Large-scale implementation of sedation and delirium monitoring in the intensive care unit: a report from two medical centers

Crit Care Med. 2005 Jun;33(6):1199-205. doi: 10.1097/


Objective: To implement sedation and delirium monitoring via a process-improvement project in accordance with Society of Critical Care Medicine guidelines and to evaluate the challenges of modifying intensive care unit (ICU) organizational practice styles.

Design: Prospective observational cohort study.

Setting: The medical ICUs at two institutions: the Vanderbilt University Medical Center (VUMC) and a community Veterans Affairs hospital (York-VA).

Subjects: Seven hundred eleven patients admitted to the medical ICUs for >24 hrs and followed over 4,163 days during a 21-month study period.

Interventions: Unit-wide nursing documentation was changed to accommodate a sedation scale (Richmond Agitation-Sedation Scale) and delirium instrument (Confusion Assessment Method for the ICU). A 20-min introductory in-service was performed for all ICU nurses, followed by graded, staged educational interventions at regular intervals. Data were collected daily for compliance, and randomly 40% of nurses each day were chosen for accuracy spot-checks by reference raters. An implementation survey questionnaire was distributed at 6 months.

Measurements and main results: The implementation project involved 64 nurses (40 at VUMC and 24 at York-VA). Sedation and delirium monitoring data were recorded for 711 patients (614 at VUMC and 97 at York-VA). Compliance with the Richmond Agitation-Sedation Scale was 94.4% (21,931 of 23,220) at VUMC and 99.7% (5,387 of 5,403) at York-VA. Compliance with the Confusion Assessment Method for the ICU was 90% (7,323 of 8,166) at VUMC and 84% (1,571 of 1,871) at York-VA. The Confusion Assessment Method for the ICU was performed more often than requested on 63% of shifts (5,146 of 8,166) at VUMC and on 8% (151 of 1871) of shifts at York-VA. Overall weighted-kappa between bedside nurses and references raters for the Richmond Agitation-Sedation Scale were 0.89 (95% confidence interval, 0.88 to 0.92) at VUMC and 0.77 (95% confidence interval, 0.72 to 0.83) at York-VA. Overall agreement (kappa) between bedside nurses and reference raters using the Confusion Assessment Method for the ICU was 0.92 (95% confidence interval, 0.90-0.94) at VUMC and 0.75 (95% confidence interval, 0.68-0.81) at York-VA. The two most-often-cited barriers to implementation were physician buy-in and time.

Conclusions: With minimal training, the compliance of bedside nurses using sedation and delirium instruments was excellent. Agreement of data from bedside nurses and a reference-standard rater was very high for both the sedation scale and the delirium assessment over the duration of this process-improvement project.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Critical Care / standards*
  • Delirium / nursing
  • Delirium / prevention & control*
  • Drug Utilization Review
  • Female
  • Guideline Adherence*
  • Hospitals, University
  • Hospitals, Veterans
  • Humans
  • Hypnotics and Sedatives / administration & dosage*
  • Intensive Care Units / standards*
  • Male
  • Middle Aged
  • Nursing Assessment*
  • Outcome and Process Assessment, Health Care*
  • Prospective Studies
  • Respiration, Artificial / nursing
  • Tennessee


  • Hypnotics and Sedatives