The paired ICU assessments in one place. Toggle between RASS (Richmond Agitation-Sedation Scale) and CAM-ICU (Confusion Assessment Method for the ICU). RASS sets the arousal level first; CAM-ICU then screens for delirium when the patient is arousable (RASS ≥ −3).
Pick the observed level
Assess in steps: observe the patient; if not alert, say their name and ask them to open their eyes and look at you; if still no response, physically stimulate (shake the shoulder, then rub the sternum). Score the patient's best response.
+1 to +4 = agitation (escalating). 0 = alert and calm. −1 to −2 = light sedation (a common target). −3 = moderate sedation. −4 to −5 = deep sedation / unarousable.
The SCCM PADIS guideline recommends targeting light sedation in most mechanically ventilated adults (commonly a RASS around 0 to −2) rather than deep sedation, unless clinically contraindicated.[3] Delirium screening with CAM-ICU is performed when the patient is arousable to voice — a RASS of −3 or higher; at −4 or −5 the patient is too sedated to assess, so re-check later.[2]Your unit's sedation goal and orders take precedence.
Disclaimer: Educational tool only — not a clinical decision-support device, not a diagnosis, and not a substitute for your assessment, the provider's sedation orders, or your unit's protocol. RASS describes a single point in time; sedation needs are dynamic, so reassess often and titrate to the ordered target. A rising RASS (agitation) and a falling RASS (over-sedation) both warrant a look at the cause, not just the infusion. Enter de-identified values only; nothing is stored or transmitted. Confirm the sedation goal your unit uses.
References
Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–1344. PMID: 12421743. (Original 10-level scale; level terms and behavioral descriptors transcribed from this instrument.)
Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003;289(22):2983–2991. PMID: 12799407. (RASS used with CAM-ICU; delirium screened at RASS ≥ −3.)
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med. 2018;46(9):e825–e873. PMID: 30113379. (Targeting light sedation over deep sedation in mechanically ventilated adults.)
Level terms and descriptors were transcribed from the validated RASS; sedation-target context is from the SCCM PADIS guideline. Your unit's sedation protocol takes precedence at the bedside.
Walk the four features
First, the patient must be arousable. Get the official test materials (the attention letters/pictures and the yes-or-no questions) from the Vanderbilt ICU Delirium worksheet and administer them at the bedside, then record the results here.
RASS
Current RASS (arousal gate)
CAM-ICU can only be done if the patient is arousable to voice — a RASS of −3 or higher (at −3, proceed only if the patient responds to your voice, not only to physical stimulation). At −4/−5 the screen is "unable to assess."
1
Acute change or fluctuating course
Is there an acute change from the patient's baseline mental status, or has mental status fluctuated in the past 24 hours (including a change in RASS or GCS)?
2
Inattention
Administer the attention test (the letters or pictures task on the worksheet). 3 or more errors = inattention present.
3
Altered level of consciousnessfrom RASS
Feature 3 is present whenever the current RASS is anything other than 0 (alert and calm). This fills in automatically from the RASS you selected above.
4
Disorganized thinking
Administer the yes-or-no questions plus the command from the worksheet. More than 1 error (2 or more) = disorganized thinking present.
Select the RASS and work through the features to see the result.
Feature 1 (acute change / fluctuation) AND Feature 2 (inattention) AND ( Feature 3 (altered LOC, RASS ≠ 0) OR Feature 4 (disorganized thinking) ).
If Feature 1 or Feature 2 is absent, the screen is negative. If the patient is at RASS −4 or −5, the screen is "unable to assess" — re-check when the patient is more awake. CAM-ICU is a screen performed alongside RASS (delirium monitoring per the SCCM PADIS bundle).[2]
Disclaimer: Educational tool only — not a clinical decision-support device, not a diagnosis, and not a substitute for your assessment, the provider's evaluation, or your unit's delirium protocol. This tool encodes the CAM-ICU algorithm and cutoffs; you must administer the validated attention and disorganized-thinking tests from the official worksheet to score Features 2 and 4 correctly. A negative screen does not rule out delirium over the shift — re-screen at least once per shift and with any change. Treat the cause (look for reversible contributors — infection/sepsis, hypoxia, metabolic disturbance, pain, withdrawal, urinary retention or constipation, and newly started medications), minimize deliriogenic meds, and use non-pharmacologic measures per protocol. Enter de-identified values only; nothing is stored or transmitted.
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Crit Care Med. 2018;46(9):e825–e873. PMID: 30113379. (Routine delirium monitoring with a validated tool such as CAM-ICU, paired with RASS.)
Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale. Am J Respir Crit Care Med. 2002;166(10):1338–1344. PMID: 12421743. (RASS; Feature 3 = current RASS other than 0; CAM-ICU requires RASS ≥ −3.)
The CAM-ICU algorithm logic and cutoffs were transcribed from the validation literature. The attention/thinking test materials are the copyrighted CAM-ICU worksheet (Vanderbilt) — obtain and administer them from icudelirium.org. Your unit's delirium protocol takes precedence.
