Loading...
Printed on 7/20/2026
For informational purposes only. This is not medical advice.
The Delirium Triage Screen (DTS) is a rapid first-pass delirium screen intended for high-throughput care settings. It is commonly used as an initial triage step before a more specific confirmatory instrument such as bCAM or CAM.
Formula: DTS output is binary: positive or negative screen.
Save your results with a free account
Keep a history of calculations, favorite tools, and access your dashboard anytime.
First evaluate the patient's level of arousal using the Richmond Agitation-Sedation Scale (RASS). If the RASS score is −4 (deep sedation) or −5 (unarousable), delirium cannot be assessed and DTS is not applicable. Document as 'unable to assess' and reassess when arousal improves.
Step 1: Ask the patient to say their own name. Step 2: Ask the patient to recite the days of the week backward. Both tasks test attention — the core domain disrupted in delirium. The entire assessment takes under 20 seconds.
If the patient successfully completes both tasks, DTS is negative and delirium is unlikely — no further delirium workup needed in that screening cycle. If the patient fails either task, DTS is positive. Proceed immediately to a confirmatory instrument such as bCAM or CAM-ICU to determine whether delirium is present.
Emergency nurses and triage staff
DTS enables all-patient delirium screening in busy emergency departments where time pressure prevents use of longer instruments. Positive screens are immediately referred for bCAM confirmation.
Admitting nurses and medical registrars
With 98% sensitivity, DTS functions as a reliable first-pass filter on acute medical wards. Any patient who fails either task is immediately flagged for confirmatory CAM or bCAM assessment.
Hospital delirium programme coordinators
DTS is designed as Stage 1 in the validated DTS + bCAM two-step protocol, balancing high-volume sensitivity with efficient resource use by reserving longer confirmatory tools for positive screens only.
On-call nurses and overnight medical teams
DTS requires no specialised training and can be reliably administered by any clinical staff, making it valuable when specialist delirium assessment teams are unavailable.
Post-anaesthetic care nurses and surgical ward teams
Post-operative delirium is common and under-detected. DTS allows rapid repeated monitoring every few hours in the post-operative period, catching early delirium onset before full assessment is needed.
A positive DTS result means delirium is possible; it does not confirm delirium. Always follow with bCAM or CAM to confirm diagnosis. A negative DTS makes delirium unlikely but does not rule out subsyndromal delirium.
Attempting DTS on an unarousable patient (RASS −4 or −5) is meaningless. Make RASS assessment the mandatory first step. If RASS is −3 (deep sedation with response to voice), assessment may still be unreliable; use judgment.
The days-of-week-backward task is particularly sensitive for attentional deficits — the core cognitive deficit in delirium. Patients with mild dementia but no acute delirium can usually complete this task. Failure suggests active delirium superimposed on baseline.
To achieve universal screening, embed DTS into the routine nursing assessment documentation — same frequency as vital signs checks. Standardised prompts in the electronic health record help maintain compliance.
Delirium is fluctuating by nature. A negative DTS at one time point does not preclude delirium developing hours later. Re-screen at minimum every shift change and after any acute clinical event.
When DTS cannot be completed (RASS ≤ −4, severe aphasia, complete unresponsiveness), document 'unable to assess — reason' rather than a negative result. This prevents misleading documentation and ensures appropriate follow-up when the patient's status changes.
Hypoactive delirium is often missed by clinical impression but not by DTS — inattention is present in both hyperactive and hypoactive subtypes. The days-backward task catches even quiet, withdrawn patients who fail due to attentional impairment.
DTS is intentionally designed with near-maximal sensitivity to minimise missed delirium cases. False positives (DTS positive but bCAM negative) are expected and acceptable; they simply trigger a brief confirmatory assessment, not treatment.
DTS has validation evidence as part of two-step delirium detection pathways in acute care.
A positive DTS suggests possible delirium and indicates need for confirmatory assessment and management pathway.
Use when rapid delirium triage is needed in emergency or acute-care intake workflows.
As a triage screen, DTS is not definitive and should be paired with a higher-specificity follow-up tool.
Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.
April 21, 2026 · v1.0.0
Added DTS calculator entry with evidence note, source links, and trust metadata fields.
A rapid positive/negative delirium screen adapted from CAM logic for acute-care workflows.
OpenGeriatricsScreen for delirium using the CAM (Confusion Assessment Method). Gold standard with ~94% sensitivity and ~89% specificity. Requires acute onset + inattention, plus disorganized thinking or altered consciousness.
OpenGeriatricsRapid delirium screening tool scored 0-12; scores of 4 or more suggest possible delirium.
OpenGeriatricsA 2-item ultra-brief delirium screen where any failed item suggests possible delirium.
Open