The 2013 clinical practice guidelines for Pain, Agitation, and Delirium (PAD) (Barr, J et al Crit Care Med. 2013 Jan;41(1):263-306) 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 Page Pediatric Care (pCAM-ICU) Rescources Page
Confusion Assessment Method for the ICU (CAM-ICU)
The Complete CAM-ICU Training Manual
Updated March 2014
A revised training manual including delirium Info, CAM-ICU worksheet, CAM-ICU flowsheet, detailed instructions for each feature, FAQs, case studies, and more.
Top Ten Tips for Teaching Delirium Monitoring
The CAM-ICU presented as a newly revised algorithm.
The CAM-ICU presented in a newly revised checklist form, and beneficial with initial teaching of CAM-ICU
CAM-ICU Pocket Cards
Pocket card version of RASS scale and new CAM-ICU Flowsheet
Attention Screening Exam Visual - Form A
A test of attention, the ability of the patient to concentrate and demonstrate short-term memory
Attention Screening Exam Visual - Form B
An alternate set of pictures
Frequently Asked Questions
CAM-ICU feature-specific instructions & questions as well as questions related to putting CAM-ICU into practice
Delirium Education Brochure
A printable brochure explaining delirium for patients and families
The Intensive Care Delirium Screening Checklist (ICDSC)
The Intensive Care Delirium Screening Checklist
ICU Communication Board
This bilingual board tool provides intubated and trached patients in the ICU or step-down units with a way to communicate with their family, visitors, and caregivers.
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.
Delirium monitoring in the ICU: strategies for initiating and sustaining screening efforts.Read on PubMed.gov
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.Read on PubMed.gov
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
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.Read on Pubmed.gov
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.Read on Pubmed.gov
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.Read on Pubmed.gov
DocumentationThe 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.
|Overall CAM-ICU score|
Compliance CheckingWe 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.
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.
Please use the following copyright line:
“Copyright © 2013, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved”