Bergeron et al developed the Intensive Care Delirium Screening Checklist to identify a patient in the intensive care unit (ICU) who may be delirious. This can help identify a patient who should have a more extensive evaluation for delirium and who may benefit from early intervention. The authors are from Hopital Masionneuve-Rosemont and McGill University in Montreal.
Screening elements:
(1) level of consciousness
(2) patient evaluation
|
Level of Consciousness |
Action |
|
no response to intense and repeated stimulation (coma) |
do not proceed |
|
responds only to intense and repeated stimulation (including loud voice and pain; stupor) |
do not proceed |
|
responds to mild or moderate stimulation (drowsy) |
1 point |
|
normal wakefulness |
0 points |
|
exaggerated response to normal stimulation (hypervigilance) |
1 point |
Patient evaluation:
(1) inattention
(2) orientation
(3) psychotic symptoms
(4) psychomotor activity
(5) speech and mood
(6) sleep/wake cycle
(7) symptom fluctuation
|
Patient Parameter |
Finding |
Points |
|
inattention |
absent |
0 |
|
|
present |
1 |
|
orientation |
oriented to person, time and place |
0 |
|
|
disoriented in one or more factors |
1 |
|
psychotic symptoms |
none |
0 |
|
|
hallucination, delusions, and/or psychosis |
1 |
|
psychomotor activity |
normal |
0 |
|
|
retarded |
1 |
|
|
agitation |
1 |
|
speech or mood |
both appropriate |
0 |
|
|
one or both inappropriate |
1 |
|
sleep/wake cycle |
normal |
0 |
|
|
disturbed |
1 |
|
symptoms fluctuation over 24 hours |
absent |
0 |
|
|
present |
1 |
where:
• Inattention included difficulty following a conversation or instruction, easy distraction, and/or difficulty shifting focus.
• Inappropriate speech or mood includes inappropriate, disorganized or incoherent speech or inappropriate displays of emotion.
• Disturbed sleep/wake included sleeping less than 4 hours, frequent wakings or sleeping most of the day.
total score =
= SUM(points for level of consciousness) + (points for patient evaluation)
Interpretation:
• If the patient shows stupor or coma, then the checklist is cancelled for the current shift.
• minimum score: 0
• maximum score: 8
• A patient with a score >= 4 should be evaluated more carefully for delirium.
Performance:
• The sensitivity was 99% with a specificity of 64%.
• The area under the ROC curve was 0.90.
Specialty: Neurology
