Inter-rater Reliability of the Ramsay Sedation Scale for Critically-ill Intubated Patients

Introduction: Titratable palliative sedation (TPS) is frequently applied in sedative therapeutics to ameliorate unendurable and refractory distress via reduction in patient consciousness. TPS may be adjusted based on objective and subjective data: vitals, labs, Ramsay Sedation Scale (RSS), and Richmond Agitation-Sedation Scale (RASS). Inappropriate dosing, including over-sedation from variability in clinician assessment of sedation scales, can contribute to significant negative clinical outcomes. We evaluated inter-rater reliability (IRR) and its relationship to variations in dosing to determine whether additional training in sedation scale assessment is necessary at our community institution. Methods: This was a prospective study assessing sedation in intensive care unit (ICU) mechanically ventilated patients without neurogenic abnormalities. Non-nursing healthcare personnel conducted independent sedation assessments using the RSS and compared their evaluations to those documented by the nursing staff. Data obtained from the patients' chart included: demographics, Ramsay Score, past medical history, diagnosis, and body mass index (BMI). Post-analysis, non-nursing healthcare personnel scores were classified into three categories: equal to, higher than, or lower than those charted by nursing staff. Results: There were 83 random RSS assessments conducted in 44 patients with a mean age of 63.6 +/10.09 years (range: 38-82) and a mean BMI of 31.2 +/12.4 (range: 15-77). 19/42 (45%) patients had a diagnosis of respiratory failure or pneumonia. Other diagnoses included congestive heart failure (3), seizures (5), aortic valve replacement (1), small bowel obstruction (1), drug overdose (2), cardiac arrest (2), and urinary tract infection (1), ST-elevated myocardial infarction (2), pulmonary embolism (2), coronary artery bypass graft (1), sepsis (1), hemoptysis (1), altered mental status (1). Non-nursing healthcare professionals' assessments were compared to nurses' and observed to be equal in 29%, higher in 59%, and lower in 12% of the cases. Of the 83 assessments, the average RSS score non-nursing healthcare professionals assigned was 4.8 +/1.6 while the nurses' charted average was3.39 +/- 0.97; a mean difference of 1.45, 95% CI (1.04 - 1.85)p< 0.0001. Conclusions: Our data demonstrated equal RSS ratings in only 29% of cases for non-nursing healthcare personnel and nurses’ evaluations. Without proper education, the RSS may not be a reliable tool for sedation assessments and may result in over-sedation of critically ill patients. Recurrent nursing education is warranted to ensure proper use and optimization of the RSS.