Richmond Agitation-Sedation Scale (RASS)
The Richmond Agitation Sedation Scale (RASS) is an instrument designed to assess the level of alertness and agitated behavior in critically-ill patients.
- Establish simple and discrete criteria for assessing arousal and agitation;
- Guide sedation therapy to better meet patients’ titration needs; and
- Improve communication regarding sedation and agitation among healthcare providers.
The RASS is a 10-point scale ranging from -5 to +4. Levels -1 to -5 denote 5 levels of sedation, starting with “awakens to voice” and ending with “unarousable.” Levels +1 to +4 describe increasing levels of agitation. The lowest level of agitation starts with apprehension and anxiety, and peaks at combative and violent. RASS level 0 is “alert and calm.” The full scale can be found below:
Richmond Agitation and Sedation Scale
|+4||Combative, violet, danger to staff|
|+3||Pulls or removes tube(s) or catheters; aggressive|
|+2||Frequent nonpurposeful movement, fights ventilator|
|+1||Anxious, apprehensive, but not aggressive|
|0||Alert and calm|
|-1||Awakens to voice (eye opening/contact) > 10 seconds|
|-2||Light sedation; briefly awakens to voice (eye opening/contant) < 10 seconds|
|-3||Moderate sedation; movement or eye opening. No eye contact|
|-4||Deep sedation; no response to voice, but movement or eye opening to physical stimulation|
|-5||Unarousable; no response to voice or physical stimulation|
The RASS is mostly applied in mechanically-ventilated patients, but may be used for any individual who is hospitalized. Regular administration and assessment is particularly useful for patients who are critically-ill, are receiving sedative medications, and/or demonstrate fluctuating levels of consciousness.
The RASS can be administered in a little as 30-60 seconds. Scoring is based on observation, and response to auditory and physical stimulation. Sessler et al. describe the testing procedure as follows:
|Test Procedure and Scoring Instructions|
|1. Observe patient. Is the patient alert and calm? (score 0)
a. Does patient have behavior that is consistent with restlessness or agitation? (score +1 to +4 using level criteria)
|2. If patient is not alert, in a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
a. Patient has eye opening and eye contact, which is sustained for more than 10 seconds (score −1).
b. Patient has eye opening and eye contact, but this is not sustained for 10 seconds (score −2).
c. Patient has any movement in response to voice, excluding eye contact (score −3).
|3. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder.
a. Patient has any movement to physical stimulation (score −4). b. Patient has no response to voice or physical stimulation (score −5).
Scoring and Interpretation
RASS scoring and interpretation should be based on the sedation protocol being used. For minimal sedation protocols (RASS -2 to 0), sedation should be modified or decreased for a RASS score of -3 or less. Scores of 2 to 4 may indicate under-sedation. At minimum, the patient should be assessed for pain, delirium, and anxiety. In addition, other underlying causes of agitation should be investigated and treated as appropriate.
In select cases, a deep sedation protocol (RASS -4 and -5) may be used. For scores of -3 or higher, sedation should be modified to achieve the desired range.
The RASS demonstrates strong validity and reliability across a range of critical care populations. Inter-rater reliability has been found to be good to excellent in adult ICU patients on surgical, medical, coronary, cardiac surgery, and neuroscience ICUs. This includes patients with and without mechanical ventilation and sedative medications. Although most studies were conducted in the United States, inter-rater reliability remained high in Swedish and Portuguese ICU settings as well.
The RASS has many advantages compared to other sedation-agitation scales. Aside from strong inter-rater reliability and ease of administration, use of the RASS improves discrimination between different levels of mild to moderate sedation (+1 to -4). Moreover, the scale is applicable to multiple disciplines, has been heavily studied, and is referenced as a key assessment tool for clinical guidelines related to pain, agitation, and delirium.
In patients with severe auditory and visual deficits, the RASS is not a suitable instrument for assessing arousal and agitation. Although the scale is well-researched in the U.S., studies assessing validity and reliability are limited in other geographical locations and languages other than English.
Physical Therapy Implications
For physical therapy clinicians, the RASS can be used to streamline communication regarding sedation and agitation with other healthcare providers. Resulting scores can guide decision making regarding the appropriateness of physical therapy intervention, and treatment priority. The RASS may also identify patients in need of further assessment and management for pain, agitation, and delirium.
The RASS is freely available online.
- Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. American journal of respiratory and critical care medicine. 2002 Nov 15;166(10):1338-44.
- Khan BA, Guzman O, Campbell NL, Walroth T, Tricker JL, Hui SL, Perkins A, Zawahiri M, Buckley JD, Farber MO, Ely EW. Comparison and agreement between the Richmond Agitation-Sedation Scale and the Riker Sedation-Agitation Scale in evaluating patients' eligibility for delirium assessment in the ICU. Chest. 2012 Jul 1;142(1):48-54.
- Richmond Agitation-Sedation Scale. Accessed July 5, 2020: https://www.mdcalc.com/richmond-agitation-sedation-scale-rass
- Ely EW, Truman B, Shintani A, Thomason JW, Wheeler AP, Gordon S, Francis J, Speroff T, Gautam S, Margolin R, Sessler CN. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). Jama. 2003 Jun 11;289(22):2983-91.
- Rasheed AM, Amirah MF, Abdallah M, Parameaswari PJ, Issa M, Alharthy A. Ramsay sedation scale and richmond agitation sedation scale: A Cross-sectional study. Dimensions of Critical Care Nursing. 2019 Mar 1;38(2):90-5.
- Almgren M, Lundmark M, Samuelson K. The Richmond Agitation‐Sedation Scale: translation and reliability testing in a Swedish intensive care unit. Acta anaesthesiologica scandinavica. 2010 Jul;54(6):729-35.
- Nassar Junior AP, Pires Neto RC, Figueiredo WB, Park M. Validity, reliability and applicability of Portuguese versions of sedation-agitation scales among critically ill patients. Sao Paulo Medical Journal. 2008 Jul;126(4):215-9.
- Benítez-Rosario MA, Castillo-Padrós M, Garrido-Bernet B, González-Guillermo T, Martínez-Castillo LP, González A, Asocación Canaria de Cuidados Paliativos (CANPAL) Research Network. Appropriateness and reliability testing of the modified Richmond Agitation-Sedation Scale in Spanish patients with advanced cancer. Journal of pain and symptom management. 2013 Jun 1;45(6):1112-9.
- Vasilevskis EE, Morandi A, Boehm L, Pandharipande PP, Girard TD, Jackson JC, Thompson JL, Shintani A, Gordon SM, Pun BT, Wesley Ely E. Delirium and sedation recognition using validated instruments: reliability of bedside intensive care unit nursing assessments from 2007 to 2010. Journal of the American geriatrics society. 2011 Nov;59:S249-55.
- Kerson AG, DeMaria R, Mauer E, Joyce C, Gerber LM, Greenwald BM, Silver G, Traube C. Validity of the Richmond Agitation-Sedation Scale (RASS) in critically ill children. Journal of Intensive Care. 2016 Dec 1;4(1):65.
- Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJ, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical care medicine. 2018 Sep 1;46(9):e825-73.