CAM-ICU

Step 1: Altered Mental Status change from baseline or fluctuating course over prior 24 hours
1. Positive
  1. Go to Step 2
2. Negative
  1. Stop - Negative for Delirium
Step 2: Inattention present
1. Technique
  1. Examiner: "Squeeze my hand when you hear the letter A"
  2. Examiner says the following letters (with 4 A's), one at a time "S-A-V-E-A-H-A-A-R-T"
2. Positive -More than 2 errors (missed at least 2 A's)
  1. Go to step 3
3. Negative
  1. Stop - Negative for Delirium
Step 3: Altered Level of Consciousness present
1. Negative (RASS Score 0)
  1. Go to Step 4
Step 4: Disorganized Thinking
1. Questions
  1. "Will a stone float on water?"
  2. "Are there fish in the sea?"
  3. "Does one pound weigh more than two pounds?"
  4. "Can you use a hammer to pound a nail?"
2. Command
  1. Examiner: "Hold up this many fingers"
    1. Examiner holds up 2 fingers
    2. Patient should hold up 2 fingers with one hand
  2. Examiner: "Now do the same thing with the other hand"
    1. Examiner does not demonstrate this time
    2. Patient should hold up 2 finger on the opposite hand
    3. Alternatively (if patient unable to move both hands): "Now hold up 3 fingers"
3. Positive (2 or more errors)
  1. POSITIVE for Delirium
4. Negative (0 or 1 error)
  1. Negative for Delirium