Overview
Delirium is positive when Feature 1 + Feature 2 + (Feature 3 or Feature 4) are all present. If RASS is −4 or −5, the patient is too deeply sedated to assess — CAM-ICU should not be performed and the result is recorded as "unable to assess".
Algorithm
Feature Details
Feature 1 — Acute Change or Fluctuation: Is there evidence of an acute change in mental status from the patient's baseline, OR did the patient's mental status fluctuate during the past 24 hours (RASS or GCS fluctuating)? If YES, proceed.
Feature 2 — Inattention (SAVE test): The assessor reads the letter sequence "S-A-V-E-A-H-A-A-R-T" and asks the patient to squeeze the hand on the letter "A". The patient scores 1 point for each correct response (squeeze on A, no squeeze on other letters). Score = number of errors subtracted from 10. A score < 8 (i.e. ≥ 3 errors) is positive for inattention.
| SAVE Sequence | Expected Response |
|---|---|
| S | No squeeze |
| A | Squeeze ✓ |
| V | No squeeze |
| E | No squeeze |
| A | Squeeze ✓ |
| H | No squeeze |
| A | Squeeze ✓ |
| A | Squeeze ✓ |
| R | No squeeze |
| T | No squeeze |
Feature 3 — Altered Level of Consciousness: RASS score other than zero (either sedated or agitated). If RASS ≠ 0, Feature 3 is positive.
Feature 4 — Disorganised Thinking: Ask four yes/no questions (e.g. "Will a stone float on water?"; "Are there fish in the sea?"; "Does 1 pound weigh more than 2 pounds?"; "Can you use a hammer to pound a nail?"). Then ask the patient to hold up two fingers and then do the same with the other hand (or add one finger). A total score < 4 out of 5 is positive.
Interpretation
| Result | Meaning |
|---|---|
| CAM-ICU Positive | Delirium present — investigate cause, initiate non-pharmacological bundle, notify physician |
| CAM-ICU Negative | No delirium at this assessment — reassess every shift |
| Unable to assess | Patient too sedated (RASS −4/−5) — reassess after spontaneous awakening trial |
Psychometric Properties
- Sensitivity: 93–100 %
- Specificity: 98–100 %
- Inter-rater reliability: κ = 0.96
- Validated in mechanically ventilated patients and non-verbal non-intubated patients
Literature
Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286(21):2703–2710.
Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825–e873.
Assess delirium with CAM-ICU interactively in the app.
Open in Scores2GoFor research and educational purposes only. Not intended for direct clinical decision-making.