Systematic CRS-R-based Evaluation of Disorders of Consciousness in the ICU

Evaluation and prognostication following disorders of consciousness (DoC) is a complex task with significant implications. The Coma Recovery Scale, Revised (CRS-R) is a standardized neurobehavioral assessment that enables clinicians to accurately differentiate between coma, unresponsive wakefulness syndrome (UWS), minimally conscious state (MCS), and emergence from MCS. Newly described paradigms present ambitious programs utilizing multidisciplinary clinical teams working in sync with new technologies to optimize and improve a systematic approach to prognostication following DoC. We developed a DoC program at a level 1 trauma and comprehensive stroke center to optimize diagnosis and management of DoC patients. Through an iterative approach our program developed a DoC team to standardize the use of the CRS-R for patients with DoC and formalize a training program for its use. In addition, a formal DoC consult group was created incorporating the neurocritical care faculty to provide expertise and to assist with collaborative decision making. We detail our program's development, barriers, outcomes, and future directions. The core features of this novel clinical paradigm-structured assessment, interdisciplinary collaboration, and iterative re-evaluation-can be adapted to more resource-limited settings to improve outcomes, communication, and the consistency and transparency of prognostication in disorders of consciousness.