Monitoring Delirium in the ICU
The 2018 clinical practice guidelines for Pain, Agitation, Delirium, Immobility, and Sleep Disruption (PADIS) recommend that all ADULT ICU patients be regularly (i.e. once per shift) assessed for delirium using either:
- The Confusion Assessment method for the ICU (CAM-ICU) or
- The Intensive Care Delirium Screening Checklist (ICDSC).
Below are some resources for these tools and some additional resources for implementing delirium monitoring into bedside practice. For information regarding monitoring delirium in other hospital settings (e.g. pediatric ICU, emergency department, and general med-surg) refer to these pages:
- Adult Non-ICU Care (CAM & bCAM resources)
- Pediatric Care (pCAM-ICU resources)
- Download the MDCalc App
- CAM-ICU Language Translations and Archived Versions
Confusion Assessment Method for the ICU (CAM-ICU)
Attention Screening Exam Visual - Form A
A test of attention, the ability of the patient to concentrate and demonstrate short-term memory
Brain Road Map
Script for Interdisciplinary Rounds to determine Pain, Agitation, and Delirium Management
CAM-ICU Frequently Asked Questions
CAM-ICU feature-specific instructions & questions as well as questions related to putting CAM-ICU into practice
The CAM-ICU presented in a newly revised checklist form, and beneficial with initial teaching of CAM-ICU
Pain, Agitation and Delirium Management Orderset
Vanderbilt University Medical Center Pain, Agitation, and Delirium Management Orderset
The Intensive Care Delirium Screening Checklist (ICDSC)
The following two implementation studies utilized a variety of strategies including didactic education (online and in person) and spot-checking.
- Spot-checking is incredibly helpful method for identifying misunderstandings about the CAM-ICU and areas that need further clarification and teaching. What is spot-checking? This can be done in a variety of ways, but typically a couple nurses (charge nurses, nurse educators, staff nurses who are looking for a clinical ladder project, etc) become very familiar with the CAM-ICU (local experts). Periodically (once a week, once a month, etc) they do delirium rounds on the unit going from bed to bed spot-checking the staff nurses. The spot-checker and the bedside nurse assess a patient together using the CAM-ICU. They walk outside the room and compare assessments. The bedside nurse explains how the patient did on each feature. Then the spot-checker shares his/her findings and takes the opportunity to educate the nurse regarding any mistakes or misconceptions. This provides one-on-one education to help fill education gaps.
- Spot-Checking could also be used for the ICDSC.
- An example spot-check form
The study below included before-and-after case-based scenarios which increased both the usage a delirium screening tool (i.e., ICDSC) and accuracy of assessment.
Combined didactic and scenario- based education improves the ability of intensive care unit staff to recognize delirium at the bedside.
Devlin JW, Marquis F, Riker RR, Robbins T, Garpestad E, Fong JJ, Didomenico D, Skrobik Y. Crit Care 2008; 12:R19.
Decreasing Inappropriate Unable-to-Assess Ratings for the Confusion Assessment Method for the Intensive Care Unit
Swan JT. Am J Crit Care. 2014 Jan;23(1):60-9. doi: 10.4037/ajcc2014567.
Delirium monitoring in the ICU: strategies for initiating and sustaining screening efforts.
Pun BT, Devlin JW. Semin Respir Crit Care Med. 2013 Apr;34(2):179-88. doi: 10.1055/s-0033-1342972. Epub 2013 May 28.
Implementation, reliability testing, and compliance monitoring of the Confusion Assessment Method for the Intensive Care Unit in trauma.
Soja SL, Pandharipande PP, Fleming SB, Cotton BA, Miller LR, Weaver SG, Lee BT, Ely EW. Intensive Care Med. 2008 Jul;34(7):1263-8.
Implementing Delirium Screening in the ICU: Secrets to Success.
Brummel NE, Vasilevskis EE, Han JH, Boehm L, Pun BT, Ely EW.Crit Care Med. 2013 Sep;41(9):2196-2208.
Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers.
Pun BT, Gordon SM, Peterson JF, Shintani AK, Jackson JC, Foss J, Harding SD, Bernard GR, Dittus RS, Ely EW. Crit Care Med. 2005 Jun;33(6):1199-205.
Meeting the Challenges of Delirium Assessment Across the Aging Spectrum.
Smith HA, Han JH, Ely EW. Crit Care Med. 2016 Sep;44(9):1775-7.
The first step is to decide where the CAM-ICU assessment results will be documented. We recommend documenting the CAM-ICU in the hourly portion of the nursing flowsheet. Most institutions document the overall CAM-ICU score and not the individual features. However, if you have room, the individual feature documentation can help with compliance and accuracy of the overall assessment and provide excellent data for chart review when trying to identifying weaknesses in the assessment.
Once you have decided where to document the CAM-ICU findings, the next step is to identify how CAM-ICU findings will be documented. We have found that different institutions choose to record the overall CAM-ICU as either "positive" or "negative" OR "Yes", "No" and "UTA." The table below shows the various terminologies that have been used. We recommend picking language that your staff best understands.
We recommend adding the CAM-ICU and RASS documentation to the check-list that you use in the regularly scheduled documentation compliance reviews (e.g. chart review).
The following studies documented the implementation of the RASS and CAM-ICU into the bedside nursing assessments of critically ill patients in Medical and Trauma Intensive Care Units.
One Clinician’s Experience with Delirium Screening Implementation
I attended the 2 day conference about delirium, 2 years ago, in Chicago. Anyway, I was the only one from my hospital and from the whole stat, that attended, and on my own time and money. I left there so so so excited and when I returned home, I couldn't get anyone of influence to listen.
I went to an administration level QI RN that I respected and shared my information. She knew of Dr. Ely's name and said he'd come to Milwaukee to talk some years prior, but no forward motion had ever been made about assessing and treating for delirium. I brought the information to my manager and wanted to spearhead a whole new campaign and she was not interested.
I kept bringing information to my practice council, at each meeting, and telling individual nurse after individual nurse about how we could assess for delirium, shorten it's duration, and even prevent worsening delirium. I would tell anyone that would listen about early mobility and how awesome it is and I would even show the video clips you sent in the email. Anyway, my educator finally told me that using the CAM-ICU was "too hard" and that they'd tried that a few years before and couldn't implement it. That was the sound of huge metal doors closing on any chance. So, I just kept using the knowledge I gained and assessed for delirium, brought it to my doctors' attention whenever needed and kept sharing all the information that I could with my peers along the way. I even created my own little card to put behind my badge (you guys should make a card like that, too), that has the CAM-ICU assessment scale on it and I would use it and share it with my co-workers and then just annotate the information right alongside my assessment in the charting.
Well, I finally just left that hospital and transferred inside the system to another hospital in the area. On my very first day, the educator for this new hospital was giving me a tour and as they had just completed their required skills days for the nursing staff, there were several posters still up in one of their meeting rooms. And guess what!?! They had a big bright poster about delirium and early mobility and the ABCDE bundle. The educator asked if I had heard of delirium and I don't think I have ever smiled that big in my life. On my very first day there, I have now joined their practice council and am on their committee regarding delirium. I can't wait!!! It may have taken 2 years, but I can now use the knowledge that I was so grateful to receive at your conference.
I sent a "thank you" email to you all back then and said it was the best conference I had ever been to and I still feel that way. Now, I just get the opportunity to really use that knowledge on a much bigger scale and once again, I must thank you!!!
Permission for use of CAM-ICU materials
The education documents on this page have been created by Dr. Ely and Ms. Pun of the Vanderbilt and VA ICU Delirium and Cognitive Impairment Study group as a tool to help educate others regarding delirium, which is experienced by so many millions of patients every year.