High inter-rater reliability between physicians and nurses utilising modified Downes' scores in preterm respiratory distress

Danielle E.Y. Ehret, Asrat Demtse Gebremedhin, Amanuel Hadgu Berhe, Yohanes Hailu, Gesit Metaferia, Kaitlin Kessler, Ryan Kessler, Marie Dunn, Agneta Golan, Miroslav Stavel, Jaroslava Belava, Jeffrey D. Horbar, Erika M. Edwards, Bogale Worku, Michael Dunn, Mahlet Abayneh

Research output: Contribution to journalArticlepeer-review


Aim: To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress. Methods: We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4. Results: Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment. Conclusion: Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.

Original languageEnglish
Pages (from-to)2329-2337
Number of pages9
JournalActa Paediatrica, International Journal of Paediatrics
Issue number11
StatePublished - 1 Nov 2023
Externally publishedYes


  • continuous positive airway pressure
  • downes' score
  • neonatal mortality
  • neonatal nursing
  • respiratory distress syndrome

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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