software Version 3.5.1 scores of 5 and 3, differentiating whether or not the
(R Foundation for Statistical Computing, Vienna, patient could fixate or track. Percent agreement be-
Austria) with package “epiR” (24), and PABAK-OS tween nurses for Communication was similar between
using a web-based calculator (www.singlecasere- “Natural Airways” versus “Artificial Airways” (toddler:
search.org/calculators/pabak-os). 86% vs 76%, 9% [–7% to 25%], child: 87% vs 86%, 1%
[–11% to 13%]). Percent agreement was similar for
Motor Function “Able to Participate” and “Unable to
RESULTS Participate” for both upper and lower extremities for
Nurse Subjects the toddler and child scales (Supplementary Table 4,
http://links.lww.com/PCC/B686).
Twenty-four PICU and 20 NICU nurses partici- There was no difference in percent agreement be-
pated. One PICU nurse completed only parts 1 and 3. tween the PICU and NICU nurses on the Mental
Therefore, 44 nurses were evaluable in parts 1 and 3 and Status, Cranial Nerve, or Communication components
only 43 nurses were evaluable in part 2. Nurses were of the infant scale (Supplementary Table 5, http://
98% female (43/44) and had a median of 4 years (3–6 yr) links.lww.com/PCC/B687); however, PICU nurses
of ICU experience (PICU 4 [3–5] and NICU 4 [3–8]). had greater agreement on the upper extremity Motor
Function compared with NICU nurses (88% vs 74%,
Protocol Adherence 13% [2–25%]).
Ninety-eight percent of nurses (43/44) had 100% There was substantial and near-perfect agreement
protocol adherence at the beginning of study, and all for determining whether a patient was scored on the
nurses 100% (44/44) had 100% protocol adherence at “Able to Participate” or “Unable to Participate” Motor
the end of the study. Function scale on the toddler (PABAK 0.79 [0.59–
0.91]) and child (0.90 [0.79–0.96]) scales, respec-
tively. Similarly, percent agreement between the nurses
Interrater Reliability
for determining whether a patient was scored on the
Forty-three nurses completed 387 paired SNAP assess- “Able to Participate” or “Unable to Participate” Motor
ments (149 infant, 91 toddler, and 147 child) on 299 Function scale was 89% (81/91) for the toddler and
patients (Supplementary Table 1, http://links.lww. 94% (138/147) for the child scale (–4% [–11% to 3%]).
com/PCC/B683). Each PICU nurse completed a These percentages did not change based on SNAP

Kirschen et al
TABLE 1.
Interrater Reliability for Testable Patients Using Prevalence- and Bias-Adjusted Kappa and
Its Ordinal Scale Version
Serial Neurologic Assess- Prevalence- and Bias-Adjusted
ment in Pediatrics Scale Observed Percent Kappa and Its Ordinal Scale Strength of
and Components Agreement Version (95% CI) Agreement
< 6 mo (infant)
Mental status 82% (88/107) 0.82 (0.73–0.91) Almost perfect
Cranial nerves 99% (107/108) 0.98 (0.89–1.00) Almost perfect
Communication 79% (84/107) 0.74 (0.65–0.83)
Motor function
Upper extremity 81% (182/226) 0.78 (0.71–0.84) Substantial
Lower extremity 77% (173/226) 0.74 (0.68–0.81) Substantial
≥ 6 mo to < 2 yr (toddler)
Communication
Natural airway 87% (26/30) 0.85 (0.68–1.00) Almost perfect
Artificial airway 76% (25/33) 0.73 (0.56–0.90) Substantial
Motor function
Able to participate
Unable to participate
Upper extremity 90% (18/20) 0.88 (0.67–1.00) Almost perfect
Lower extremity 100% (20/20) 1 (0.78–1.00) Almost perfect
≥ 2 yr old (child)
Communication
Natural airway 90% (52/58) 0.88 (0.75–1.00) Almost perfect
Artificial airway 85% (45/53) 0.84 (0.70–0.97) Almost perfect
Motor function
Able to participate
Upper extremity 85% (112/132) 0.82 (0.74–0.91) Almost perfect
Lower extremity 85% (112/132) 0.82 (0.73–0.90) Almost perfect

Feature Articles
experience; however, they were lower for patients status of critically ill patients who were pharmacolog-
with developmental disabilities compared with those ically sedated, had artificial airways, or had develop-
without (toddler: 80% vs 96%, –15% [–28% to –3%]; mentally disabilities than the GCS. Nurses highlighted
child: 89% vs 99%, –11% [–18% to –3%]). the evaluation of communication in patients with en-
There were no differences in percent agreement be- dotracheal or tracheostomy tubes and evaluation of
tween testable patients with and without developmental eye tracking as particularly beneficial.
disabilities for Cranial Nerves, Communication, upper Theme 3: Improved Communication. Nurses felt that
extremity Motor Function for patients deemed “Able SNAP improved communication about a patient’s neu-
to Participate,” and upper and lower extremity Motor rologic examination between the nurses during change
Function for patients deemed “Unable to Participate” of shift and between the nurses and provider teams.
(Table 2). For patients with developmental disabilities Theme 4: Sensitivity to Change. Nurses thought
on both the toddler and child scales, percent agreement SNAP more accurately described a patient’s neurologic
was lower on Mental Status and lower extremity Motor status, and thus, it was their impression that SNAP was
Function for patients deemed “Able to Participate.” more sensitive to detect changes in a patient’s neuro-
There were no differences in agreement between logic examination than the GCS.
nurses with more or less experience with SNAP except Theme 5: Learning Curve. Most nurses described
that percent agreement among experienced nurse pairs that the overall SNAP assessment took time to learn
was lower for the lower extremity Motor Function on and may take longer than the GCS to complete, espe-
the child scale for patients deemed Able to Participate cially when learning the scale. However, all nurses felt
(83% vs 89%, –21% [–42% to –1%]) (Supplementary that the time to learn and perform the scale was reason-
Table 6, http://links.lww.com/PCC/B688). able. Eighty-eight percent of nurses (21/24) felt SNAP
was easier or equally easy to use and 54% (13/24) felt
Feasibility and Acceptability for PICU Nurses SNAP took the same amount of time or was faster to
use than GCS-based neurologic assessments.
Twenty-four PICU nurses performed a total of 2,045
assessments on 342 patients, with each nurse performing
SNAP on a median of 21 (20–23) patients. A median of 3 DISCUSSION
(range 1–13) SNAP assessments were performed on each We developed a novel assessment tool, SNAP, with the
patient in a 12-hour nursing shift. All PICU nurses com- intent of standardizing the modified neurologic exam-
pleted a semistructured interview (ranging 10–30 min ination performed by bedside nurses to detect clinical
in length), where they compared SNAP with our clinical changes in the neurologic examination of patients in
standard GCS-based neurologic assessment tool. Overall, contemporary PICUs, including those with develop-
92% (22/24) of PICU nurses preferred using SNAP over ment delays. We demonstrated that SNAP was easy to
GCS-based assessments for routine neurologic assess- learn, had excellent protocol adherence, and had sub-
ments and 8% (2/24) were neutral (Supplementary Table stantial to near-perfect IRR between the trained ICU
7, http://links.lww.com/PCC/B689). Qualitative anal- nurses. Notably, the IRR did not differ between the
ysis from open-ended responses revealed the following patients with and without developmental delays on
themes: comprehensiveness, better fit for the patient pop- most SNAP components, as intended. Additionally,
ulation, improved communication, sensitivity to change, nurses felt that SNAP more clearly described the neu-
and the learning curve (Table 3). rologic status of critically ill patients who have artifi-
Theme 1: Comprehensiveness. Nurses described SNAP cial airways, are pharmacologically sedated, or have
as more specific, detailed, and objective than the GCS. developmental disabilities than GCS. More than 90%
Despite having more words, nurses felt the additional de- of nurses preferred to use SNAP over GCS as a routine
tail in SNAP more fully characterized their patient’s neuro- neurologic assessment tool.
logic examination. All nurses agreed that SNAP was more Current pediatric neurologic assessment or “coma”
precise than the GCS-based neurologic assessment tool. scales have suboptimal reliability (25–28). The GCS
Theme 2: Better Fit for Patient Population. All is the most commonly used scale in North American
nurses felt that SNAP better described the neurologic PICUs (8). It was initially designed to assess adult

Kirschen et al
TABLE 2.
Percent Agreement Between Nurses Based on Preillness Developmental Disability for
Testable Patients
Serial Neurologic
Assessment in Patients Without Patients With
Pediatrics Scale and Developmental Disabilities Developmental Disabilities Marginal Absolute
Components (PCPC 1–2) (PCPC ≥ 3) Difference (95% CI)
≥ 6 mo to < 2 yr (toddler)
Mental status 100% (44/44) 84% (31/37) 16% (5–28%)a
Cranial nerves 100% (46/46) 97% (36/37) 3% (–3% to 8%)a
Communication
Natural airway 92% (24/26) 70% (7/10) Not availableb
Artificial airway 75% (15/20) 77% (24/31) –2% (–25% to 21%)
Motor function
Able to participate
Upper extremity 84% (69/82) 80% (35/44) 5% (–17% to 26%)
Lower extremity 87% (71/82) 64% (28/44) 26% (8–44%)
Upper extremity 100% (6/6) 82% (18/22) 20% (–5% to 45%)a
Lower extremity 100% (6/6) 91% (20/22) 10% (–9% to 28%)a
≥ 2 yr old (child)
Mental status 96% (69/72) 82% (54/66) 14% (3% to 25%)
Cranial nerves 97% (72/74) 95% (60/63) 2% (–1% to 5%)a
Communication
Natural airway 84% (38/45) 92% (23/25) –10% (–21% to 2%)a
Artificial airway 89% (24/27) 83% (35/42) 6% (–11% to 23%)
Motor function
Able to participate
Lower extremity 90% (110/122) 67% (24/36) 34% (4–65%)
Lower extremity 83% (20/24) 74% (61/82) 10% (–15% to 35%)
PCPC = Pediatric Cerebral Performance Category.
a
Generalized estimating equation (GEE) model with Poisson distribution was used when the model with binomial distribution did not converge.
b
Did not converge for GEE models with either binomial or Poisson distribution specifications.

Feature Articles
trauma patients; however, its use has spread to popula- We designed SNAP to overcome many limitations
tions for which it was not originally intended. There of the GCS (12, 16, 17, 30, 31). Unlike GCS, SNAP has
have been numerous modifications of the GCS to scales specifically for infants and young children to de-
account for variable ages and developmental stages; scribe more accurately the neurologic examination based
however, only 60% of PICUs use a pediatric modifica- on developmental capabilities of these age groups. SNAP
tion of the GCS (8). Additionally, none of the pediatric also assesses cranial nerves, which are not included in the
modifications are validated in patients with neuro- GCS, but are one of the most commonly assessed meas-
developmental disabilities, a cohort that comprises a ures of neurologic function in PICUs (8). The Mental
quarter of contemporary PICU populations and is at Status component of SNAP assesses both eye opening
high risk for acute neurologic decline (29). and the patient’s ability to fixate and track. Patients can
TABLE 3.
Representative Open-Ended Responses for Each of the Qualitative Themes
Comprehensiveness
“There are a lot of words, but if you look through them and read them, everything is different and everything
relates to a patient. It really does. Wordy is fine if it helps. [And] I think it helps immensely.”
“I feel like it [SNAP] is more detailed. It's pretty clear on what you're looking for and what you're not looking
for. And it differentiates a lot of the unclear stuff that's in the regular GCS. For example, there are people open
their eyes spontaneously, but they don’t track and follow.”
“They’re both considered a snapshot of the patient’s neurological exam, but the GCS - you can tell we’re trying
to fit a circle in a square hole. With our patient population, I think SNAP is a better representation of what we
do, and what we’re looking for in as far as changes in the neuro exam. Better and important that we pick up on.”
“I just feel like there was less guesswork with SNAP. The categories seemed more definitive and easier to
choose from. So, I felt like it was easier to choose an answer based on an objective assessment rather than
with the GCS, where sometimes it just felt more like you were trying to choose a box that maybe the patient
didn't necessarily fit into. And this [SNAP] seemed more like it was made based off of patients.”
Better fit for the PICU patient population
“I think it’s more inclusive of our population. And this gives us better options to score them. All the ands and ifs
and ors really make a difference, I feel, in these different assessments.”
“I like the natural airway and the artificial airway differences. If you had an artificial airway, we would always do
non-testable [on GCS], and you would never understand how they are able to communicate. However, some-
times they’re able to answer questions or make facial expressions. So instead of saying non-testable, you can
actually understand that they’re neurologically appropriate to communicate [on SNAP].”
“I think so many people just assume because you have a trach you can’t communicate. And, that’s easy to skip
over in the current GCS, whereas this one [SNAP], it’s like, you know what? They do communicate. And this
shows it.”
Improved communication
“I feel like I would be able to have a better idea during nursing report, knowing what I'm walking into, and get-
ting that snapshot from another nurse or Epic documentation. I would be able to better describe to my other
colleagues or practitioners the changes that I'm seeing in a uniform manner that everyone else would be able
to follow as well.”
“I think it’s more beneficial for our patients and our team communication wise. We can get a better picture of
our patient and we can convey a better picture of our patients to our team.”
(Continued)

Kirschen et al
TABLE 3. (Continued).
Representative Open-Ended Responses for Each of the Qualitative Themes
Sensitivity to change
“I think the change in terms of their motor ability was slight, but enough that with the categories and in the
SNAP, it was able to be distinguished. But with the GCS the categories were just too general to really cap-
ture it.”
“SNAP just feels like a more accurate way to describe their neuro assessment. And I feel like just thinking
about how it might work clinically, if there were to be a change in the SNAP rating and you were to call a pro-
vider, I feel like in a lot of cases it would be an actual change versus sometimes with the GCS, there will be a
change in the numbers, but it won't necessarily reflect an actual change in the patient's status.”
“I think you would be able to see a decline faster and more effectively [using SNAP] than you would in the reg-
ular GCS.”
“I mean, for GCS like for verbal, you would put not testable [for an intubated patient]. And then in the comment
you would put intubated. So, for the GCS you're not really getting any information, it's just saying it's not test-
able. Whereas for SNAP, you are getting a score, it's just under a different category. But if there is a decline
you would be able to see it. And for a lot of our intubated patients, especially the ones that are appropriate
teenagers, sometimes they can like be intubated for a while and be answering yes or no questions and follow-
ing commands. And then if something were to change, the GCS wouldn't reflect that, but the SNAP would
because you would be able to score it. So, that's really helpful.”
Learning curve
“With the learning curve, I think that it's going to naturally be more difficult because it's something new and
you're rewiring your brain to think a little bit differently. But I think the actual assessment tool was very good,
and I do think it was easy to use.”
“You have more options, and there’s a lot of and, or, if questions. So, I think because of that, you need to pay
more attention. But it also gives you a better neurologic assessment on these children. So, it was definitely not
burdensome at all. And I think with time, everything becomes easier.”
“I would say that it takes a while to get used to because there are so many options and so many different
scales, but I would say that it more accurately describes or classifies our patients, especially the ones that
come in with baseline issues or are sick.”
“It's more user-friendly once you take the time to learn it. And, like I said, it's easier to speak to your assess-
ment. I feel like for GCS, it's sort of like your GCS is different than my GCS. But this [SNAP] is very con-
crete. Like this is what we're looking for. Everybody in theory should have the same SNAP.”
GCS = Glasgow Coma Scale, SNAP = Serial Neurologic Assessment in Pediatrics.
achieve the maximal score if they are able to track, even The Communication component of SNAP assesses
if they require stimulation to open their eyes, because it receptive and expressive language in patients with both
demonstrates interaction with their environment. This natural and artificial airways. This is more advantageous
prevents patients from receiving a lower Mental Status than GCS, where intubated patients receive a verbal score
score when awakened from sleep, as often occurs with of nontestable or 1T. The Motor Function component of
GCS (14, 15). Percent agreement on Mental Status was SNAP differentiates responses for patients who are able to
lower for infants less than 6 months, with a majority of participate in the evaluation and those who are unable to
disagreement around whether an infant could fixate or participate due to effects of medications, acute brain in-
track. Inconsistent responses may be related to infants’ jury, or baseline developmental delays. The “Unable to
variable performance of this task, consistent with their Participate” category characterizes motor function for
developmental abilities. patients with spasticity and contractures and those with

Feature Articles
abnormal motor responses due to acute brain injury. The as evidenced by disagreements between the duration
“Able to Participate” category uses a functional strength patients held their extremity antigravity (Fig. 4B).
assessment that is performed separately on all four extrem- Agreement between the nurses for determining
ities, and therefore has the potential to detect weakness whether a patient was “Able” versus “Unable to Participate”
that would be missed by GCS, which only reports motor was lower for patients with developmental disabilities.
response on the best extremity. Finally, all SNAP compo- We hypothesize that developmentally disabled patients
nents are scored on a 0–5 scale, and thus, the scale is not may have variable participation for different nurses,
biased toward motor response like GCS (30, 32, 33). which reinforces that most neurologic assessments are
Agreement was similar for patients with and without effort-dependent and patients must be encouraged to
developmental disabilities for most SNAP components. give maximal effort. A nurses’ determination of ability to
In this way, SNAP is more suitable for a contempo- participate may also have been biased by previous know-
rary PICU population than GCS, which has reduced ledge of the patient’s neurologic capabilities.
reliability for patients with developmental delays (14). SNAP is intended to be a screening tool, performed
Agreement was lower, however, between patients with by bedside nurses, to alert providers to clinical changes
and without developmental disabilities on Mental in a patient’s neurologic examination. SNAP is less
Status and lower extremity Motor Function for patients succinct than the GCS; however, nurses felt it more
deemed “Able to Participate.” Disagreements in Mental accurately and objectively characterized a patient’s
Status were due to differences in whether patients could neurologic examination. Nurses noted a learning curve
fixate or track, and the degree of stimulation required with acquiring SNAP experience and expertise, but felt
for patients to open their eyes (Fig. 4A). Patients with the benefits of SNAP justified the investment in learn-
developmental disabilities who are able to participate ing a new tool. They also acknowledged that because
in the Motor Function assessment are a challenging co- SNAP was more detailed than GCS, it took longer to
hort, because many have spastic cerebral palsy and can complete, but was not burdensomely slower, and ease of
follow commands with their arms, but have more dif- use improved over time. Nurses felt that SNAP would
ficulty with their legs. They can also fatigue easily, thus improve communication regarding a patient’s neuro-
having lower stamina for the second nurse’s assessment, logic capabilities between the nurses and providers.
Figure 4. Distribution of Serial Neurologic Assessment in Pediatrics ratings between pairs of nurses for testable patients with and
without developmental disabilities on the toddler and child scales. A, Ratings for mental status. B, Ratings for lower extremity motor
function for patients deemed "Able to Participate". Numbers in each cell indicate the number of nurse responses.

Kirschen et al
This study was limited by relatively small numbers of

3 Department of Pediatrics, Children’s Hospital of
patients in many of the grouping categories, especially Philadelphia, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia, PA.
for patients with developmental disabilities. Nurses per-
4 Department of Nursing, Children’s Hospital of Philadelphia,
formed SNAP assessments serially rather than simul-
Philadelphia, PA.
taneously, which may have led to lower agreement. We
5 Division of Neonatology, Children’s Hospital of Philadelphia,
did not directly compare IRR between the SNAP and Perelman School of Medicine at the University of
GCS scales in this study. We also did not assess whether Pennsylvania, Philadelphia, PA.
SNAP scores can predict neurologic outcomes, since the 6 Department of Physical Therapy, Children’s Hospital of
scale is only intended to be used as a screening assess- Philadelphia, Philadelphia, PA.
ment for changes in a patient’s neurologic examination. 7 Department of Occupational Therapy, Children’s Hospital of
The SNAP scale does not directly account for preexisting Philadelphia, Philadelphia, PA.
neurologic deficits; however, providers can document a 8 Department of Speech-Language Pathology, Children’s
Hospital of Philadelphia, Philadelphia, PA.
preillness SNAP score at admission based on caregiver
history and the medical record that can be used as com- 9 Department of Family Medicine and Community Health,
Perelman School of Medicine at the University of
parison during the hospitalization. There are some im- Pennsylvania, Philadelphia, PA.
portant features of the neurologic examination, which 10 M. Louise Fitzpatrick College of Nursing, Villanova University,
are not captured in the SNAP score like tone, posture, Villanova, PA.
bulbar function, and abnormal involuntary movements.
11 Division of Neurosurgery, Children’s Hospital of
These are typically assessed by provider teams during Philadelphia, Perelman School of Medicine at the University
routine daily and intermittent physical examinations. of Pennsylvania, Philadelphia, PA.
Finally, this study did not assess the accuracy or timing 12 Department of Medicine, Perelman School of Medicine at
of SNAP for detecting clinically meaningful changes in the University of Pennsylvania, Philadelphia, PA.
a patient’s neurologic examination, nor did it compare Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
accuracy between SNAP and GCS.
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/pccmjournal).
Supported, in part, by the Departments of Anesthesiology and
CONCLUSIONS Critical Care Medicine and Neurology at the Children’s Hospital
of Philadelphia, the Hearst Foundation, and the Neurocritical
When used by nurses, SNAP has substantial to near- Care Society.
perfect IRR, excellent protocol adherence, and is fea- Drs. Kirschen’s and Flibotte’s institutions received funding
sible to implement in a pediatric critical care setting. from the Hearst Foundation. Drs. Kirschen’s and Barg’s insti-
Further validation studies are needed to determine the tutions received funding from the Neurocritical Care Society.
sensitivity and specificity of SNAP for detecting clin- Ms. Smith received funding from AstraZeneca. Dr. Flibotte re-
ceived funding from Hunton Andrews Kurth law firm and St
ically meaningful changes in a critically ill patient’s Peter’s University Hospital in New Brunswick, NJ, and he re-
neurologic examination. ceived support for article research from the Hearst Foundation.
Dr. Mensinger’s institution received funding from Children’s
Hospital of Philadelphia for statistical work. The remaining
ACKNOWLEDGMENTS authors have disclosed that they do not have any potential
conflicts of interest.
We thank the patients and their families who par- For information regarding this article, E-mail: kirschenm@chop.
ticipated in this study, Jonathan Stewart and Caroline edu
Miller for assistance with data entry, and Martin Tuttle The work for this study was performed at the Children’s Hospital
for assistance with graphic arts. of Philadelphia.
1 Department of Anesthesiology and Critical Care Medicine,

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