Richmond Agitation-Sedation Scale (RASS)
The Richmond Agitation-Sedation Scale (RASS) is an instrument in which the presence and extent of agitation, ranging from combative to calm, as well as the level of consciousness, ranging from alert to comatose, can be evaluated quickly and reliably in 3 easy steps. Occurring first is a baseline observation, a response to verbal stimulation, and then a response to physical stimulation. These steps result in a single digit score with positive and negative values ranging from a low of -5 (comatose) to a high of +5 (combative). Use of RASS can guide sedative therapy, identify patients at risk for self-injury from agitation, and identify excessive sedation, among other used applications.
RASS has been widely used and published for research purposes, as well as been translated into numerous other languages. It is designed specifically to be accurate and reliable with emphasis on ease of use and recall. The specific criteria and pattern of testing was designed to be more definitive with multiple well discriminated levels of sedation and agitation in comparison to other instruments.
|+4||Combative||Overly combative, violet, immediate danger to staff|
|+3||Very agitated||Pulls or removes tube(s) or catheter(s), aggressive|
|+2||Agitated||Frequent nonpurposeful movement, fights ventilator|
|+1||Restless||Anxious but movements not aggressively vigorous|
|0||Alert and calm|
|-1||Drowsy||Not fully alert but has sustained awakening
(eye opening/eye contact) to voice (≥ 10 seconds)
|-2||Light sedation||Briefly awakens to voice with eye contact (<10 seconds)|
|-3||Moderate sedation||Movement or eye opening to voice (but no eye contact)|
|-4||Deep sedation||No response to voice but movement or eye opening to physical stimulation||Physical stimulation|
|-5||Unarousable||No response to voice or physical stimulation|