Neuro ICU >Common ICU Scores & Metrics
Common ICU Scores & Metrics
The following scales are commonly used in the ICU to assess the level of consciousness, sedation, agitation, delirium, and functional status. Familiarity with these tools helps therapy practitioners understand the medical team's documentation, interpret patient behavior in context, and contribute meaningfully to team communication.
Richmond Agitation-Sedation Scale (RASS)
Used to describe the level of alertness or agitation. Most commonly used for mechanically ventilated (MV) patients to avoid over- and under-sedation. Valid and reliable to assess the level of sedation.
Patients requiring MV who are deeply sedated (RASS of -3 or less) are generally intubated for longer periods of time, leading to longer ICU stays and higher mortality. A RASS of -2 to 0 has been advocated in this patient population to minimize sedation. Strategy has been shown to reduce mortality and decrease duration of MV/length of stay in the ICU. Similarly, patients who are too agitated are at risk for self-extubation and/or vent dyssynchrony.
Richmond Agitation-Sedation Scale (RASS)
| Score | Label | Description |
|---|---|---|
| Agitation | ||
| +4 | Combative | Overtly combative, violent; immediate danger to staff |
| +3 | Very Agitated | Pulls or removes tubes/catheters; aggressive behavior toward staff |
| +2 | Agitated | Frequent nonpurposeful movement; ventilator dyssynchrony |
| +1 | Restless | Anxious or apprehensive; movements not aggressive or vigorous |
| Alert | ||
| 0 | Alert & Calm | Spontaneously pays attention to caregiver |
| Sedation | ||
| −1 | Drowsy | Sustained eye opening and contact to voice (≥10 seconds); not fully alert |
| −2 | Light Sedation | Briefly awakens with eye contact to voice (<10 seconds) |
| −3 | Moderate Sedation | Movement or eye opening to voice, but no eye contact |
| −4 | Deep Sedation | No response to voice; any movement to physical stimulation |
| −5 | Unarousable | No response to voice or physical stimulation |
Ely et al., 2003 · Target RASS for most mechanically ventilated patients: −2 to 0
Procedure for RASS Assessment
1. Observe the patient
a. Patient is alert, restless, or agitated (score 0 to +4)
2. If not alert, state the patient’s name and say to open eyes and look at the speaker. Ask “Describe how you are feeling?”
a. Patient awakens with sustained eye opening and eye contact (score -1)
b. Patient awakens with eye opening and eye contact, but not sustained (score -2)
c. Patient has any movement in response to voice but no eye contact (score -3)
3. When there is no response to verbal stimulation, physically stimulate the patient by shaking the shoulder and/or rubbing the sternum.
a. Patient has any movement to physical stimulation (score -4)
b. Patient has no response to any stimulation (score -5)
A scale used to measure the level of consciousness of patients with acute brain injury. Assess a person’s ability to perform eye movements, speak, and move their body.
3 Elements of the Scale: Eyes, Verbal, & Motor. GCS score can range from 3 (completely unresponsive) to 15 (responsive). *Scores of 8 or below should be strongly considered for intubation as unlikely to maintain the airway.
Glasgow Coma Scale (GCS)
(Jain & Iverson, 2021)
Glasgow Coma Scale (GCS)
| Domain | 1 | 2 | 3 | 4 | 5 | 6 |
|---|---|---|---|---|---|---|
| Eye Opening (E) | None | To pressure | To sound | Spontaneous | — | — |
| Verbal Response (V) | None | Sounds | Words | Confused | Oriented | — |
| Motor Response (M) | None | Extension | Abnormal flexion | Withdrawal | Localizes | Obeys commands |
Jain & Iverson, 2021 · Total score: 3–15 · ≤8: consider intubation · 9–12: moderate injury · 13–15: mild injury
Modified Rankin Scale (mRS)
(The Joint Commission, 2018)
A scale used to measure the degree of disability or dependence in daily activities following a stroke or other neurological disability.
Modified Rankin Scale (mRS)
| Score | Level | Description |
|---|---|---|
| 0 | No symptoms | No symptoms at all |
| 1 | No significant disability | Able to carry out all usual activities despite some symptoms |
| 2 | Slight disability | Able to look after own affairs without assistance, but unable to carry out all previous activities |
| 3 | Moderate disability | Requires some help, but able to walk unassisted |
| 4 | Moderately severe disability | Unable to attend to own bodily needs without assistance, and unable to walk unassisted |
| 5 | Severe disability | Requires constant nursing care and attention; bedridden, incontinent |
| 6 | Dead | — |
The Joint Commission, 2018 · Scores 0–2 are generally considered functionally independent · Scores 3–5 indicate varying degrees of dependence
CAM-ICU
(Ely, 2016; Ely et al., 2003)
Quick bedside assessment tool and delirium monitoring instrument for ICU patients. Can be used by all providers and is adapted for use with non-verbal patients. Delirium is defined in terms of four diagnostic features and is deemed positive when Feature 1 and Feature 2 AND either Feature 3 OR 4 is present.
*more information in the assessment section
References
Ely, E. W. (2016). Confusion assessment method for the ICU (CAM-ICU): The complete training manual (pp. 1–32). Vanderbilt University Medical Center. https://uploads-ssl.webflow.com/5b0849daec50243a0a1e5e0c/5bad3d28b04cd592318f45cc_The-Complete-CAM-ICU-training-manual-2016-08-31_Final.pdf
Ely, E. W., Truman, B., Shintani, A., Thomason, J. W. W., Wheeler, A. P., Gordon, S., Francis, J., Speroff, T., Gautam, S., Margolin, R., Sessler, C. N., Dittus, R. S., & Bernard, G. R. (2003). Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA, 289(22), 2983–2991. https://doi.org/10.1001/jama.289.22.2983
Jain, S., & Iverson, L. M. (2021). Glasgow Coma Scale. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK513298/
The Joint Commission. (2018). Modified Rankin Score (mRS). https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html