Continuing Education Activity

The Rancho Los Amigos Scale (RLAS), also known as the Ranchos Scale, is a widely accepted medical scale used to describe the cognitive and behavioral patterns found in brain injury patients as they recover from injury. It was originally developed by the head injury team at the Rancho Los Amigos Hospital in Downey, California to assess patients emerging from a coma. It is often used in conjunction with the Glasgow Coma Scale during the initial assessment of a brain injury patient. However, unlike the Glasgow Coma Scale, it is used throughout the recovery period and not limited to the initial assessment. It takes into account state of consciousness as well as their reliance on assistance to carry out their cognitive and physical functions. This activity describes the clinical use of the Ranchos Los Amigos scale to assess patients with a head injury.

Objectives:

• Identify the function of the Ranchos Los Amigos scale.
• Describe the issues of concern in regards to the Ranchos Los Amigos scale in medicine.
• Outline the clinical significance of the Ranchos Los Amigos scale.
• Summarize interprofessional team strategies for improving care coordination and communication to advance the use of Ranchos Los Amigos scale in head trauma and improve outcomes.

Introduction

 The Rancho Los Amigos Scale (RLAS), also known as the Ranchos Scale, is a widely accepted medical scale used to describe the cognitive and behavioral patterns found in brain injury patients as they recover from injury. It was originally developed by the head injury team at the Rancho Los Amigos Hospital in Downey, California to assess patients emerging from a coma.[1][2][3]

It is often used in conjunction with the Glasgow Coma Scale during the initial assessment of a brain injury patient. However, unlike the Glasgow Coma Scale, it is used throughout the recovery period and not limited to the initial assessment. It takes into account a patient’s state of consciousness as well as their reliance on assistance to carry out their cognitive and physical functions.[4][5][6][4]

The original scale consisted of eight levels, with level 1 representing the lowest level of function and level 8, the highest level of function. As a patient progresses to higher levels, they demonstrate improved cognitive and behavioral states and move toward greater independence. Individuals move through the different levels in a sequential pattern. However, the amount of time spent in each level and the maximum level achieved is variable among individuals. Individuals can also demonstrate an overlap of behaviors between two different levels and they can skip levels during their recovery.

The original scale has since been revised and is known as the Rancho Los Amigos Revised Scale (RLAS-R). One of the limitations of the original eight level scale was that it did not accurately reflect the individuals with higher levels of recovery. Two more levels were added to the initial eight level Ranchos Scale to create a more comprehensive ten level scale named the Rancho Los Amigos Revised Scale (RLAS-R). Each level will be further described in detail below.

• No response to external stimuli            

• Responds inconsistently and non-purposefully to external stimuli
• Responses are often the same regardless of the stimulus

Level III: Localized Response: Total Assistance

• Responds inconsistently and specifically to external stimuli
• Responses are directly related to the stimulus, for example, patient withdraws or vocalizes to painful stimuli
• Responds more to familiar people (friends and family) versus strangers

• The individual is in a hyperactive state with bizarre and non-purposeful behavior
• Demonstrates agitated behavior that originates more from internal confusion than the external environment
• Absent short-term memory

Level V: Confused, Inappropriate Non-Agitated: Maximal Assistance

• Shows increase in consistency with following and responding to simple commands
• Responses are non-purposeful and random to more complex commands
• Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates
• If action or tasks is demonstrated individual can perform but does not initiate tasks on own
• Memory is severely impaired and learning new information is difficult
• Different from level IV in that individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli.

• Able to follow simple commands consistently
• Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks
• Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns 
• Responses may be incorrect secondary to memory impairments but appropriate to the situation

• Oriented in familiar settings
• Able to perform daily routine automatically with minimal to absent confusion
• Demonstrates carry over for new tasks and learning in addition to familiar tasks
• Superficially aware of one’s diagnosis but unaware of specific impairments
• Continues to demonstrate lack of insight, decreased judgment and safety awareness
• Beginning to show interest in social and recreational activities in structured settings
• Requires at least minimal supervision for learning and safety purposes.

• Consistently oriented to person, place and time
• Independently carries out familiar tasks in a non-distracting environment
• Beginning to show awareness of specific impairments and how they interfere with tasks, however, requires standing by assistance to compensate
• Able to use assistive memory devices to recall daily schedule
• Acknowledges other’s emotional states and requires only minimal assistance to respond appropriately 
• Demonstrates improvement of memory and ability to consolidate the past and future events
• Often depressed, irritable and with low frustration threshold

• Able to shift between different tasks and complete them independently
• Aware of and acknowledges impairments when they interfere with tasks and able to use compensatory strategies to cope
• Unable to independently anticipate obstacles that may arise secondary to impairment
• With assistance able to think about consequences of actions and decisions
• Acknowledges the emotional needs of others with stand by-assistance.
• Continues to demonstrate depression and low frustration threshold

• Able to multitask in many different environments with extra time or devices to assist
• Able to create own methods and tools for memory retention
• Independently anticipates obstacles that may occur as a result of impairments and take corrective actions
• Able to independently make decisions and act appropriately but may require more time or compensatory strategies
• Demonstrate intermittent periods of depression and low frustration threshold when under stress
• Able to appropriately interact with others in social situations

Function

The Rancho Los Amigos Scale-Revised (RLAS-R) is a ten level descriptive scale that provides a standardized measure that healthcare professionals can use to understand a brain injury patient's abilities, impairments, and prognosis better, as they move through the stages of recovery. It facilitates communication among treating healthcare professionals and aids in treatment planning.[7]

Clinical Significance

The RLAS-R is often used in conjunction with the Glasgow Coma Scale (GCS) to provide an early assessment of cognitive function in brain injury patients. Differing from the GCS, the RLAS-R is helpful in evaluating a patient's recovery beyond the initial emergence from coma. Earlier screening of cognitive function plays an important role in the prediction of recovery outcomes and facilitates rehabilitation planning in a clinical setting.[8][9][10]

The Ranchos Los Amigos Scale was shown to have high inter-rater reliability and concurrent, predictive value. It is often used in conjunction with the GCS.

Enhancing Healthcare Team Outcomes

The Rancho Los Amigos Scale-Revised (RLAS-R) is a ten level descriptive scale that provides a standardized measure that healthcare professionals including nurses, therapists and physicians can use to understand a brain injury patient's abilities, impairments, and prognosis better, as they move through the stages of recovery. It facilitates communication among treating healthcare professionals and aids in treatment planning