STEP Sedation Assessment

Label
COMBATIVE VERY AGITATED AGITATED RESTLESS ALERT & CALM DROWSY LIGHT SEDATION Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non-purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive Spontaneously pays attention to caregiver Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) Briefly awakens to voice (eyes open & contact <10 sec)

RICHMOND AGITATION-SEDATION SCALE (RASS)

Sedation Assessment
Scale
+4 +3 +2 +1 0 -1 -2 -3

STEP
Description

RICHMOND AGITATION-SEDATION SCALE (RASS)

Scale

Label

Description

+4

COMBATIVE

Combative, violent, immediate danger to staff

+3

VERY AGITATED

Pulls to remove tubes or catheters; aggressive

+2

AGITATED

Frequent non-purposeful movement, fights ventilator

+1

RESTLESS

Anxious, apprehensive, movements not aggressive

ALERT & CALM

Spontaneously pays attention to caregiver

-1

DROWSY

Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) V O I C E

-2

LIGHT SEDATION

Briefly awakens to voice (eyes open & contact <10 sec)

-3

MODERATE SEDATION Movement or eye opening to voice (no eye contact)

MODERATE SEDATION Movement or eye opening to voice (no eye contact)

V O I C E

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)

-4 -5 UNAROUSEABLE DEEP SEDATION

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)

No response to voice, but movement or eye opening to physical stimulation No response to voice or physical stimulation

-4

DEEP SEDATION

No response to voice, but movement or eye opening to physical stimulation

-5

UNAROUSEABLE

No response to voice or physical stimulation

If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Ely, et al., JAMA 2003; 286, 2983-2991

T O U C H

If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991

T O U C H

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344

STEP

RICHMOND AGITATION-SEDATION SCALE (RASS)

Sedation Assessment

STEP
Scale
+4 +3 +2 +1 0 -1 -2 -3

RICHMOND AGITATION-SEDATION SCALE (RASS)

Sedation Assessment
Label
COMBATIVE VERY AGITATED AGITATED RESTLESS ALERT & CALM DROWSY LIGHT SEDATION

Scale

Label

Description

Description
Combative, violent, immediate danger to staff Pulls to remove tubes or catheters; aggressive Frequent non-purposeful movement, fights ventilator Anxious, apprehensive, movements not aggressive Spontaneously pays attention to caregiver Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec) Briefly awakens to voice (eyes open & contact <10 sec) MODERATE SEDATION Movement or eye opening to voice (no eye contact)

+4

COMBATIVE

Combative, violent, immediate danger to staff

+3

VERY AGITATED

Pulls to remove tubes or catheters; aggressive

+2

AGITATED

Frequent non-purposeful movement, fights ventilator

+1

RESTLESS

Anxious, apprehensive, movements not aggressive

ALERT & CALM

Spontaneously pays attention to caregiver

-1

DROWSY

Not fully alert, but has sustained awakening to voice (eye opening & contact >10 sec)

-2

LIGHT SEDATION

Briefly awakens to voice (eyes open & contact <10 sec)

-3

MODERATE SEDATION Movement or eye opening to voice (no eye contact)

V O I C E

V O I C E

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)

-4 -5

If RASS is -3 proceed to CAM-ICU (Is patient CAM-ICU positive or negative?)

DEEP SEDATION UNAROUSEABLE No response to voice, but movement or eye opening to physical stimulation No response to voice or physical stimulation

-4

DEEP SEDATION

No response to voice, but movement or eye opening to physical stimulation

-5

UNAROUSEABLE

No response to voice or physical stimulation

If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Ely, et al., JAMA 2003; 286, 2983-2991

T O U C H

If RASS is -4 or -5 STOP (patient unconscious), RECHECK later

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344 Ely, et al., JAMA 2003; 286, 2983-2991

T O U C H

Sessler, et al., Am J Repir Crit Care Med 2002, 166: 1338-1344

STEP DELIRIUM ASSESSMENT

NO

Confusion Assessment Method for the ICU (CAM-ICU)

DELIRIUM ASSESSMENT
1. Acute Change or Fluctuating Course of Mental Status:
Is there an acute change from mental status baseline? OR Has the patients mental status fluctuated during the past 24 hours?

STEP

Confusion Assessment Method for the ICU (CAM-ICU)

1. Acute Change or Fluctuating Course of Mental Status: NO YES 2. Inattention: 0-2 Errors

Is there an acute change from mental status baseline? OR Has the patients mental status fluctuated during the past 24 hours?

CAM-ICU negative NO DELIRIUM

CAM-ICU negative NO DELIRIUM

YES

2. Inattention:

Squeeze my hand when I say the letter A. Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with A & Squeeze on letter other than A

CAM-ICU negative NO DELIRIUM

If unable to complete Letters Pictures

Squeeze my hand when I say the letter A. Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with A & Squeeze on letter other than A

0-2 Errors

CAM-ICU negative NO DELIRIUM

If unable to complete Letters Pictures

> 2 Errors RASS other than zero

> 2 Errors

3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)

RASS = zero

CAM-ICU positive DELIRIUM Present

RASS = zero 4. Disorganized Thinking:
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?

3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)

RASS other than zero

CAM-ICU positive DELIRIUM Present

4. Disorganized Thinking:

1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?

> 1 Error
0-1 Error

> 1 Error
0-1 Error

Command: Hold up this many fingers (Hold up 2 fingers) Now do the same thing with the other hand (Do not demonstrate) OR Add one more finger (If patient unable to move both arms)

CAM-ICU negative NO DELIRIUM

Command: Hold up this many fingers (Hold up 2 fingers) Now do the same thing with the other hand (Do not demonstrate) OR Add one more finger (If patient unable to move both arms)
Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

CAM-ICU negative NO DELIRIUM

Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

STEP

Confusion Assessment Method for the ICU (CAM-ICU)

DELIRIUM ASSESSMENT
NO

STEP

Confusion Assessment Method for the ICU (CAM-ICU)

DELIRIUM ASSESSMENT
1. Acute Change or Fluctuating Course of Mental Status:
Is there an acute change from mental status baseline? OR Has the patients mental status fluctuated during the past 24 hours?

1. Acute Change or Fluctuating Course of Mental Status:

Is there an acute change from mental status baseline? OR Has the patients mental status fluctuated during the past 24 hours?

CAM-ICU negative NO DELIRIUM

NO YES 2. Inattention:

CAM-ICU negative NO DELIRIUM

YES

2. Inattention: 0-2 Errors

Squeeze my hand when I say the letter A. Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with A & Squeeze on letter other than A

CAM-ICU negative NO DELIRIUM

Squeeze my hand when I say the letter A. Read the following sequence of letters: S A V E A H A A R T ERRORS: No squeeze with A & Squeeze on letter other than A If unable to complete Letters Pictures

0-2 Errors

CAM-ICU negative NO DELIRIUM

If unable to complete Letters Pictures

> 2 Errors RASS other than zero

> 2 Errors

3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1)

RASS = zero

CAM-ICU positive DELIRIUM Present

3. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1) RASS = zero 4. Disorganized Thinking:
1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?

RASS other than zero

CAM-ICU positive DELIRIUM Present

4. Disorganized Thinking:

1. Will a stone float on water? 2. Are there fish in the sea? 3. Does one pound weigh more than two? 4. Can you use a hammer to pound a nail?

> 1 Error
0-1 Error

> 1 Error
0-1 Error

Command: Hold up this many fingers (Hold up 2 fingers) Now do the same thing with the other hand (Do not demonstrate) OR Add one more finger (If patient unable to move both arms)

CAM-ICU negative NO DELIRIUM

Command: Hold up this many fingers (Hold up 2 fingers) Now do the same thing with the other hand (Do not demonstrate) OR Add one more finger (If patient unable to move both arms)
Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

CAM-ICU negative NO DELIRIUM

Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved