Advanced Emergency Nursing Journal

Vol. 40, No. 2, pp. 131–137

Copyright 
C 2018 Wolters Kluwer Health, Inc. All rights reserved.

Evaluation of Richmond Agitation

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Sedation Scale (RASS) in

Mechanically Ventilated in the
Emergency Department
Marianne K. Pop, PharmD, BCPS
Katelyn R. Dervay, PharmD, MPH, BCPS, FASHP
Mary Dansby, PharmD, BCPS
Carolina Jones, RN, CEN, ATCN, EMT

Abstract
The purpose of this study was to assess Richmond Agitation Sedation Scale (RASS) goal implemen-
tation in mechanically ventilated patients sedated in the emergency department (ED), compliance
with RASS, and goal achievement. This study was a retrospective chart review at a large Level I
trauma academic medical center. Patients who were intubated in the ED or en route to the ED
between October 1, 2013, and October 1, 2014, were eligible for inclusion if they met the fol-
lowing criteria: aged 18 years or older, 24 hr or more on mechanically ventilated support receiving
continuous sedation and/or analgesia during the first 48 hr of admission, and a hospital stay of
6 days or more. There were 205 patients identified; 104 failed inclusion, 101 were enrolled, and 62
were excluded. Thirty-nine patients (94.9%) had an RASS goal implemented in the ED, of which 37
patients (81.1%) had an RASS goal set by an ED physician. Assessment of the RASS was found
to be inconsistent, as 56.8% of patients were evaluated by an ED nurse within 1 hr of sedative
initiation. Of the 37 patients who had an RASS goal in the ED, 18.9% achieved their goal in the ED.
A review of sedation prescribing revealed that 39% received a regimen of varied combinations of
continuous infusions of propofol, dexmedetomidine, and midazolam throughout admission, 33%
received a regimen of 2 of the aforementioned drugs, and 28% received only propofol. Median
extubation time was 129 hr. Seven patients expired within 180 days of admission. The assessment
of the RASS was a common practice, but there were inconsistencies in measurement. A limited
number of patients achieved their RASS goal in the ED. These results support a provider and nurs-
ing knowledge deficit regarding RASS goal setting, proper documentation of RASS measurement,
and the need for appropriate assessments. Key words: early sedation, emergency department,
mechanically ventilated, Richmond Agitation Sedation Scale (RASS)

Author Affiliations: Department of Pharmacy Prac-

tice, (Dr Pop) University of Illinois College of Pharmacy
Rockford, Illinois; Department of Pharmacy Services,
(Drs, Dervay, and Dansby) and Emergency Department
(Ms Jones), Tampa General Hospital, Tampa, Florida.
Disclosure: The authors report no conflicts of interest.
E NDOTRACHEAL INTUBATION and
subsequent mechanical ventilation are
initiated in patients who are unable to
protect their airway and require assistance
with breathing. Approximately 3% of hos-
Corresponding Author: Marianne K. Pop, PharmD,
BCPS, University of Illinois College of Pharmacy, 1601 pitalized patients studied in six U.S. states
Parkview Ave, Rockford, IL 61107 (mpop@uic.edu). have received invasive mechanical ventilation
DOI: 10.1097/TME.0000000000000184 (Wunsch et al., 2010). Sedation is integral to

131

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 132
the management of the mechanically venti-
lated patients because these patients often
experience anxiety and agitation that may,
in turn, have negative physiological effects
(Barr et al., 2013; Sessler et al., 2002). Opti-
mal sedation minimizes agitation while allow-
ing the health care team to wake the patient
for neurological assessments as needed. Phar-
macological options include sedatives such as
propofol, dexmedetomidine, midazolam, lo-
razepam, and ketamine administered through
continuous infusion. Although sedation is im-
portant in the management of mechanically
ventilated patients, long-term deep sedation
is associated with increased morbidity and
mortality (Barr et al., 2013). Patients who
present to the emergency department (ED)
in need of mechanical ventilation may initially
require larger sedative doses due to additional
stress from their illness or because the re-
quired procedures or diagnostic testing neces-
sitates it. Sedation in the case of patients who
have spent extended periods in the ED may
need to be reassessed and adjusted to meet
the Society of Critical Care Medicine (SCCM)
guidelines.
SEDATION ASSESSMENT
Sedation assessment scales have been devel-
oped and evaluated for use in assessing the
levels of sedation in mechanically ventilated
patients. The Richmond Agitation and Seda-
tion Scale (RASS) is a validated tool originally
designed for the intensive care unit (ICU)
setting. The RASS is used to measure quality
and the depth of sedation in mechanically
ventilated patients (Barr et al., 2013; Ely et al.,
2003; Sessler et al., 2002). The RASS scores
range from −5 to +4. An RASS score of −5
indicates deep sedation and +4 indicates no
sedation (see Table 1). The SCCM recom-
mends light levels of sedation (RASS score
−2 to 0) in mechanically ventilated patients
to improve clinical outcomes, as indicated
by shorter duration on the ventilator and de-
creased length of stay in the ICU (Barr et al.,
2013). Early goal-directed sedation (EGDS)
has yet to be studied in ED patients, but it
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Advanced Emergency Nursing Journal
Table 1. Richmond Agitation Sedation Scale
Target
RASS RASS Description
+4 Combative, violent, 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) for more than 10 s
−2 Light sedation, briefly awakens to
voice (eye opening/contact) for
less than 10 s
−3 Any movement (but no eye
contact) to voice
−4 Deep sedation, no response to
voice, but movement or eye
opening to physical stimulation
−5 Unarousable, no response to voice
or physical stimulation
Note. RASS = Richmond Agitation Sedation Scale. From
“The Richmond Agitation-Sedation Scale: Validity and Re-
liability in Adult Intensive Care Patients,” by C. N. Sessler,
M. Gosnell, M. J. Grap, G. T. Brophy, P. V. O’Neal, . . . R.
K. Elswick, 2002, American Journal of Respiratory and
Critical Care Medicine, 166, p. 1339. Copyright 2002 by
the American Thoracic Society. Adapted with permission.
is likely that ventilated ED patients who are
awaiting transfer to an ICU would also have
improved outcomes. Given the potential for
significant morbidity and mortality associated
with deep sedation, we found it beneficial to
study both the rates of EGDS by physicians
and the implementation of RASS assessment
by nurses in the ED setting.
GOALS
Previous studies have discussed outcomes
related to sedation in the ICU setting (see
Figure 1); however, there are no published
trials to date that evaluate the concept of
EGDS in the ED setting (Shehabi et al., 2012,
2013). It is unclear whether results would be
 April–June 2018 r Vol. 40, No. 2 Evaluation of RASS in Mechanically Ventilated Patients in the ED 133

Figure 1. Early goal-directed sedation; goals and potential benefits. ICU = intensive care unit. From “Goals
of Goal-Directed Sedation,” by Y. Shehabi, 2015, Revista Brasileira de Terapia Intensiva, 27(1), p. 2.
Copyright 2015 by Creative Commons Attribution. Adapted with permission.

similar or improved if EGDS was initiated
while patients were still in the ED. Currently,
our facility has an adult trauma and ICU me-
chanical ventilation sedation protocol that re-
quires an RASS assessment every 4 hr for me-
chanically ventilated patients on continuous
infusion sedation, but no protocol exists in
the ED. The purpose of this investigation was
to assess prescriber goal setting for the RASS,
compliance with this assessment tool, and
achievement of target sedation goals in the
ED. Secondary objectives included the num-
ber of patients initiated on mechanical ventila-
tion, appropriateness of sedation assessment
according to hospital protocols of every 4
hr, and appropriate sedative agent selection
in the ED, based on SCCM guidelines. In ad-
dition, we assessed the time to extubation,
length of hospital stay, and 180-day mortality.
METHODS
This study was an institutional review board-
approved retrospective chart review con-
ducted at a large Level I trauma academic
medical center where more than 90,000 pa-
tients are seen per year in the ED. Patients
were identified via a report that sought In-
ternational Classification of Diseases, Ninth
Revision (ICD-9) codes for endotracheal in-
tubation. Patients who were intubated in the
ED or en route to the ED between October 1,
2013, and October 1, 2014, were eligible for
inclusion if they met the following criteria:
aged 18 years or older, 24 hr or more on me-
chanically ventilated support, administration
of continuous sedation and/or analgesia dur-
ing the first 48 hr of admission, and a hospital
stay of 6 days or more. A hospital stay of 6 days
or more was chosen to identify outcomes as-
sociated with EGDS. Patients were excluded
if had a previous tracheostomy, were admit-
ted for routine uncomplicated postoperative
care (ICU stay of less than 48 hr), were trans-
ferred out within 48 hr of arrival, were be-
ing readmitted within 30 days, had a termi-
nal condition, were missing sedation data for
the second day, were on noninvasive me-
chanical ventilation, were pregnant, or had
an existing neurological injury. Patient data
were collected via a retrospective review of
the electronic medical record and included

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 134 Advanced Emergency Nursing Journal

demographics, clinical and laboratory results,

RASS goal implementation, pharmacological
sedative selection, and RASS scores. Rates of
RASS goal implementation were calculated by
reviewing sedative orders. If an order had an
RASS goal written in the administration in-
structions, it was included. Sedative selection
was deemed to be appropriate if the sedative
was propofol, dexmedetomidine, midazolam,
or lorazepam per SCCM guidelines. Sedation
was deemed inappropriate if the medication
did not follow SCCM guidelines, if the patient
was allergic to the selected agent, or if the pa-
tient had a contraindication to an agent (e.g.,
liver failure). Patients met the hospital pro-
tocol requirement of RASS assessment if the
RASS was assessed within 1 hr of continuous
sedative initiation at the study site. Descrip-
tive statistics were used to evaluate patient
demographics, vital signs, laboratory values, Figure 2. Flow diagram for enrollment in the trial.
medications selected/administered, length of
stay, time to extubation, RASS score assess- (81.1%) had an RASS goal set by an ED physi-
ment, and prescribing physician. cian. Assessment of the RASS score was found
to be inconsistent during the study period,
with 56.8% (n = 21) of the patients meeting
RESULTS
protocol by being evaluated by an ED nurse
Of 205 patients mechanically ventilated in the within 1 hr of sedative initiation. Of the 37
ED during the study period, 104 patients failed patients who had their RASS goal set in the
to meet the inclusion criteria (most hospital- ED, 18.9% (n = 7) achieved their target RASS
ized for less than 6 days), and 101 patients goal while still in the ED.
qualified for enrollment into the study. Sixty- With regard to our secondary objectives
two patients were excluded because of exclu- (see Table 3), appropriate sedation (as per
sion criteria, resulting in the ultimate sample SCCM guidelines) was prescribed in all pa-
of 39 patients (see Figure 2). In the group of tients. In addition, 39% (n = 15) of patients re-
39 patients who were included, there were ceived an appropriate regimen of varied com-
23 male patients and 16 female patients, pre- binations of continuous infusions of propofol,
dominantly Caucasian, with a median age of dexmedetomidine, and midazolam through-
60 years (SD = 14.99), APACHE II median out admission. In the 39 patients, 18% (n =
score of 21 (SD = 6.4), and a median length 7) received propofol + midazolam, 13% (n =
of stay of 13 days (SD = 20.97; see Table 2). 5) propofol + dexmedetomidine, 2% (n = 1)
The three most common diagnoses were res- dexmedetomidine + midazolam throughout
piratory failure (n = 8), altered mental status their hospital stay, and 28% (n = 11) received
(n = 8), and trauma (n = 6; see Table 2). only propofol. Seven patients (18%) expired
Median time to extubation was 129 hr (see within 180 days of admission, whereas six
Table 2). expired while still in the hospital. Although
Data for the primary objectives (see EGDS was not evaluated for all patients be-
Table 3) revealed that of the 39 patients, cause of varied RASS assessments and goal
37 patients (94.9%) had their RASS goal im- achievement, we reviewed EGDS for the pa-
plemented in the ED; of those, 30 patients tients who expired. Four of seven expired

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 April–June 2018 r Vol. 40, No. 2 Evaluation of RASS in Mechanically Ventilated Patients in the ED 135

Table 2. Patient demographics as a patient was placed on ventilation (see

Table 4). In a study by Shebabi et al. (2013),
N 39 researchers evaluated the viability and safety
Age, mean (SD) 60.3 (14.9) of EGDS when compared with the standard
APACHE II score, mean (SD) 22.1 (6.4)
sedation in 37 mechanically ventilated pa-
Race, n
tients. Findings demonstrated that during the
Caucasian 29
African American 6 first 48 hr, 203 of EGDS scores (66%) were in
Asian 1 the light sedation RASS range versus 74 scores
Unknown/other 3 in the standard sedation group (38%, p =
Diagnosis, n 0.01) and 93 (30%) versus 112 (57%, p = 0.02)
Respiratory failure 8 were in the deep sedation range, respectively.
Altered mental status 8 These studies helped highlight the benefits of
Trauma 6 EGDS, which led us to study rates of EGDS by
Cardiac arrest 4 physicians and the implementation of RASS
Sepsis 4 assessment by nurses in the ED setting.
Burn 3
A majority of patients had an RASS goal im-
ST-segment elevation 2
plemented. Providers may include an RASS
myocardial infarction
Pneumonia 2 goal in administration instructions when or-
Intentional overdose 1 dering continuous sedation agents. Providers
Congestive heart failure 1 are assisted when entering continuous seda-
Mean total length of stay (days) 21.2 tion orders, as the order has built-in word-
ing that requires RASS goal recommendations;
however, these orders can be modified by
providers to exclude RASS goal recommen-
patients had EGDS implemented within 1 hr dations. Initial sedative bolus dosing for en-
of sedative initiation. Of the four patients who dotracheal intubation does not require RASS
expired and had EGDS implemented, two had goal recommendation. Alternatively, sedative
an RASS ordered in the ED and met their RASS bolus dosing that is provided to patients once
goal. Two had an RASS assessment ordered a continuous infusion of a sedative is initi-
as an inpatient and met their RASS goal. The ated requires RASS assessment. We found that
three patients who expired and did not have there is an opportunity to increase the fre-
EGDS implemented did not meet their RASS quency of patient assessment when targeting
goal. No patients had allergies or contraindi- an RASS goal by the nursing staff during the
cations to the prescribed sedatives. first hour. It was encouraging that a majority
of the patients were evaluated using the RASS
close to intubation time with a target RASS
DISCUSSION
goal of −2 to 0, as per SCCM guidelines.
Previous studies have discussed outcomes There were limitations found to this study.
related to EGDS in the ICU setting. In a study One challenge was the difficulty in assessing
by Shehabi et al. (2012), the relationship the implications and outcomes of RASS scores
between early sedation and the time to as only one-half of the patients had their RASS
extubation, delirium, and hospital/180-day scores measured while still in the ED. This
mortality was studied in 251 mechanically could possibly be due to sample size. Another
ventilated ICU patients. Clinicians provided limitation was that a power analysis was
RASS goals in only 3,602 (24.9%) of all RASS not performed. An a priori power analysis
assessments, and only 34.7% of the patients would have provided guidance for an initial
met their goals. Strategies for EGDS include sample size. The sample size could have
providing light sedation (RASS score −2 to been increased if the exclusion criteria were
0) that was initiated and assessed as soon modified such as those with neurological

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 136 Advanced Emergency Nursing Journal

Table 3. Primary and secondary objectives

N 39
ED RASS goal implementation, n (%) 37 (94.9)
ED prescriber set RASS goal, n (%) 30 (81.1)
Evaluated by the ED nurse, n (%) 21 (56.8)
Achieved RASS goal in the ED, n (%) 7 (18.9)
Sedation prescribing, n (%) 39 (100)
prop + dex + mid 15 (39)
prop only 11 (28)
prop + mid 7 (18)
prop + dex 5 (13)
dex + mid 1 (2)
prop + dex + prop + prop + dex +
mid prop mid dex mid

Sedation prescribing and diagnosis

Respiratory failure 3 1 2 2 0
Altered mental status 1 2 2 2 1
Trauma 2 2 1 1 0
Cardiac arrest 2 2 0 0 0
Sepsis 2 1 0 0 0
Burn 1 0 2 0 0
ST-segment elevation myocardial 0 2 0 0 0
infarction
Pneumonia 1 1 0 0 0
Intentional overdose 1 0 0 0 0
Congestive heart failure 1 0 0 0 0
Median time to extubation, hr 129

Note. dex = dexmedetomidine; ED = emergency department; mid = midazolam; prop = propofol; RASS = Richmond
Agitation Sedation Scale.

injuries and those readmitted within
30 days. Patients with neurological injury
require weaning from sedation to optimize
neurological assessments. Including these
patients might decrease the frequency of
RASS assessments and altered goal achieve-
ment, as it would have taken longer to meet
goals again as patients were titrated back on
sedation. The documentation process may
also have limitations. Documentation limita-
tions were not studied, but they may have
been influenced by the normal ED workflow.
At the study site, the ED is staffed by ED,
ICU, and other trained nurses, depending on
ED staffing needs. The variation in training
may have affected the RASS assessments. We
were unable to assess the appropriateness
of the sedative regimen in patients with
hypotension, as it was unknown if sedation
was being limited because of concerns for
sedative-induced hypotension. One way to
overcome these limitations would be to rein-
force the use and assessment of the current
trauma and adult ICU protocols. Patients
who are in the ED may undergo critical
procedures, such as central line placements,
reductions, and suturing that may require
deeper levels of sedation. Adjustments of
RASS score are relayed from the provider
to the nurse and currently do not require
reordering of the sedation target goals.
Length of stay in the ED and procedures
could have influenced the achievement of
the target RASS score. Patients were found

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 April–June 2018 r Vol. 40, No. 2 Evaluation of RASS in Mechanically Ventilated Patients in the ED
Table 4. Strategies for early goal-directed
sedation
Coordinated overall care plan for critically ill
patients
Initiation and assessment as soon as the
patient is ventilated, either invasively or
noninvasively
Light sedation
Monitored deep sedation for the shortest
time only if necessary
Facilitate mobilization and early access to
rehabilitation
Monitors pain, agitation, and delirium
Note. From “Goals of Goal-Directed Sedation,” by Y.
Shehabi, 2015, Revista Brasileira de Terapia Intensiva,
27(1), p. 3. Copyright 2015 by Creative Commons Attri-
bution. Adapted with permission.
to be in the ED for a median time of 6 hr
(SD = 3.04) prior to their unit transfer. The
goal is to initiate ED admission medications
once they are ordered; however, it is not a
common practice for nurses to implement
RASS assessments in mechanically ventilated
patients while patients are still in the ED. This
perception could be assessed by surveying
ED nurses to evaluate their familiarity with
the RASS evaluation.
CONCLUSION
Evaluation of RASS assessments in the ED pro-
vided a review of current practice at this in-
stitution. Our study demonstrates that EGDS
was predominately implemented for patients
while in the ED. This highlights the benefit of
sedative order sets requiring RASS goal recom-
mendations. However, the evaluation of these
patients was less common, as only one-half of
the patients were evaluated and only seven
achieved their target goals. As of December 8,
2014, the EPIC electronic health record was
updated to ensure RASS score documentation
at continuous sedation administration time by
nursing. Other updates included target RASS
score added to the Medication Administration
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
137
Record as well as an RASS score and an RASS
goal within the Comprehensive Flow sheet.
These changes allowed for quicker identifica-
tion of provided RASS goals, easier documen-
tation, the and ability to compare the goal
and current score in one location. Future di-
rection for this study may include education,
evaluation of how scores are documented,
and determination of whether there should
be a standardized RASS protocol for mechan-
ically ventilated patients who are sedated in
the ED.
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