The Delirium Triage Screen (DTS) is an ultra-brief (<20 seconds) rule out delirium assessment that is designed for busy clinical environments such as the emergency department. A negative DTS rules out delirium, but a positive DTS requires a more specific assessment to rule delirium in. Read more about the DTS.
The Delirium Triage Screen (DTS) was developed to rapidly rule-out delirium and reduce the need for formal delirium assessments. It takes less than 20 seconds to perform and consists of two components:
- Level of consciousness as measured by the Richmond Agitation Sedation Scale (RASS).
- Inattention by spelling the word “LUNCH” backwards.
If the patient has a RASS of 0 (normal level of consciousness) or makes 0 or 1 errors on “LUNCH” backwards spelling test, then the DTS is considered negative. Because the DTS is 98% sensitive, delirium is ruled out in this case and no additional delirium testing is needed. If the patient has a RASS other than 0 (altered level of consciousness) or makes >1 error on the “LUNCH” backwards spelling test, then the DTS is considered positive. Because the DTS is 55% specific, confirmatory testing is needed using the bCAM or CAM to rule in delirium.
Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, Graves AJ, Storrow AB, Shuster J, Ely EW. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013; 62(5):457-465.