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Monitoring Sedation Status Over Time in ICU Patients
Reliability and Validity of the Richmond Agitation-Sedation Scale (RASS)
E. Wesley Ely, MD, MPH;
Brenda Truman, RN, MSN;
Ayumi Shintani, PhD, MPH;
Jason W. W. Thomason, MD;
Arthur P. Wheeler, MD;
Sharon Gordon, PsyD;
Joseph Francis, MD, MPH;
Theodore Speroff, PhD;
Shiva Gautam, PhD;
Richard Margolin, MD;
Curtis N. Sessler, MD;
Robert S. Dittus, MD, MPH;
Gordon R. Bernard, MD
JAMA. 2003;289:2983-2991.
Context Goal-directed delivery of sedative and analgesic medications is recommended as standard care in intensive care units (ICUs) because of the impact these medications have on ventilator weaning and ICU length of stay, but few of the available sedation scales have been appropriately tested for reliability and validity.
Objective To test the reliability and validity of the Richmond Agitation-Sedation Scale (RASS).
Design Prospective cohort study.
Setting Adult medical and coronary ICUs of a university-based medical center.
Participants Thirty-eight medical ICU patients enrolled for reliability testing (46% receiving mechanical ventilation) from July 21, 1999, to September 7, 1999, and an independent cohort of 275 patients receiving mechanical ventilation were enrolled for validity testing from February 1, 2000, to May 3, 2001.
Main Outcome Measures Interrater reliability of the RASS, Glasgow Coma Scale (GCS), and Ramsay Scale (RS); validity of the RASS correlated with reference standard ratings, assessments of content of consciousness, GCS scores, doses of sedatives and analgesics, and bispectral electroencephalography.
Results In 290-paired observations by nurses, results of both the RASS and RS demonstrated excellent interrater reliability (weighted  , 0.91 and 0.94, respectively), which were both superior to the GCS (weighted , 0.64; P<.001 for both comparisons). Criterion validity was tested in 411-paired observations in the first 96 patients of the validation cohort, in whom the RASS showed significant differences between levels of consciousness (P<.001 for all) and correctly identified fluctuations within patients over time (P<.001). In addition, 5 methods were used to test the construct validity of the RASS, including correlation with an attention screening examination (r = 0.78, P<.001), GCS scores (r = 0.91, P<.001), quantity of different psychoactive medication dosages 8 hours prior to assessment (eg, lorazepam: r = - 0.31, P<.001), successful extubation (P = .07), and bispectral electroencephalography (r = 0.63, P<.001). Face validity was demonstrated via a survey of 26 critical care nurses, which the results showed that 92% agreed or strongly agreed with the RASS scoring scheme, and 81% agreed or strongly agreed that the instrument provided a consensus for goal-directed delivery of medications.
Conclusions The RASS demonstrated excellent interrater reliability and criterion, construct, and face validity. This is the first sedation scale to be validated for its ability to detect changes in sedation status over consecutive days of ICU care, against constructs of level of consciousness and delirium, and correlated with the administered dose of sedative and analgesic medications.
Author Affiliations: Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine (Drs Ely, Thomason, Wheeler, and Bernard, and Ms Truman), and Geriatric Psychiatry and Neuroscience (Drs Gordon and Margolin), Center for Health Services Research (Drs Ely, Shintani, Dittus, Gordon, Speroff, and Ms Truman) of Vanderbilt University School of Medicine, Nashville, Tenn; Geriatric Research Education and Clinical Center of the Veterans Administration Tennessee Valley Healthcare System, Nashville (Drs Ely, Gordon, Speroff, and Dittus); Department of Preventive Medicine, Division of Biostatistics (Dr Gautam), Division of Quality and Data Management (Dr Francis), St Vincent Hospital Health System, Indianapolis, Ind; Department of Internal Medicine, Virginia Commonwealth University, Richmond (Dr Sessler).
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