Two delirium screening tools (with reliability evidence) are in widespready use for screening critically ill patients. They include the Confusion Assessment Method for the ICU (CAM - ICU) and the Intensive Care Delirium Screening Checklist (ICDSC).
All patients admitted for longer than 24 hours in CCTC will be screened every shift using the ICDSC.
Delirium screening is done toward the end of each shift, to provide an opportunity to observe for symptom fluctuation.
Steps to Delirium Screening
Step One: Screen the patient for pain
- Ask patient to self-report pain
- If pain is present, ask the patient to rate on scale of 1-10
- If pain is present, determine pain characteristics using PQRST
- If unable to self-report, screen for pain using Critical care Pain Observation Tool (CPOT)
- Treat pain prior to screening for delirium
Reason for pain assessment:
- Pain can cause delirium
- Untreated pain can cause symptoms that are also present during delirium, leading to potential false positive screens
- If the patient has no pain but is receiving continuous doses of narcotics, screening is a reminder to reassess for potential medication reduction
Continue to assess pain at the start of each shift, Q4H and prn. Coordinate delirium screening with pain assessment to avoid duplication.
Step Two: Screen for sedation
- Screen all patients for sedation whether ventilated or unventilated
- Using VAMASS if ventilated; obtained MASS portion of score if unventilated
- Treat anxiety or decreased medication if over-sedated
Reason for sedation assessment:
- The MASS score provides the answer to first question on ICDSC
- The MASS score determines whether the patient is awake enough to use the ICDSC
- If the MASS is < 3, the dose of sedating drugs should be reassessed and weaned if appropriate
Continue to assess the level of sedation using VAMASS or MASS at the start of each shift, Q4H and prn. Coordinate delirium screening with pain and sedation assessment to avoid duplication.
Step Three: Screen for Delirium
- Screen all patients for delirium once per shift using ICDSC
- Screen all patients during the second half of the shift to allow time to observe for symptom fluctuation
If the MASS score is 0 or 1:
- Enter the ICDSC as U/A (unable to assess)
The patient must have a sufficient level of consciousness to screen for delirium; a MASS of 0 or 1 is insufficient
- Review sedating drugs and decrease dose if appropriate; document a DAR note to describe the reduction or the reason why reduction is inappropriate
If the MASS score is > 2:
- Obtain a copy of the ICDSC tool from the laminated bedside tools or from this website
- If the patient has a MASS of 2, 4, 5 or 6, give the patient a score of "1" for the first question ("Does the patient have an altered level of consciousness?")
- If the patient has a MASS of 3, give the patient a score of "0" for the first question
- Attempt to assess the remaining 7questions, giving a score of "1" for each item that the patient screens positive
- Give a score of "0" for each item that the patient screens negative
- If the patient has a MASS of 2 and does not have a sufficient level of consciousness to assess items 2-8 of the ICDSC, record the ICDSC as "U/A*" and document a DAR not to explain reason
- If U/A recorded, review sedating drugs and decrease dose if appropriate (document a DAR note to describe the reduction or the reason why reduction is inappropriate)
- Enter the sum of the positive items
- Score an item positive if the patient manifested this symptom at any point in the past 24 hours
- Do not waken patients for screening; score the patient based on findings throughout the shift
- Treat pain and excessive sedation before completing ICDSC screen
- If you are uncertain about a positive or negative screening result, you may choose to rescreen with the ICDSC
- Report all positive screens to the physician and document that the physician was notified
- The physician should assess the patient for possible causes or risk factors
- Delirium is a clinical diagnosis and not made on the basis of the screen alone
Bergeron, N., Dubois, M., Dumont, M., Dial, S., and Skrobik, Y. (2001). Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Medicine. 27:859-864.
Ely, W. CAM - ICU. Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved