SDS-N — Subjective Delirium Screening Scale by Nurse
2020A four-feature nurse-observation screen developed for adult surgical wards. Its weighted score ranges from 0 to 5, with a published threshold of 2 or more; current evidence is development with internal bootstrap assessment rather than external validation.
What this tool is and how to interpret its evidence
Published in 2020, SDS-N is described here as monitoring / repeated screening, screening / case-finding for adults admitted to surgical wards for at least five days. The linked study examined it in General / acute hospital, Perioperative. The recorded form contains 4 scored items or observations. The reported administration time is nurse observation; exact completion time not reported. The catalogue records the published scoring or threshold information as Weighted total ≥2 of 5.
The linked source is Kubota K and colleagues, Development of a Simple and Practical Delirium Screening Tool for Use in Surgical Wards in The journal of nursing research : JNR (2020); this catalogue treats it as development and internal bootstrap evaluation; no independent external validation identified. For SDS-N, the evidence stage is one eligible diagnostic-accuracy study. The reconciled DTA dataset associates 1 eligible study with SDS-N. The first recorded accuracy result reports sensitivity 61% and specificity 96.7%; the recorded sample is 2168. AUC 81.9% in 2,168 retrospective surgical-ward patients; internal bootstrap assessment only.
Recorded limitations include development and internal bootstrap evaluation only; sensitivity was modest; reference classification used routine DST or CAM-ICU. Repeated SDS-N observation may capture fluctuation, but interpretation depends on when and how observations are collected. For SDS-N, no verified public instrument form is recorded; the source article documents the tool but is not a substitute administration form.
Evidence and practical details
- Full name
- Subjective Delirium Screening Scale by Nurse
- Also known as
- SDS-N, Subjective Delirium Screening Scale
- Catalogue class
- Core instrument family
- Record type
- core-family
- Family
- subjective-delirium-screening-scale-by-nurse
- Purpose
- Monitoring / repeated screening, Screening / case-finding
- Population
- Adult
- Setting
- General / acute hospital, Perioperative
- Items
- 4
- Administration
- nurse observation; exact completion time not reported
- Evidence
- One DTA study identified
- Evidence maturity
- derivation-and-internal-validation
- Evidence stage
- diagnostic-accuracy-single-study
- DTA studies identified
- 1
- Current audit status
- provisional DTA identified
- Reference type
- Development and internal bootstrap evaluation; no independent external validation identified
- Reference standard
- Retrospective routine DST or CAM-ICU documentation rather than prospective independent DSM assessment
- Validation sample
- n = 2168
- Cut-off / scoring
- Weighted total ≥2 of 5
- Limitations
- − Development and internal bootstrap evaluation only; sensitivity was modest; reference classification used routine DST or CAM-ICU
- Original/source citation
- Kubota K, Suzuki A, Ohde S, Yamada U, Fujitani I, Koitabashi A Development of a Simple and Practical Delirium Screening Tool for Use in Surgical Wards The journal of nursing research : JNR. 2020;28(3):e90. PMID 32073481
Format and clearly labelled links
A four-feature nurse-observation score: disorientation contributes two points, while restlessness, somnolence and hallucination contribute one each. The total is 0-5 and the development study evaluated a threshold of 2 or more.
Rights, version and permission record
- Instrument access state
- No verified public instrument form
- Instrument host
- No verified instrument host
- Current instrument/version note
- No version verified
- Rights holder
- Not yet verified
- Licence / rights basis
- No licence verified
- Rights checked
- 2026-07-19
- Rights-holder contact
- Not yet verified
Permission scope recorded at the last check
- Clinical use: Not verified; obtain the current authorised instrument and follow its terms.
- Research use: Not verified; check with the developer or rights holder.
- Web republication: Not verified; do not reproduce the form or item wording.
- Translation/adaptation: Not verified; written permission may be required.
- EHR/software integration: Not verified; check before implementation.
- Commercial use: Not verified; check before use.
Site-text licence boundary: the CC BY 4.0 notice for original deliriumtools.com editorial text does not cover third-party instruments, item wording, forms, article text, logos, screenshots or linked material.
Page record and review status
- Page version
- 3.1.0
- Last factual/source check
- 2026-07-19
- Last rights/link check
- 2026-07-19
- Curator and responsible editor
- Professor Alasdair M J MacLullich — Curator factual and source review complete (not an independent external reviewer)
- Independent external clinical review
- Not yet completed. No independent external reviewer, consortium endorsement or institutional endorsement is claimed.
Corrections and rights-holder notices can be submitted through the contribute and corrections page.
* Where shown, sensitivity/specificity are from the cited evaluation and are not pooled estimates. “DTA studies identified” describes the current audit, not a completed systematic-review count. Citation metadata checked against PubMed or a publisher record does not imply validation, study quality, endorsement or suitability for a setting. See Methodology.