A Multidisciplinary Delirium Prevention Strategy Involving Psychiatry in the Intensive Care Unit (ICU): Effects on Delirium Incidence and Outcomes
Phase: NA
Conditions: Delirium
Sponsor: University of Southern California

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PROTOCOL NUMBER: HS-17-00617 
 
 
 
TITLE: 
The Impact of a Multifaceted Delirium Preventing Strategy in the ICU involving Psychiatry: Effects on 
Delirium Incidence and Outcomes 
 
 
 
 
 
PRINCIPAL INVESTIGATOR(S): 
 
CATHERINE KUZA, M.D. 
Department of Anesthesiology, Division of Critical Care 
KECK HOSPTIAL OF USC 
1500 SAN PABLO STREET 
LOS ANGELES, CA 90033 
 
 
CO-PRINCIPAL INVESTIGATOR(S): 
DAVID SHESKI, M.D. 
Department of Psychiatry at KSOM of the USC 
 
 
CO-INVESTIGATOR: 
Kelly Jones, M.D. 
Department of Psychiatry at KSOM of the USC 
 
SPONSOR: none 
 
 
PARTICIPANTS/LOCATONS: Keck Hospital of USC 
 
 
AMENDMENTS/REVISIONS:  Third Revision 11-02-2017 
 
 
 
 
 
 
 
 
 
 

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TABLE OF CONTENTS 
 
 
SCHEMA, SYNOPSIS, OR STUDY SUMMARY 
 
 
 
 
 
PAGE 
 
1.0 
BACKGROUND AND HYPOTHESES  
__3-4___ 
 
2. 
OBJECTIVES AND PURPOSE 
__4___ 
 
3.0 
STUDY DESIGN  
__4-6___ 
 
4.0 
DRUG/DEVICE INFORMATION 
__6___ 
 
5.0  
SELECTION AND WITHDRAWAL OF SUBJECTS 
__6-7___ 
 
6.0 
DESCRIPTIVE FACTORS/STRATIFICATION/RANDOMIZATION SCHEME 
__7___ 
 
7.0  
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY     
MANAGEMENT PLAN 
__7___
 
 
 
 
8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
__7___
 
 
 
9. 
CLINICAL AND LABORATORY EVALUATIONS 
__8___ 
 
10.0 
CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS  
__8___  
 
11.0 
SPECIAL INSTRUCTIONS 
 
 
 
 
 
 
__8___ 
 
12. 
DATA COLLECTION AND MONITORING 
__8___ 
 
13.0 
STATISTICAL CONSIDERATIONS  
__8-9___ 
 
14.0 
REGISTRATION GUIDELINES  
__9__ 
 
15.0 
BIOHAZARD CONTAINMENT 
__9___ 
 
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
__9___ 
 
17.0 
REFERENCES 
 
 
 
 
 
 
 
 
__9-10___ 
 
APPENDICES 
 
 
 
 
 
 
 
 
 
__10-14__ 
 
 
 
 
 
 
 

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1.0 BACKGROUND AND HYPOTHESIS 
 
We are interested in evaluating a multifaceted prevention protocol for ICU delirium. Delirium affects  
45-80% of elderly ICU patients, 60-80% of mechanically ventilated ICU patients, and 20-50% of non- 
mechanically ventilated ICU patients (1-4). About 30-40% of cases are preventable (1, 2). Without  
routine screening, delirium is often undiagnosed (5-7). Numerous studies have consistently shown 
 that ICU delirium is associated with a worse prognosis (8). The annual cost of delirium and its  
ramifications in the U.S., is estimated to be $4-16 billion (1). 
 
Delirium impacts emotional well-being, as delirious patients experienced delusional memories and had 
less factual recall than non-delirious patients (9-11). A meta-analysis performed by Zhang et al. found 
delirium to be associated with a higher mortality rate, longer ICU and hospital lengths of stay, longer 
duration of mechanical ventilation, and higher probability of discharge to a skilled placement facility. 
(9) ICU-acquired delirium is independently associated with increased cognitive and physical 
impairment and health care costs (6, 12). Delirium was also found to be associated with more 
complications (9,13). Patients who develop delirium have a 2-3 times increased risk of dying during 
ICU admission (8, 14), with ICU mortality ranging from 1-16% (15-17), and an in-hospital mortality 
rate of 25% to 33%. (12, 18). It is also associated with increased hospital length of stay (13, 19) and 
each additional day of delirium increases post-discharge mortality up to a year after discharge (14, 16, 
19). 
 
Patients with ICU delirium had a higher incidence of cognitive impairment at hospital discharge, and 
up to 18 months post-discharge (20, 21) A longer duration of delirium in the hospital was associated 
with worse global cognition and executive function scores at 3 and 12 months (22), and it is associated 
with the development of new-onset dementia, or worsening of existing dementia (2, 22).  In addition to 
cognitive problems, delirium was found to be associated with more problems in activities of daily 
living and worse scores on sensorimotor function tests at follow-up (3). Anxiety, depression, and 
posttraumatic stress disorder are common in survivors of critical illness (20, 21). 
 
Recent studies evaluating interventions to prevent delirium have focused on “care bundles”, which are 
comprised of several care procedures incorporated into routine clinical care, that improve patient 
outcomes. “Bundling” therapies used in the prevention of sepsis, ventilator-associated pneumonia, and 
central line infections have demonstrated improved clinical outcomes (12). The ABCDEF bundle 
(daily awakening and breathing coordination trials, delirium monitoring and treatment, early mobility, 
and family involvement), a multidisciplinary and multicomponent intervention strategy, is increasingly 
being used in ICUs to decrease length of stay, mechanical ventilation time, complications, and improve 
outcomes (23). The purpose is to minimize exposure to sedating medications and facilitate early 
extubation and mobilization (23). It has also been evaluated in the prevention and treatment of delirium 
and found to decrease delirium incidence and duration, mortality, mechanical ventilator days, hospital 
length of stay, and improve functional status and overall outcomes (12). 
 
Psychiatric interventions have been evaluated in trauma patients (24), post-CABG patients who 
develop a psychiatric disorder postoperatively (25) post-intensive care syndrome (PICS) patients (26), 
and inpatients with delirium (27, 28) and were shown to have beneficial effects. The role of psychiatric 
interventions in the ICU has not been extensively studied. There are only 3 studies which evaluated the 
role of psychiatry in the ICU aimed at: 1. minimizing PTSD/anxiety/depression incidence in ICU 
patients (29), 2. providing a support system for ICU patients (30), and 3. improving the mental health 

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of ICU patients (31). Additionally, the presence of a psychiatry team rounding with a medical ICU 
team on nursing and resident education improvement was examined (32). No studies have evaluated 
the role of psychiatry rounding with the ICU team to prevent delirium and improve long-term 
outcomes. 
 
  
The aim of our study is to determine the effect of delirium prevention care bundle protocols and a 
multi-disciplinary care model rounding with a psychiatry team (intervention group) on the incidence of 
delirium as compared to a group undergoing standard care without psychiatry participating in ICU 
rounds (control group). The psychiatric intervention entails a multidisciplinary approach to patient care 
during rounds, working with the ICU team to make recommendations on non-pharmacological and 
pharmacological prevention and treatment strategies for patients who are positive for delirium, and 
helping to differentiate delirium from other psychiatric conditions, that the ICU team may not have the 
training background to easily identify. Since the incidence of ICU delirium is so high and it has 
negative ramifications on patient survival, long-term outcomes, cognitive function, and places a heavy 
burden on the healthcare system and cost, preventative strategies are desperately needed. Using bundle 
care protocols and multidisciplinary rounding with psychiatry may be a feasible and cheap measure to 
help prevent delirium in ICU patients. 
 
2.0 OBJECTIVES AND PURPOSE 
 
The purpose of our study is to determine the effect of delirium prevention care bundle protocols, and a 
multi-disciplinary care model rounding with a psychiatry team (intervention group) on ICU delirium 
and patient outcomes as compared to a group undergoing standard care without routine psychiatry 
team participating in ICU rounds (control group). Since the incidence of ICU delirium is so high and it 
has negative ramifications on patient survival, long-term outcomes, cognitive function, and places a 
heavy burden on the healthcare system and cost, preventative strategies are desperately needed. Using 
bundle care protocols and multidisciplinary rounding with psychiatry may be a feasible and cheap 
measure to help prevent delirium in ICU patients.  
 
The primary objective is the incidence of ICU delirium. 
 
The secondary objectives are:  
-duration of delirium 
-ICU and hospital length of stay 
-days of mechanical ventilation (if applicable) 
-in-hospital mortality 
 
Our primary hypothesis is that the intervention of psychiatry team participation in multidisciplinary 
ICU rounds with the surgical ICU team will result in a decreased incidence of delirium compared to 
standard care without routine psychiatry team involvement.  Our secondary hypothesis is that 
psychiatric team participation in multidisciplinary ICU rounds will decrease delirium duration, 
decrease ICU and hospital length of stay, decrease mechanical ventilation duration, and decrease in-
hospital mortality compared to the standard care group. 
 
3.0 STUDY DESIGN 
 
This is a prospective, single institution, controlled, pilot study of patients admitted to the 7W ICU 
which will compare the incidence and delirium rates among patients undergoing routine care before 

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intervention (no routine psychiatric involvement) (control group) and patients after the intervention 
(psychiatry team rounding with the ICU team daily) (intervention group) . Randomization is not 
possible for this study; although block randomization was considered, it will result in sub-optimal data 
subject to bias. 
 
A sample size of 104 (52 per group) is targeted based on an a priori sample size calculation. Patients 
will be screened on a daily basis for study eligibility by study personnel and ICU team members, 
before delirium develops. Patients in both groups will be given and information sheet, verbal consent 
will be obtained, and the patient’s agreement to participate will be documented in the medical record. 
For patients who are unable to make their own decisions, the information sheet will be given to  their 
designated healthcare decision maker, verbal consent will be obtained, and the healthcare decision 
maker’s agreement will be documented in the medical record. 
 
The control group will receive standard care, including the use of the ABCDEF bundle (Appendix 1) 
daily, which involves delirium screening using the Confusion Assessment Method-Intensive Care Unit 
(CAM-ICU) score (Appendix 2), but will not have routine psychiatric involvement in care. The CAM-
ICU is performed by the ICU nurses on a daily basis. It consists of several questions that assess 
patient’s mental status, if the change in mental status fluctuates, the sedation score (using Richmond 
Agitation Sedation Score [RASS]), and the patient’s attention span and if disorganized thinking is 
present by asking several questions. The CAM-ICU can be performed in intubated patients by asking 
the patient to follow commands with their hands, or squeeze the nurse’s hand in response to a question.  
The CAM-ICU will be done every morning, but may also be repeated later on in the day if the patient’s 
mental status changes from the morning-this will be the same for both the control and intervention 
group. Enrollment and data collection will continue for as long as it takes to reach the target sample 
size of 52 patients for this group. We will then provide standard care (including ABCDEF bundle 
implementation, which is standard practice in 7W ICU) and provide routine psychiatric care, which 
entails a member of the psychiatric team (attending, resident, and/or fellow) participating in daily 
(Monday-Friday) multidisciplinary rounds with the ICU team (intervention group); the psychiatry team 
will help provide nonpharmacological and pharmacological intervention strategies in patients 
diagnosed with delirium and help distinguish delirium from other psychiatric disorders which may be 
missed by the ICU team and provide earlier treatment of these conditions. This study phase will 
continue until the target sample size of 52 patients is reached.  
 
In both the control and intervention groups, delirium will be diagnosed by a positive CAM-ICU score. 
Both groups will have the CAM-ICU test administered by the patient’s nurse on a daily basis (which is 
standard practice in 7W ICU) in the morning and may be repeated later on in the day if the patient’s 
mental status changes.  Data on the incidence of ICU delirium, duration of delirium/mechanical 
ventilation, in-house mortality, hospital and ICU length of stay will be collected.  
Additionally, we will collect the following data: age, gender, body mass index, history or alcohol or 
substance abuse, admitting diagnosis, dementia, comorbid conditions, admitting Sequential Organ 
Failure Assessment (SOFA) score, deliriogenic medications used during study enrollment, the 
interventions/medications used to treat delirium as designated by psychiatry and the ICU team (in 
intervention group) and the ICU team (control group), and the number of days from ICU admission to 
study enrollment. We will input data into a secure, password protected, encrypted, electronic database, 
RedCap.  

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The data points will be compared between the control and intervention groups (see section 13.0). 
 
Our primary outcome is: incidence of ICU delirium.  
 
The secondary outcomes are: duration of delirium/mechanical ventilation, in-house mortality, and 
hospital and ICU length of stay. 
 
4.0 
DRUG/DEVICE INFORMATION 
 
 
Not applicable  
 
5.0 SELECTION AND WITHDRAWAL OF SUBJECTS 
Inclusion criteria are:  
1. Patients who are ≥18 years of age 
2. Patients admitted to the surgical ICU for >48 hours OR 
3. Patients admitted to the ICU <24 hours who have been in the hospital >48 hours OR 
4. Patients who return to the ICU after being discharged from the ICU to the floor due a complication  
or need for higher acuity care.  
5. Patients admitted to any surgical service who are receiving care in the 7 West surgical ICU, who are 
 either medically or conservatively managed (non-surgical) or surgically managed as part of their care  
 
Exclusion criteria are:  
1. Patients in whom CAM-ICU cannot be performed (severe dementia, stroke or other neurological  
condition, encephalopathy, mental retardation, severe psychiatric disorder, vegetative state, severe  
traumatic brain injury, deaf/blind, etc.) 
2. Patients who don’t speak or understand English 
3. Current alcohol or substance abuse 
4. Patients who already have delirium within 24-48 hours of their ICU admission [Defined as a 
positive CAM-ICU test, or based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth 
Edition ( DSM-V) diagnostic criteria: 
 
Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and 
awareness.  
 
 
Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual 
disturbance) that is not better accounted for by a preexisting, established, or evolving dementia.  
 
 
The disturbance develops over a short period (usually hours to days) and tends to fluctuate 
during the course of the day.  
 

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 
There is evidence from the history, physical examination, or laboratory findings that the 
disturbance is caused by a direct physiologic consequence of a general medical condition, an 
intoxicating substance, medication use, or more than one cause.] 
 
 
Patients will be screened for eligibility on rounds daily. Patients may withdraw from the study at any 
point without impacting their healthcare. 
 
6.0 
 STRATIFICATION/DESCRIPTIVE FACTORS/RANDOMIZATION SCHEME 
This is a prospective, single institution, controlled, pilot study of patients admitted to the 7W ICU. A 
sample size of 104 (52 per group) is targeted. Patients will be screened for study eligibility on a daily 
basis The control group will undergo standard ICU care, which includes the use of the ABCDEF 
bundle (Appendix 1) daily, which involves delirium screening using the CAM-ICU tool (Appendix 2), 
but will not have routine psychiatric involvement in care. Enrollment and data collection will continue 
for as long as it takes to reach the target sample size of 52 patients for this group. We will then proceed 
to enroll patients into the intervention group, who undergo standard care (including ABCDEF bundle 
implementation, which is standard practice in 7W ICU) in addition to a psychiatric team intervention, 
which entails having a member of the psychiatric team (attending, resident, and/or fellow) participate 
in daily (Monday-Friday) multidisciplinary rounds with the ICU team; they will help provide 
nonpharmacological and pharmacological intervention strategies in patients diagnosed with delirium 
and help distinguish delirium from other psychiatric disorders which may be missed by the ICU team 
and provide earlier treatment of these conditions. This study phase will continue until the target sample 
size of 52 patients is reached.  
 
Data will be collected for both the control and intervention groups (see Section 12) and compared. 
 
Randomization is not possible for this study; although block randomization was considered, it  
will result in sub-optimal data subject to bias.  
 
7.0 
STUDY AGENT ADMINISTRATION OR INTERVENTION AND TOXICITY  
           MANAGEMENT PLAN 
In addition to standard care (ABCDEF bundle, which includes daily CAM-ICU screening for  
Delirium by ICU nurses), the intervention will be daily multidisciplinary ICU rounds with a psychiatry  
team member, who will collaborate with the ICU team in implementing preventative strategies, assist  
in the pharmacological and nonpharmacological treatment of patients with delirium, and assist in  
differentiating delirium from other psychiatric disorders which may not be detected by ICU providers,  
thus, identifying, addressing, and treating these illnesses at an earlier time.   
 
8.0 
ASSESSMENT OF EFFICACY AND SAFETY 
 
Not applicable  
 
9.0 
CLINICAL AND LABORATORY EVALUATIONS AND STUDY CALENDAR 
We will collect basic demographic data and screen for delirium using the CAM-ICU (which is  
standard practice in the ICU). The ABCDEF bundle and CAM-ICU screening tool are performed by  
the ICU nurses on a daily basis in the morning. The CAM-ICU may be performed later on in the day if  
the patient’s mental status changes. The findings in the ABCDEF bundle and CAM-ICU screening tool  
are communicated to the ICU team on morning rounds. In patients who develop delirium, we will  

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collect data on their total ICU/hospital LOS (length of stay), days on mechanical ventilation (if 
applicable), duration of delirium, and in-hospital mortality.  
 
No additional laboratory studies or investigative studies will be performed for the study.  
 
10.0 CRITERIA FOR EVALUATION AND ENDPOINT DEFINITIONS 
 
Primary outcome: incidence of delirium, defined by a positive CAM-ICU. 
 
Secondary outcomes: delirium duration, ICU/hospital length of stay, in-hospital mortality, and 
mechanical ventilation duration. 
 
11.0 
SPECIAL INSTRUCTIONS: 
 
Not applicable  
 
12. DATA COLLECTION AND MONITORING  
Data which will be collected includes: age, gender, body mass index, history or alcohol or substance 
abuse, admitting diagnosis, dementia, comorbid conditions, admitting Sequential Organ Failure 
Assessment (SOFA) score, deliriogenic medications used during study enrollment, the 
interventions/medications used to treat delirium as designated by psychiatry in conjunction with the 
ICU team (in intervention group) and the ICU team (control group), and the number of days from ICU 
admission to study enrollment. Data on the incidence of ICU delirium, duration of delirium/mechanical 
ventilation, in-house mortality, and length of stay will also be collected. 
 
Data will be collected using RedCap, a password protected website. No patient identifiers will be used. 
A copy of the information sheet will be provided to the patient and be placed in the patient’s chart. We 
will retain a copy of the information sheet in a double locked storage office.  
 
13.0 STATISTICAL CONSIDERATIONS  
In this pilot study, sample size considerations were based on obtaining sufficient patient numbers to 
assess feasibility of the intervention and data collection on the surgical unit, as well as to obtain 
estimates of incidence of delirium in the current care model (the base incidence) and the magnitude of 
effect of introduction of psychiatric involvement on the unit.  All of these data are required for 
determination of feasibility of and sample size estimation for a larger definitive trial that would likely 
be a multi-centered cluster randomized trial.  Based on our clinical experience in the 7W ICU, the 
incidence of delirium over the past year was roughly 40%; from the literature, a large intervention 
effect would be on the order of 25% reduction in incident delirium.  We used these initial 
approximations to determine the precision (i.e., width of a 95% confidence interval) with which we can 
estimate these two parameters for use in future trial planning.   Given a sample size of 94 patients (47 
in each group), we will be able to estimate the actual difference in the incidence of delirium in our 
proposed intervention group (compared to SOC) with a precision (95% confidence interval) of 8%-
42%.  In the 47 in the SOC group, we will be able to estimate the base rate of delirium incidence with a 
95% confidence interval of 26%-55%.  The effect size and base rate estimated from this pilot trial will 
help us design future multi-center, larger population studies. 
 A sample size of 104 will be targeted to account for a 10% drop-out rate.  
 
Descriptive statistics, including Student’s t-test or Mann–Whitney U-test, for continuous variables and 
χ2 or Fisher’s exact test, for categorical variables, will be used to summarize the data and compare 

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characteristics between the 2 groups. The incidence of delirium will be compared using χ2 test and 
multivariable logistic regression. Differences in the duration of delirium and MV between the 
intervention and control groups will be analyzed by analysis of variance (ANOVA). The length of stay 
will be compared by truncated negative binomial regression, while mortality rates will be compared 
via logistic regression. A sensitivity analysis will be performed in order to assess the possible 
confounding effect of the non-randomized nature of our study design. A propensity score model for 
receipt of standard care vs. psychiatric involvement will be performed in order to approximate a 
balanced covariate distribution between the 2 groups as that would be expected by randomization. We 
will then use the propensity score for each subject to perform an inverse probability weighted 
comparison of the groups on our trial outcomes. 
 
14.0 
REGISTRATION GUIDELINE 
 
Not applicable  
 
15.0 
BIOHAZARD COMTAINMENT 
 
Not applicable  
 
16.0 
ETHICAL AND REGULATORY CONSIDERATIONS 
 
All institutional and Federal regulations concerning the Informed Consent form will be 
fulfilled.  The study will be conducted in adherence to ICH Good Clinical Practice. 
 
17.0 
REFERENCES 
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4. Ely EW et al. JAMA.2004;291:1753-1762. PMID: 15082703 
5. Van Eijk MM et al. Crit Care Med. 2009;37(6):1881-5. PMID:19384206 
6. Barr J et al. Crit Care Med. 2013; 41: 263-306. PMID: 23269131 
7. Hayhurst CJ et al. Anesthesiology. 2016;125(6):1229-1241. PMID:27748656 
8 Salluh JI et al. Intensive Care Med. 2015; 41 (7):1327-9. PMID:26077062 
9 Zhang H et al. Crit Care. 2013; 17(2):R47. PMID:23506796 
10 Ringdal GI et al. Dement Geriatr Cogn Disord. 2011; 32(6):394-400. PMID:22301509 
11 Roberts et al Crit Care Med 2009;37(10):2767-74. PMID:19865006 
12 Collinsworth AW et al. J Intensive Care Med. 2016; 31(2):127-141. PMID:25348864 
13 Kalabalik J et al. J Pharm Pract. 2014; 27 (2):195-207. PMID:24326408 
14 Slooter AJ et al. Handb Clin Neurol. 2017; 141: 449-466. PMID:28190430 
15 Abelha FJ et al. Crit Care. 2013; 17 (5):R257. PMID:24168808 
16. Van Rompaey B, Schuurmans MJ, Shortridge-Baggett LM, et al. Long term outcome after delirium 
in the intensive care unit. J Clin Nurs 2009;18:3349-57. PMID:19735334 
17 Pisani MA, Kong SY, Kasl SV, et al. Days of delirium are associated with 1-year mortality in an 
older intensive care unit population. Am J Respir Crit Care Med 2009;180:1092-7. PMID:19745202 
18 Turnbull AE et al. Crit Care. 2015; 19:29. PMID:25887540 
19 Leslie DL et al. J Am Geriatr Soc. 2011; Suppl 2:S241-3. PMID:22091567 
20. Van den Boogaard M et al. Crit Care Med. 2012; 40:112-118. PMID:21926597 
21. Davydow D. Psychosomatics. 2009; 50:309-316. PMID:19687169 
22 Pandharipande PP et al. N Engl J Med 2013;369:1306-16. PMID:24088092 
23. Marra A et al. Crit Care Clin. 2017; 33(2):225-243. PMID:28284292 
24. Holmes A et al. Aust N Z J Psychiatry. 2007; 41(11):926-33. PMID:17924246 

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25 Rymaszewska J et al. European Psychiatry. 2003; 18:155-160. PMID:12814847 
26.Lasiter S et al. Am J Nurs.2015;115(3):24-46. PMID:25674682 
27. Desan PH et al. Psychosomatics. 2011; 52:513-520. PMID:22054620 
28. Angel C et al. Perm J. 2016;20(4):27-32. PMID:27644045 
29. Peris A et al. Critical Care. 2011;15:R41-49. http://ccforum.com/content/15/1/R41. PMID: 
21272307 
30. Papathanassoglou EDE. Nursing in Critical Care. 2010; 15(3):118-128. PMID:20500650 
31. Guastelli LR et al. Critical Care. 2011; 15(Suppl 2):P47 (doi: 10.1186/cc10195) 
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PMCID:PMC3795585. PMID:24171148 
 
APPENDICES  
APPENDIX 1. ABCDEF BUNDLE USED IN 7 West ICU. 
Symptoms 
Pain, Agitation, Delirium 
Guidelines 
Monitoring 
Tools 
Care 
ABCDEF Bundle 
Pain 
Critical-care Pain 
Observation Tool (CPOT) 
Numeric Rating Scale (NRS) 
Behavioral Pain Scale (BPS) 
A: Assess, prevent and 
manage pain 
B: Both spontaneous 
awakening trials (SAT) and 
spontaneous breathing trials 
(SBT) 
C: Choice of 
analgesia/sedation 
D: Delirium-Assess, prevent 
and manage 
E: Early mobility/exercise 
F: Family engagement and 
empowerment 
Agitation 
Richmond Agitation Sedation 
Scale (RASS) 
Delirium 
Confusion Assessment 
Method for the Intensive Care 
Unit (CAM-ICU) 
 
APPENDIX 2. CAM-ICU.  

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APPENDIX 3. Critical-Care Pain Observational Tool (CPOT).  

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APPENDIX 4. Numeric Rating Scale (NRS). 
 
 
APPENDIX 5. Behavioral Pain Scale (BPS). 
 

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APPENDIX 6. Richmond Agitation-Sedation Score (RASS).