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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

0

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

0

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

” 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’. Inattention: • “Squeeze my hand when I say the letter ‘A’. Does one pound weigh more than two? 4. Disorganized Thinking: 1. Disorganized Thinking: 1.” 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. Wesley Ely. Acute Change or Fluctuating Course of Mental Status: • Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours? CAM-ICU negative NO DELIRIUM NO YES 2. Will a stone float on water? 2. E. 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. 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. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1) RASS = zero CAM-ICU positive DELIRIUM Present 3. Will a stone float on water? 2. MD. all rights reserved CAM-ICU negative NO DELIRIUM Copyright © 2002. MPH and Vanderbilt University.” 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’. Can you use a hammer to pound a nail? RASS other than zero CAM-ICU positive DELIRIUM Present 4. 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. MPH and Vanderbilt University. MPH and Vanderbilt University. Wesley Ely. Does one pound weigh more than two? 4. Does one pound weigh more than two? 4. MPH and Vanderbilt University. Altered Level of Consciousness Current RASS level (think back to sedation assessment in Step 1) RASS = zero 4. Can you use a hammer to pound a nail? 3. Wesley Ely. E. Inattention: CAM-ICU negative NO DELIRIUM YES 2. MD. Inattention: 0-2 Errors • Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours? CAM-ICU negative NO DELIRIUM CAM-ICU negative NO DELIRIUM YES 2. Acute Change or Fluctuating Course of Mental Status: • Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours? STEP Confusion Assessment Method for the ICU (CAM-ICU) 1. E. all rights reserved . MD. 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. Are there fish in the sea? 3. MD. Are there fish in the sea? 3. Disorganized Thinking: 1. Disorganized Thinking: 1. Are there fish in the sea? 3.” 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. E. Are there fish in the sea? 3. Acute Change or Fluctuating Course of Mental Status: • Is there an acute change from mental status baseline? OR • Has the patient’s mental status fluctuated during the past 24 hours? 1. all rights reserved CAM-ICU negative NO DELIRIUM Copyright © 2002. Acute Change or Fluctuating Course of Mental Status: NO YES 2. Will a stone float on water? 2. 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. Will a stone float on water? 2.STEP DELIRIUM ASSESSMENT NO Confusion Assessment Method for the ICU (CAM-ICU) DELIRIUM ASSESSMENT 1. Wesley Ely. Inattention: 0-2 Errors • “Squeeze my hand when I say the letter ‘A’. Does one pound weigh more than two? 4.