This Article Full Text Full Text (PDF) Online Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sessler, C. N. Articles by Elswick, R. K. Search for Related Content PubMed PubMed Citation Articles by Sessler, C. N. Articles by Elswick, R. K.

The Richmond Agitation–Sedation Scale

Validity and Reliability in Adult Intensive Care Unit Patients

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; School of Nursing and Nursing Service; Department of Pharmacy; and Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, Virginia

Correspondence and requests for reprints should be addressed to Curtis N. Sessler, M.D., F.C.C.P., F.C.C.M., Professor of Medicine, Pulmonary & Critical Care Medicine, Virginia Commonwealth University, Box 980050, Richmond, VA 23298–0050. E-mail: csessler{at}hsc.vcu.edu

Sedative medications are widely used in intensive care unit (ICU) patients. Structured assessment of sedation and agitation is useful to titrate sedative medications and to evaluate agitated behavior, yet existing sedation scales have limitations. We measured inter-rater reliability and validity of a new 10-level (+4 "combative" to -5 "unarousable") scale, the Richmond Agitation–Sedation Scale (RASS), in two phases. In phase 1, we demonstrated excellent (r = 0.956, lower 90% confidence limit = 0.948; = 0.73, 95% confidence interval = 0.71, 0.75) inter-rater reliability among five investigators (two physicians, two nurses, and one pharmacist) in adult ICU patient encounters (n = 192). Robust inter-rater reliability (r = 0.922–0.983) ( = 0.64–0.82) was demonstrated for patients from medical, surgical, cardiac surgery, coronary, and neuroscience ICUs, patients with and without mechanical ventilation, and patients with and without sedative medications. In validity testing, RASS correlated highly (r = 0.93) with a visual analog scale anchored by "combative" and "unresponsive," including all patient subgroups (r = 0.84–0.98). In the second phase, after implementation of RASS in our medical ICU, inter-rater reliability between a nurse educator and 27 RASS-trained bedside nurses in 101 patient encounters was high (r = 0.964, lower 90% confidence limit = 0.950; = 0.80, 95% confidence interval = 0.69, 0.90) and very good for all subgroups (r = 0.773–0.970, = 0.66–0.89). Correlations between RASS and the Ramsay sedation scale (r = -0.78) and the Sedation Agitation Scale (r = 0.78) confirmed validity. Our nurses described RASS as logical, easy to administer, and readily recalled. RASS has high reliability and validity in medical and surgical, ventilated and nonventilated, and sedated and nonsedated adult ICU patients.

Key Words: sedation • agitation • mechanical ventilation • validation • scale

This article has been cited by other articles:

				N. I Cherny, L. Radbruch, and The Board of the European Association for Palliati European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care Palliative Medicine, October 1, 2009; 23(7): 581 - 593. [Abstract] [PDF]

				M. Haenggi, H. Ypparila-Wolters, S. Buerki, R. Schlauri, I. Korhonen, J. Takala, and S. M. Jakob Auditory Event-Related Potentials, Bispectral Index, and Entropy for the Discrimination of Different Levels of Sedation in Intensive Care Unit Patients Anesth. Analg., September 1, 2009; 109(3): 807 - 816. [Abstract] [Full Text] [PDF]

				M. J. Grap Not-so-Trivial Pursuit: Mechanical Ventilation Risk Reduction Am. J. Crit. Care., July 1, 2009; 18(4): 299 - 309. [Abstract] [Full Text] [PDF]

				M. Munkwitz Dexmedetomidine vs Midazolam in Critically Ill Patients: a RCT AAP Grand Rounds, July 1, 2009; 22(1): 7 - 7. [Full Text] [PDF]

				C. Sona Assessing Delirium in the Intensive Care Unit Crit. Care Nurse, April 1, 2009; 29(2): 103 - 105. [Full Text] [PDF]

				H. Wunsch and J. P. Kress A New Era for Sedation in ICU Patients JAMA, February 4, 2009; 301(5): 542 - 544. [Full Text] [PDF]

				R. R. Riker, Y. Shehabi, P. M. Bokesch, D. Ceraso, W. Wisemandle, F. Koura, P. Whitten, B. D. Margolis, D. W. Byrne, E. W. Ely, et al. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial JAMA, February 4, 2009; 301(5): 489 - 499. [Abstract] [Full Text] [PDF]

				M. C. Balas, M. B. Happ, W. Yang, L. Chelluri, and T. Richmond Outcomes Associated With Delirium in Older Patients in Surgical ICUs Chest, January 1, 2009; 135(1): 18 - 25. [Abstract] [Full Text] [PDF]

				F Goncalves, M. Bento, M Alvarenga, I Costa, and L Costa Validation of a Consciousness Level Scale for Palliative Care Palliative Medicine, September 1, 2008; 22(6): 724 - 729. [Abstract] [PDF]

				N. A. Ali, J. M. O'Brien Jr., S. P. Hoffmann, G. Phillips, A. Garland, J. C. W. Finley, K. Almoosa, R. Hejal, K. M. Wolf, S. Lemeshow, et al. Acquired Weakness, Handgrip Strength, and Mortality in Critically Ill Patients Am. J. Respir. Crit. Care Med., August 1, 2008; 178(3): 261 - 268. [Abstract] [Full Text] [PDF]

				T. A. Williams, S. Martin, G. Leslie, L. Thomas, T. Leen, S. Tamaliunas, K. Y. Lee, and G. Dobb Duration of Mechanical Ventilation in an Adult Intensive Care Unit After Introduction of Sedation and Pain Scales Am. J. Crit. Care., July 1, 2008; 17(4): 349 - 356. [Abstract] [Full Text] [PDF]

				S. Akada, S. Takeda, Y. Yoshida, K. Nakazato, M. Mori, T. Hongo, K. Tanaka, and A. Sakamoto The Efficacy of Dexmedetomidine in Patients with Noninvasive Ventilation: A Preliminary Study Anesth. Analg., July 1, 2008; 107(1): 167 - 170. [Abstract] [Full Text] [PDF]

				W. F. Dunn, S. C. Adams, and R. W. Adams Iatrogenic Delirium and Coma: A "Near Miss" Chest, May 1, 2008; 133(5): 1217 - 1220. [Abstract] [Full Text] [PDF]

				C. N. Sessler and K. Varney Patient-Focused Sedation and Analgesia in the ICU* Chest, February 1, 2008; 133(2): 552 - 565. [Abstract] [Full Text] [PDF]

				R. Katznelson, L. Minkovich, Z. Friedman, L. Fedorko, W. S. Beattie, and J. A. Fisher Accelerated Recovery from Sevoflurane Anesthesia with Isocapnic Hyperpnoea Anesth. Analg., February 1, 2008; 106(2): 486 - 491. [Abstract] [Full Text] [PDF]

				P. P. Pandharipande, B. T. Pun, D. L. Herr, M. Maze, T. D. Girard, R. R. Miller, A. K. Shintani, J. L. Thompson, J. C. Jackson, S. A. Deppen, et al. Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients: The MENDS Randomized Controlled Trial JAMA, December 12, 2007; 298(22): 2644 - 2653. [Abstract] [Full Text] [PDF]

				S. Nunes, L. Berg, L.-P Raittinen, H. Ahonen, J. Laranne, L. Lindgren, I. Parviainen, E. Ruokonen, and J. Tenhunen Deep Sedation with Dexmedetomidine in a Porcine Model Does Not Compromise the Viability of Free Microvascular Flap as Depicted by Microdialysis and Tissue Oxygen Tension Anesth. Analg., September 1, 2007; 105(3): 666 - 672. [Abstract] [Full Text] [PDF]

				M. A. Pisani, T. E. Murphy, P. H. Van Ness, K. L. B. Araujo, and S. K. Inouye Characteristics Associated With Delirium in Older Patients in a Medical Intensive Care Unit Arch Intern Med, August 13, 2007; 167(15): 1629 - 1634. [Abstract] [Full Text] [PDF]

				B. T. Pun and E. W. Ely The Importance of Diagnosing and Managing ICU Delirium Chest, August 1, 2007; 132(2): 624 - 636. [Abstract] [Full Text] [PDF]

				T. D. Girard and G. R. Bernard Mechanical Ventilation in ARDS: A State-of-the-Art Review Chest, March 1, 2007; 131(3): 921 - 929. [Abstract] [Full Text] [PDF]

				J. E. Nelson, N. Tandon, A. F. Mercado, S. L. Camhi, E. W. Ely, and R. S. Morrison Brain dysfunction: another burden for the chronically critically ill. Arch Intern Med, October 9, 2006; 166(18): 1993 - 1999. [Abstract] [Full Text] [PDF]

				J. Zak Mapping Ventricular Tachycardia Crit. Care Nurse, October 1, 2006; 26(5): 13 - 20. [Full Text] [PDF]

				C. Lepouse, C. A. Lautner, L. Liu, P. Gomis, and A. Leon Emergence delirium in adults in the post-anaesthesia care unit Br. J. Anaesth., June 1, 2006; 96(6): 747 - 753. [Abstract] [Full Text] [PDF]

				J. M LeBlanc, J. F Dasta, and S. L Kane-Gill Role of the Bispectral Index in Sedation Monitoring in the ICU Ann. Pharmacother., March 1, 2006; 40(3): 490 - 500. [Abstract] [Full Text] [PDF]

				M. M. J. De Jong, S. M. Burns, M. L. Campbell, M. Chulay, M. J. Grap, L. N.B. Pierce, and T. Simpson Development of the American Association of Critical-Care Nurses' Sedation Assessment Scale for Critically Ill Patients Am. J. Crit. Care., November 1, 2005; 14(6): 531 - 544. [Abstract] [Full Text] [PDF]

				S. Jaber, G. Chanques, C. Altairac, M. Sebbane, C. Vergne, P.-F. Perrigault, and J.-J. Eledjam A Prospective Study of Agitation in a Medical-Surgical ICU: Incidence, Risk Factors, and Outcomes Chest, October 1, 2005; 128(4): 2749 - 2757. [Abstract] [Full Text] [PDF]

				M. J. Grap, C. T. Borchers, C. L. Munro, R. K. Elswick Jr, and C. N. Sessler Actigraphy in the Critically Ill: Correlation With Activity, Agitation, and Sedation Am. J. Crit. Care., January 1, 2005; 14(1): 52 - 60. [Abstract] [Full Text] [PDF]

				K. J. Lafleur Will Adequate Sedation Assessment Include the Use of Actigraphy in the Future? Am. J. Crit. Care., January 1, 2005; 14(1): 61 - 63. [Full Text] [PDF]

				C. N. Sessler Sedation Scales in the ICU Chest, December 1, 2004; 126(6): 1727 - 1730. [Full Text] [PDF]

				C. Weinert and L. McFarland The State of Intubated ICU Patients: Development of a Two-Dimensional Sedation Rating Scale for Critically Ill Adults Chest, December 1, 2004; 126(6): 1883 - 1890. [Abstract] [Full Text] [PDF]

				B. D Watson and S. L Kane-Gill Sedation Assessment in Critically Ill Adults: 2001-2004 Update Ann. Pharmacother., November 1, 2004; 38(11): 1898 - 1906. [Abstract] [Full Text] [PDF]

				D. Li and K. Puntillo What is the current evidence on pain and sedation assessment in nonresponsive patients in the intensive care unit? Crit. Care Nurse, October 1, 2004; 24(5): 68 - 3. [Full Text] [PDF]

				E. W. Ely, A. Shintani, B. Truman, T. Speroff, S. M. Gordon, F. E. Harrell Jr, S. K. Inouye, G. R. Bernard, and R. S. Dittus Delirium as a Predictor of Mortality in Mechanically Ventilated Patients in the Intensive Care Unit JAMA, April 14, 2004; 291(14): 1753 - 1762. [Abstract] [Full Text] [PDF]

				Abbott/American Association of Critical-Care Nurse Consensus Conference on Sedation Assessment: A Collaborative Venture by Abbott Laboratories, American Association of Critical-Care Nurses, and Saint Thomas Health System Crit. Care Nurse, April 1, 2004; 24(2): 33 - 41. [Full Text] [PDF]

				M. J. Grap, D. Strickland, L. Tormey, K. Keane, S. Lubin, J. Emerson, S. Winfield, P. Dalby, R. Townes, and C. N. Sessler Collaborative Practice: Development, Implementation, and Evaluation of a Weaning Protocol for Patients Receiving Mechanical Ventilation Am. J. Crit. Care., September 1, 2003; 12(5): 454 - 460. [Abstract] [Full Text] [PDF]

				E. W. Ely, B. Truman, A. Shintani, J. W. W. Thomason, A. P. Wheeler, S. Gordon, J. Francis, T. Speroff, S. Gautam, R. Margolin, et al. Monitoring Sedation Status Over Time in ICU Patients: Reliability and Validity of the Richmond Agitation-Sedation Scale (RASS) JAMA, June 11, 2003; 289(22): 2983 - 2991. [Abstract] [Full Text] [PDF]

				B. Truman and E. W. Ely Monitoring Delirium in Critically Ill Patients: Using the Confusion Assessment Method for the Intensive Care Unit Crit. Care Nurse, April 1, 2003; 23(2): 25 - 35. [Full Text] [PDF]

				M. J. Tobin Critical Care Medicine in AJRCCM 2002 Am. J. Respir. Crit. Care Med., February 1, 2003; 167(3): 294 - 305. [Full Text] [PDF]