Common ICU Scores & Metrics

Richmond Agitation-Sedation Scale (RASS)

• Used to describe level of alertness or agitation. Most commonly used for mechanically ventilated (MV) patients to avoid over and under-sedation. Valid and reliable to assess level of sedation.

• Patients requiring MV who are deeply sedated (RASS of -3 or less) are generally intubated for longer periods of time leading to longer ICU stays and higher mortality. A RASS of -2 to 0 has been advocated in this patient population to minimize sedation. Strategy has been shown to reduce mortality and decrease duration of MV/length of stay in the ICU. Similarly, patients who are too agitated are at risk for self-extubation and/or vent dyssynchrony.

Procedure for RASS Assessment

1.   Observe patient

a.   Patient is alert, restless, or agitated (score 0 to +4)

2.  If not alert, state patient’s name and say to open eyes and look at speaker. Ask “Describe how you are feeling?”

a.   Patient awakens with sustained eye opening and eye contact (score -1)

b.  Patient awakens with eye opening and eye contact, but not sustained (score -2)

c.   Patient has any movement in response to voice but no eye contact (score -3)

3.  When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum.

a.  Patient has any movement to physical stimulation (score -4)

b.  Patient has no response to any stimulation (score -5)

Glasgow Coma Scale (GCS)

(Jain & Iverson, 2021)

• Scale used to measure level of consciousness of patients with acute brain injury. Assess a person’s ability to perform eye movements, speak, and move their body.

• 3 Elements of the Scale: Eyes, Verbal, & Motor. GCS score can range from 3 (completely unresponsive) to 15 (responsive). *Score of 8 or below should strongly considered for intubation as unlikely to maintain airway.

Modified Rankin Scale (mRS)

(The Joint Commission, 2018)

Scale used to measure the degree of disability or dependence in daily activities following stroke or other neurological disability.

• 0 - No symptoms.

• 1 - No significant disability. Able to carry out all usual activities, despite some symptoms.

• 2 - Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.

• 3 - Moderate disability. Requires some help, but able to walk unassisted.

• 4 - Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.

• 5 - Severe disability. Requires constant nursing care and attention, bedridden, incontinent.

• 6 - Dead.

CAM-ICU

(Ely, 2016; Ely et al., 2003)

Quick bedside assessment tool and delirium monitoring instrument for ICU patients. Can be used by all providers and is adapted for use with non-verbal patients. Delirium is defined in terms of four diagnostic features and is deemed positive when Feature 1 and Feature 2 AND either Feature 3 OR 4 is present.

*more information in the assessment section