Reference aid only. This step-down 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. Verify against your local protocol before unit use.

Why a distinct step-down screen?

The CAM-ICU loses sensitivity in verbal, non-intubated patients — it misses much mild and hypoactive delirium on the ward. The CAM-IMC was developed for the monitored non-intubated (intermediate-care) patient, and adds a disorientation item. It was validated in non-intubated patients after cardiac surgery (sensitivity 0.96, specificity 0.94); using it across the wider step-down population extends that scope. Post-ICU transfers also carry sedative/opioid-withdrawal risk and PICS, whose cognitive impairment can persist after critical illness and be mistaken for new delirium. It is worth screening: delirium was diagnosed in 20.1% of patients in an emergency-department intermediate care unit, where it predicted a longer stay and worse outcome. (Beyer 2024; Neufeld 2013; Gusmão-Flores 2012; Kuczmarska 2016; Mariz 2013; Wang 2017; Rousseau 2021; Nakanishi 2024.)

1 Arousal — Richmond Agitation-Sedation Scale

Score the RASS first — it is the CAM-IMC's level-of-consciousness item (any value other than 0 scores a point). RASS −4/−5 is stupor or coma: record it and reassess when the patient responds to voice.

2 CAM-IMC — screening (0–10, positive at ≥3)

0/10

A weighted, additive screen for monitored non-intubated patients. Disorientation or inattention can drive a positive result on their own — unlike the CAM-ICU, a negative acute-change item does not veto the diagnosis. Screen on arrival in the unit, then per unit protocol and with any change in mental status: in intermediate care, delirium is largely present on admission rather than acquired later.

1 — Acute change or fluctuating course

Acute change from the mental-status baseline, or fluctuation over the past 24 h?

2 — Altered level of consciousness

Record the RASS above.

3 — Inattention

4 — Disorientation (five dimensions)

Record the RASS to begin.

Admission delirium risk (Martinez 2012)

A validated ward prediction rule for direct admits — three admission variables, 0–3 points, banded to predicted incidence. Use it to target the prevention bundle. This is a risk estimate, not a diagnosis.

Multicomponent prevention bundle

0/0 applied · 0%

A multicomponent non-pharmacologic bundle reduced incident delirium in non-ICU inpatients (Cochrane RR 0.69). Apply it to every at-risk patient and document each shift.

Antipsychotics do not prevent delirium. Systematic reviews show no reduction in incidence, duration, length of stay, or mortality — do not use them prophylactically. Reserve short-term, low-dose use for severe agitation that endangers the patient.

Unit setup

Facility / unit label (prints on the summary)

Which screen, which setting: the CAM-IMC here is for verbal, non-intubated step-down / progressive-care patients. If a patient is intubated or under ICU-level sedation, use the CAM-ICU (adult ICU tool). On a general acute ward, the ward-validated 3D-CAM or the 4AT are the appropriate screens (Marcantonio 2014; SIGN 157; NICE CG103), and front-line staff have carried the 3D-CAM in routine practice as the second step of a two-step protocol (Marcantonio 2022).

De-identified summary

A de-identified snapshot of this assessment — RASS, CAM-IMC, risk, and prevention — generated on this device. No data leaves the browser; do not add identifiers to the notes.

Step-Down Delirium — Summary

Reference aid only — supports, and does not replace, clinical judgment and local protocol. De-identified; generated locally. Sources: Beyer 2024 · Martinez 2012 · Siddiqi 2016.

Assessor (name / credentials)

Assessed (date & time)

Notes (de-identified)