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SDS-N — Subjective Delirium Screening Scale by Nurse

2020

A 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.

Monitoring / repeated screeningScreening / case-findingOne DTA study identifiedCore instrument family

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

61%
Sensitivity*
96.7%
Specificity*
n=2168
Sample
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.