UCSF uses the Vanderbuilt Delirium Protocol
CAM-ICU Delirium Assessement Flow
The CAM ICU is a validated assessment tool created in 1990 to be used by non-psychiatrists to assess for delirium in the ICU. Neurocritical-ill patients that acquire delirium have increased length of stay and decline in functional recovery and cognition. Monitoring delirium in this population is challenging but can help improve ICU prognostics for these outcomes. The CAM-ICU can be used as a complement to the neuro exam but a positive CAM-ICU score may not reflect active delirium. A positive score could be indicative of an underlying neurologic disease or worsening neuro condition, so it may be necessary to assess further to fully understand the change in patient status.
The CAM-ICU assesses for delirium using four assessment features: 1) acute change or fluctuating course of mental status, 2) Inattention 3) alerted Level of consciousness or LOC and 4) disorganized thinking.
References
SAT/SBT policies and SOC documentation
http://manuals.ucsfmedicalcenter.org/NursingDept/SOC/PDF/SOC-AdultCriticalCare.pdf
Family flyer
ICU Bundle
RASS Video displays different levels of agitation and sedation