The comfort score can reliably be extended for use in sedated PICU patients with abnormal baseline muscle tone

Introduction: The COMFORT score was previously validated^1,2 for sedation evaluation in PICU patients with normal underlying muscle tone and invasive BP monitors. Inter-rater reliability (IRR) of the COMFORT score applied to patients with normal baseline muscle tone showed muscle tone the least reliable dimension and influenced sedative clinical pathway variance (PVAR)³. This study examines IRR of the COMFORT score extended to all PICU patients requiring sedation after focused nursing education and reports IRR impact on PVAR. Methods: 43 trained raters performed 100 paired, blinded, simultaneous 2-minute assessments for the 8 COMFORT score dimensions: Alertness, Calmness, RR, BP, HR, Movement, Facial Tension, Muscle Tone. The total score [Min = 8, Max = 40] was compared to the prospectively defined clinical pathway COMFORT score target range of 17-26. Ongoing nursing education offered detailed instruction for COMFORT scoring, specifically muscle tone. Data analyzed by Chronbach's alpha (α) for IRR, Cohen's kappa (κ) and Pearson correlation coefficient (r) for observer agreement, and Number Needed to Treat methodology⁴ for PVAR. Results: 61% had abnormal underlying baseline muscle tone, and 31% had invasive BP monitors. Total COMFORT score IRR was very high (α= 0.94, κ= 0.62, and r = 0.89, p<.001). The least reliable dimension remained muscle tone (α= 0.50, κ=0.30, r = 0.33). After mathematical correction for muscle tone variability by averaging paired ratings, PVAR decreased from 23% to 16% and IRR increased (α= 0.96, k = 0.70, r = 0.92, p<.001). Only 1 of 14 medication interventions were predicted to be altered if muscle tone assessment variability alone was eliminated. Conclusions: The COMFORT score remains a reliable and consistent PICU sedation assessment tool, even when including patients with abnormal baseline muscle tone and non-invasive BP monitoring. Despite focused education, muscle tone remains the least reliable dimension. Correction for muscle tone assessment variability may alter sedation intervention decisions. COMFORT score IRR clearly impacts PVAR when COMFORT score target ranges guide sedation practice.