Scoring Tool
VISAGE Score: NeuroICU Risk Stratification for Early Tracheostomy & PUG
The VISAGE score is a structured Day 1 and Day 3 clinical assessment used to identify mechanically ventilated neuro-ICU patients who are most likely to need early tracheostomy and percutaneous gastrostomy (PUG). It replaces subjective gestalt with a repeatable, team-shareable score that drives timely procedural planning.
What Does VISAGE Stand For?
Each letter represents a clinical factor that predicts prolonged ventilator dependence and procedural need:
- V — Ventilator dependence
- I — ICU stay ≥3 days (Day 3 assessment only)
- S — Secretion burden
- A — Aspiration risk
- G — GCS ≤8
- E — Extubation failure / not candidate (Day 3 assessment only)
Day 1 Assessment (4 Factors, Max 9 Points)
Day 1 Risk Thresholds
| Score | Risk Level | Recommendation |
|---|---|---|
| 0–2 | LOW | Standard monitoring; reassess Day 3 |
| 3–4 | MODERATE | Monitor closely; reassess Day 3 |
| ≥5 | HIGH | Begin tracheostomy + PUG planning; confirm on Day 3 |
Day 3 Assessment (6 Factors, Max 14 Points)
Day 3 Risk Thresholds
| Score | Risk Level | Recommendation |
|---|---|---|
| 0–2 | LOW | Continue conservative management |
| 3–5 | MODERATE | Likely needs procedures — schedule trach + PUG by Day 5 |
| ≥6 | HIGH | Proceed with tracheostomy + PUG; complete both by Day 5 |
How to Use VISAGE in Practice
- Day 1: Score all four Day 1 factors at the time of ICU admission or shortly after intubation.
- If Day 1 score ≥5, alert the care team and begin anticipatory planning for procedures.
- Day 3: Score all six Day 3 factors. Use this score to confirm or reconsider the procedural plan.
- If Day 3 score ≥6, schedule combined trach + PUG for Day 4–5.
VISAGE is a decision-support tool. Clinical judgment, patient and family preferences, and institutional expertise must also inform the decision.
Frequently Asked Questions
Ventilator dependence, ICU stay ≥3 days, Secretion burden, Aspiration risk, GCS ≤8, Extubation failure.
Day 1 ≥5 initiates planning; Day 3 ≥6 confirms the indication and targets Day 5 procedure completion.