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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.

At a glance

Purpose
Episodic assessment
Population
Adult
Setting
General / acute hospital, Perioperative
Time
nurse observation; exact completion time not reported
Items
4
Score or threshold
Weighted total ≥2 of 5

Format: 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.

  • Limitations: Development and internal bootstrap evaluation only; sensitivity was modest; reference classification used routine DST or CAM-ICU

Primary validation papers

1 identified diagnostic-accuracy paper

Other forms of validation are described in the evidence section. What is counted?

Large-scale clinical implementation

Not yet reviewed.

A focused implementation review has not yet been completed for this profile.

Training and instructions

Public training resources have not yet been confirmed in this review. Check the linked developer or original source for instructions.

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Tool and original sources

This record describes a method rather than a downloadable bedside form. The main source is linked below.

Original paper

  • Principal sourceKubota 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. doi: 10.1097/jnr.0000000000000366. PMID: 32073481.

    This is the principal published source for SDS-N itself. It is the main source for the method, its intended use and the evidence available at publication.

    Open PubMed ↗
One DTA study identifiedCore instrument family
Classification

Classification

Episodic assessmentMonitoring for new onset delirium

A tool may belong to more than one category. Select a linked category to see other relevant profiles.

Evidence

Diagnostic-accuracy evidenceOne DTA study identified

Reported sensitivity and specificity

61%
Sensitivity
96.7%
Specificity

AUC 81.9% in 2,168 retrospective surgical-ward patients; internal bootstrap assessment only.

More evidence and citation details
Full name
Subjective Delirium Screening Scale by Nurse
Also known as
SDS-N, Subjective Delirium Screening Scale
Evidence summary
derivation-and-internal-validation
Diagnostic-accuracy evaluations
1
Reference standard
Retrospective routine DST or CAM-ICU documentation rather than prospective independent DSM assessment
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
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Primary validation studies

Distinct primary publications from the current diagnostic-accuracy audit. Reviews and repeated evaluations within one paper are not counted again. Overlapping cohorts have not all been reconciled. Read the counting rules and limitations.

Open 1 identified paper
  1. Kubota K, Suzuki A, Ohde S, Yamada U, Fujitani I, Koitabashi A (2020). Development of a Simple and Practical Delirium Screening Tool for Use in Surgical Wards. The journal of nursing research : JNR.

    Reference category: other comparator or secondary accuracy evidence.

Copyright and reuse
Information checked
2026-07-19

Instrument-specific terms apply. See the access and copyright policy or send a correction.

Base clinical review: 2026-07-29. Instrument description source check: 2026-09-05. Scope and limitations.