The current clinical practice guidelines of the Society of Critical Care Medicine (SCCM) for the sustained use of analgesics and sedatives are geared toward the maintenance of optimal comfort in critically ill patients by focusing on 3 central components - pain, anxiety and delirium. The SCCM guidelines recommended that the emergence and/or persistence of delirium be regularly monitored in critically ill patients. Two of the validated tools for assessing delirium in ICU patients are the CAM-ICU and ICDSC.

The Confusion Assessment Method for the ICU (CAM-ICU) was adapted for use in nonverbal ICU patients from the original Confusion Assessment Method (CAM) (Inouye, Ann Intern Med 1990). The CAM-ICU was designed to be a serial assessment tool for use by bedside clinicians (e.g. nurses, physicians, etc). Thus it is easy to use, taking less than 2 minutes to complete and requires minimal training.

The Intensive Care Delirium Screening Checklist is an eight item delirium checklist (Bergeron, Intensive Care Med 2001). This checklist is completed based on data from the previous 24 hours. The eight items are scored 1 (present) or 0 (absent), for a total of 8 points. A score of 4 or greater is a positive screen for delirium.

Education
Use the educational tools below, as well as the videos for delirium education (on the right).

Implementation of the CAM-ICU

The CAM-ICU was designed to be used as a bedside delirium assessment tool for any healthcare professionals. On average, the entire test takes less than 1 minute to complete. Since implementation of any new tool in healthcare can be a challenge, we have created this page to include some helpful hints for the implementation of the CAM-ICU, and we consider it a work in progress. While we plan on providing more information in the future, this a brief set of comments to get you started. More than anything, we want you to feel free to contact us with any questions.

Spot-Checking
We have found that a system of spot-checking is incredibly helpful in identifying misunderstandings about the CAM-ICU and areas that need further clarification and teaching. What is spot-checking? This can be done in a variety of ways, but typically a couple nurses (charge nurses, nurse educators, staff nurses who are looking for a clinical ladder project, etc) become very familiar with the CAM-ICU (local experts). Periodically (once a week, once a month, etc) they do delirium rounds on the unit going from bed to bed spot-checking the staff nurses. The spot-checker and the bedside nurse assess a patient together using the CAM-ICU. They walk outside the room and compare assessments. The bedside nurse explains how the patient did on each feature. Then the spot-checker shares his/her findings and takes the opportunity to educate the nurse regarding any mistakes or misconceptions.

Spot-Checking Form

Case-Based Scenarios
Case scenarios have been used to improve recognition of delirium and accuracy of delirium assessment at the bedside. This is a simple educational intervention using before-and-after case studies. These case scenarios can be found here.

Case-Based Scenario Study Read more here.

Documentation
The first step is to decide where the CAM-ICU assessment results will be documented. We recommend documenting the CAM-ICU in the hourly portion of the nursing flowsheet. Most institutions document the overall CAM-ICU score and not the individual features. However, if you have room, the individual feature documentation can help with compliance and accuracy of the overall assessment and provide excellent data for chart review when trying to identifying weaknesses in the assessment.

Once you have decided where to document the CAM-ICU findings, the next step is to identify how CAM-ICU findings will be documented. We have found that different institutions choose to record the overall CAM-ICU as either "positive" or "negative" OR "Yes", "No" and "UTA." The table below shows the various terminologies that have been used. We recommend picking language that your staff best understands.

Compliance Checking
We recommend adding the CAM-ICU and RASS documentation to the check-list that you use in the regularly scheduled documentation compliance reviews (e.g. chart review).

Implementation Studies
The following studies documented the implementation of the RASS and CAM-ICU into the bedside nursing assessments of critically ill patients in Medical and Trauma Intensive Care Units.

Implementation Study – Medical ICU
Read more here.

Implementation Study – Trauma ICU
Read more here.

Delirium & CAM-ICU Resources

This slide set has been created by Dr. Ely and Ms. Pun of the Vanderbilt and VA ICU Delirium and Cognitive Impairment Study group as a tool to help educate others regarding delirium, which is experienced by so many millions of patients every year. Please contact us through the website if you have any suggestions or questions regarding this material.

ICU Delirium. Epidemiology, Monitoring & Management

Obtaining Printed Materials
(i.e. Picture packets and/or Pocket cards)

We will be glad to assist you in ordering the materials. Please contact Stephanie Hamilton. Make the subject of your email "CAM-ICU order". This will ensure that your request is processed in a timely manner.

Permission for use of CAM-ICU materials
 
We have obtained copyright for the CAM-ICU and its educational materials and have deliberately made it unrestricted in terms of use.  We ask that you include the copyright line on the bottom of the pocket cards and other educational materials, but do not require you to obtain a written letter of permission for implementation and clinical use. Please use the following copyright line:

“Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved”

Pictures
(One of the tools that can be used to assess Attention for CAM-ICU Feature 2)

With the CAM-ICU, Inattention is evaluated with either a Letters (auditory) test or a Pictures (visual) test. Either test can be used to test for attention. The Letters test is the SAVEAHAART described in the training manual. The Pictures test uses pre-made picture packets. We have created a Power Point file to make it easier to reproduce the picture packet. Below is a link to the Power Point files. There are two sets of picture packets (Set A and Set B). However, only one packet is needed per assessment. You may choose to alternate daily between the two sets.

Adult Pictures – Set A

Adult Pictures – Set B

Directions for printing the Picture packets:
1. Print the pdf file one slide per page.
2. Size these to no smaller than 5X7.
3. Laminate with matte lamination (to avoid glare).
4. Punch a hole in the upper left hand corner of each card.
5. Place a ring in the holes to hold the packet together.

Note: The pdf file has a white background for all the pictures and a colored (yellow, red or green) for the instructional pages. The colors were specifically designed to help the rater know where to start the first step (green = go) and when to stop for the second step (red = stop and read instructions). In addition, it is important to have the white cards copied onto natural white paper because bright white is harder for elderly eyes to read.