The Delirium Triage Screen (DTS) was designed to be the optional first step of a two-step delirium monitoring process for very busy clinical environments such as the emergency department. The DTS is a 10 to 20 second assessment designed to rapidly rule-out delirium and can reduce the number of formal delirium assessments needed by 50%. It consists of two components: (1) a measure of level of consciousness and (2) a brief measure of inattention.

The DTS is 98% sensitive and 55% specific for delirium as diagnosed by a psychiatrist and can be performed by physicians and non-physicians such as nurses, paramedics, or patient care technicians (Han et al. Ann Emerg Med. 2013). Its diagnostic performance appears to be similar in older patients who are admitted to the hospital. Given its high sensitivity, the DTS is an excellent delirium rule-out screen; if negative, no additional delirium assessment is needed. If the DTS is positive, however, a more specific or confirmatory assessment is needed to rule-in delirium. Some examples of confirmatory delirium assessments are the CAM or its offsprings (CAM-ICU, bCAM, 3D-CAM) or the 4AT.

The DTS is currently part of the Geriatric Emergency Medicine Guidelines released in October 2013.

For additional details on how to perform the DTS and practice videos, see the links below:

DTS Flowsheet


DTS Training Manual


DTS Patient Demonstration

How to Perform the DTS Video

DTS Practice Videos

Feel free to download DTS Flowsheet and print it prior to watching the DTS practice videos.

DTS Calculator