Richmond Agitation-Sedation Scale (RASS)

Introduction

The Richmond Agitation Sedation Scale (RASS) is an instrument designed to assess levels of alertness and agitation in critically ill patients. [1]

Purpose

The scale was developed by a team of intensivist nurses and pharmacists to achieve the following goals:[1][2]

1. Establish simple and discrete criteria to assess arousal and arousal;
2. Guide sedation therapy to better meet patient titration needs; and
3. Improve communication between healthcare providers regarding sedation and agitation.

Structure

RASS is a 10-point scale ranging from -5 to +4. [1] Scales -1 to -5 represent 5 levels of sedation starting with “wakeup sound” and ending with “no wakeup”. A scale of +1 to +4 describes increasing levels of agitation. Minimal Agitation Begins with Worry and anxiety, peaking at times of aggression and violence. RASS level 0 is “alert and calm”. The full scale can be found below: [1]

Richmond Agitation and Sedation Scale

Rass Score Description +4 Combat Violet Hazard to Staff +3 Pulling or removing tube or catheter; Aggressive +2 Frequent Aimless Movement Against Ventilator +1 Anxiety Apprehensive but not Aggressive 0 Alertness and Calm -1 Sound Arousal (eyes open/contact)><10 seconds – 3 moderate sedation; exercise or Eye-opener. No eye contact – 4 deep sedation; no response to sound, but movement or eye opening to physical stimuli – 5 no arousal; no response to sound or physical stimuli

Indications

RASS is primarily used in mechanically ventilated patients, but can be used in any hospitalized patient. [3] Periodic dosing and assessment is especially useful in critically ill patients who are receiving sedative medications and/or exhibit fluctuating levels consciousness.

Procedure

RASS can be done in as little as 30-60 seconds. [1] Scoring is based on observation and response to auditory and physical stimuli. Sessler et al. [1] described the test procedure as follows:

Test Procedure and Scoring Instructions 1. Observe the patient. Is the patient alert and calm? (Score 0) a. Does the patient have behaviors consistent with restlessness or agitation? (Score +1 to +4 using level criteria)2. If the patient is not alert when speaking loudly, state the patient’s name and Instruct the patient to open their eyes and look at the speaker. Repeat if necessary. The patient can be prompted to continue watching speaker.a. Patient keeps eyes open and makes eye contact for more than 10 seconds (score -1). Patient can open eyes and make eye contact, but this is not continuous Lasts 10 seconds (score -2). c. Patient has no response to sound, excluding eye contact (score -3). 3. If the patient does not respond to the sound, physically stimulate the patient by shaking the shoulders and rubbing the sternum if there is no response to shaking the shoulders. patient has any Physically stimulating movement (score -4). b. Patient does not respond to sound or physical stimuli (score -5).

Scoring and Interpretation

RASS scoring and interpretation should be based on the sedation protocol used. For minimal sedation regimens (RASS -2 to 0), sedation should be modified or reduced for RASS scores of -3 or lower. [3] A score of 2 to 4 may indicate insufficient sedation. As a minimum, patients should be assessed for Pain delirium and anxiety. In addition, other underlying causes of agitation should be investigated and appropriately treated.

In specific cases, deep sedation regimens (RASS -4 and -5) may be used. [3] For scores of -3 or higher, sedation should be modified to achieve the desired range.

Psychometric information

RASS has shown strong validity and reliability across a range of critical care populations. [1][4][5][6][7][8][9] have found that inter-rater reliability ranged from good to excellent. [1][4][5][6][7][9] this Patients with and without mechanical ventilation and sedation were included. Inter-rater reliability was high in Swedish [7] and Portuguese [6] ICU settings, although most studies were conducted in the United States.

In adult ICU patients in the US, the RASS demonstrated good standard[4] construct[1][4] and face validity. [4] Kerson et al. [10] also found that critically ill children had high criterion validity.

Strengths

The RASS has many advantages over other sedation-agitation scales. In addition to strong inter-rater reliability [5][7] and ease of administration, the use of RASS improved discrimination between varying degrees of mild to moderate sedation (+1 to -4). [1] In addition, the scale applies to It has been extensively studied across multiple disciplines and cited as a key assessment tool in clinical guidelines related to pain agitation and delirium. [11]

Limitations

The RASS is not an appropriate tool for assessing arousal and agitation in patients with severe auditory and visual deficits. [1] Although the scale has been well studied in studies in the United States, studies assessing validity and reliability have been limited in other geographic locations and languages English.

Physical Therapy Implications

For physical therapy clinicians, RASS can be used to simplify communication about sedation and agitation with other healthcare providers. The resulting scores can guide decisions about the appropriateness of physical therapy interventions and treatment prioritization. RASS is OK Identify patients who require further evaluation and management of pain agitation and delirium.