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Sutter Health: Sacramento-Sierra Regional ICU Delirium Protocol  

A delirium protocol shared by Sutter Health.

All ICU patients will be assessed for delirium by the RN, using validated and reliable evidence based tools.  The tools utilized will be the RASS (Richmond Agitation-Sedation Scale) assessment tool every 2 hours through the shift and prn, the CAM-ICU (Confusion Assessment Method for the ICU) assessment tool at least once per shift and prn with any change in cognition.  

Review the patient’s medication history and the medication reconciliation form.  This should include any use of psychoactive medications, benzodiazepines or analgesics, and the patient’s responses to these medications. Resume home medications as soon as clinically appropriate.  

Step 1. Look for possible causes of delirium using the THINK acronym
Step 2. In addition to identifying possible causes of delirium, the RN will implement NPDMS (Non-pharmacologic delirium mitigation strategies)
Step 3. If patient remains CAM-ICU positive after steps 1 and 2, consider pharmacologic interventions

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Categories: Quality and Patient Safety, ICU Liberation,
Content Type: Protocols, Checklists, and Tools,