Accuracy and Documentation of Richmond Agitation-Sedation Scale Assessments in a Cardiothoracic Critical Care Unit: A Prospective, Cross-Sectional Audit.

backgroundSedation is a fundamental component of critical care and requires regular, accurate assessment to support its safe titration and minimise harm. International guidelines and local policy at the Wythenshawe Hospital's Cardiothoracic Critical Care Unit mandate hourly documentation of the Richmond Agitation-Sedation Scale (RASS).

aimsThis audit evaluated adherence to these standards and explored factors associated with documentation completeness and assessment accuracy. STUDY

designA prospective, cross-sectional audit of bedside RASS assessment was conducted without prior notification. Nursing RASS scores were compared with expert auditor ratings. Data were collected using an anonymous, secure, auditor-completed online survey. Statistical analysis examined the relationship between documentation completion and RASS accuracy.

resultsSeventy-six nursing assessments were included. Most nurses were Band 5, with a median of 3.5 years of experience. Patients were predominantly male, mechanically ventilated and receiving sedation. Overall, 75% of nurse RASS assessments (n = 57) were accurate; however, only 33% (n = 25) were documented hourly as required by policy. Greater nursing experience was associated with improved accuracy in RASS. Deeper sedation was associated with lower agreement between nurse and expert assessments. Higher self-reported confidence was associated with poorer completion of documentation. Most discrepancies were small, with nurse and expert ratings differing by one RASS point.

conclusionsThis audit identified important gaps in the accuracy and documentation of nurse-led RASS assessment in a cardiothoracic critical care setting. The findings suggest that perceived familiarity and confidence may not be sufficient to ensure accurate and consistently documented sedation assessment. RELEVANCE TO CLINICAL PRACTICE: Suboptimal RASS documentation and scoring accuracy may limit reliable titration of sedation in critically ill patients and reduce the effectiveness of protocolised sedation strategies. These findings support targeted staff education, reinforcement of standardised assessment processes and improvements in documentation systems to strengthen sedation monitoring and patient safety.