Clinical field reference

ED Delirium Screening Tool

For older ED patients (DTS → bCAM · bCAM · 4AT). In the ICU, use CAM-ICU; for children, use the pediatric tool.

Adult ICU tool Pediatric tool Templates
Reference aid only. This emergency-department tool supports — and does not replace — clinical judgment and local protocol. It is not a validated decision-support device or an order set. A positive screen suggests delirium but is not diagnostic; evaluate the cause and confirm clinically. Clinical content carries an emergency-clinician review gate — verify against your local protocol before unit use.
Why screen older ED adults?

Delirium affects roughly 8–17% of older ED patients and is missed in up to three-quarters of cases without a screen — most ED delirium is hypoactive and quiet. A positive ED screen independently predicts death within 6 months. (Han 2009; Han 2010; GED Guidelines 2.0.)

Screening pathway

GED Guidelines 2.0 conditionally recommends these instruments for ED use. The two-step DTS → bCAM starts with a <20-second, 98%-sensitive rule-out at triage; the direct bCAM suits high-risk screening; the 4AT is a single ~2-minute test that also flags cognitive impairment and needs no special training. Your unit's default is set in Setup.

Arousal — Richmond Agitation-Sedation Scale

Score the RASS first. A RASS other than 0 makes the DTS positive on its own; at RASS 0, the LUNCH-backwards task decides. RASS −4/−5 is stupor or coma — record “unable to assess” and reassess when the patient responds to voice.

Richmond Agitation-Sedation Scale

Step 1 · Delirium Triage Screen (DTS)

Record the RASS to begin.

A positive screen is a finding, not a diagnosis — the next moves are to find the cause, manage without new harm, and hand the finding off. (ADEPT; ACEP ED-DEL program.)

If the 4AT scored 1–3 (possible cognitive impairment)

A 1–3 band is not delirium-specific: arrange more detailed cognitive testing and informant history-taking, and document the result for the admitting or follow-up team. Delirium can coexist with cognitive impairment — rescreen with any change in mental status.

Sources: 4AT v1.2 · SIGN 157

Unit setup

Default screening pathway
Who to screen: routine screening of all older ED adults is resource-intensive, and GED Guidelines 2.0 notes it does not consistently increase delirium recognition; its recommendations offer validated risk scores (e.g. the Delirium Risk Score) to identify low-risk patients and reduce universal screening. Follow your department's policy.

De-identified summary

A de-identified snapshot of this assessment — pathway, scores, and result — generated on this device. No data leaves the browser; do not add identifiers to the notes.

ED Delirium Screening — Summary

Reference aid only — supports, and does not replace, clinical judgment and local protocol. De-identified; generated locally. Sources: Han 2013 · 4AT v1.2 · GED Guidelines 2.0.

Sources

Every clinical value above maps to a cited source; the full mapping lives in the project's clinical methodology document.

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