If a patient’s RASS score is -3 or higher, what is the next step?

If a patient’s RASS score is -3 or higher, what is the next step?

• A. Reassess in 1 hour
• B. Proceed to CM-ICU delirium assessment
• C. Increase sedation
• D. Ignore delirium assessment

Answer: (B)

When the patient’s level of arousal is not deeply sedated (RASS -3 or higher), you can reliably assess for delirium at the bedside. At this level, the brain is reachable and responsive enough to perform a structured delirium screen. The standard tool used in the ICU for this purpose is the CM-ICU delirium assessment, which helps detect delirium accurately and guides subsequent management. So the next step is to perform the delirium assessment using the CM-ICU (CAM-ICU) tool. If the screen shows delirium, you would follow the institution’s protocol to manage it (e.g., minimize sedatives, optimize sleep, analgesia, and mobilization as appropriate). Delaying the assessment by reassessing later would miss an opportunity to detect delirium now. Increasing sedation would conceal delirium and obscure the assessment, and ignoring delirium assessment would neglect a key factor linked to worse outcomes in the ICU.

When the patient’s level of arousal is not deeply sedated (RASS -3 or higher), you can reliably assess for delirium at the bedside. At this level, the brain is reachable and responsive enough to perform a structured delirium screen. The standard tool used in the ICU for this purpose is the CM-ICU delirium assessment, which helps detect delirium accurately and guides subsequent management.

So the next step is to perform the delirium assessment using the CM-ICU (CAM-ICU) tool. If the screen shows delirium, you would follow the institution’s protocol to manage it (e.g., minimize sedatives, optimize sleep, analgesia, and mobilization as appropriate).

Delaying the assessment by reassessing later would miss an opportunity to detect delirium now. Increasing sedation would conceal delirium and obscure the assessment, and ignoring delirium assessment would neglect a key factor linked to worse outcomes in the ICU.