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Application Of The Review Of System (ROS)

Protocol In The ICU And Its Effect On Patient

Outcome and Length and Cost Of Stay

Principal investigator

Abdul Hamid Alraiyes, M.D.

Co-investigators

Manju Pillai, M.D.

Samer Alhindi, M.D.

Khalid Alokla, M.D.

Mentor

Joseph Sopko M.D., F.C.C.P

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Application Of The Review Of System (ROS) Protocol In The ICU And

Its Effect On Patient Outcome and Length And Cost Of Stay

Abdul Hamid Alraiyes M.D., Manju Pillai M.D., Samer Alhindi M.D., Khalid Alokla M.D., Joseph Sopko MD, FCCP

ABSTRACT PURPOSE

The purpose of this study is to assess the impact of daily round checklist using Review of System (ROS) protocol in

an open ICU system on patient‟s outcome plus length and cost of stay.

METHODS

Over 4 months 81 patients with APACHE II (Acute Phase and Chronic Health Evaluation II) score ≥ 20 were

admitted to ICU and randomly distributed to three on-call groups per call schedule; the (ROS) protocol was applied

on one ICU team while the other two teams didn‟t use the (ROS); the three groups studied looking at APACHE II

score at 24 hrs and 48 hrs, cost of the stay in the ICU and length of stay (LOS) in the ICU. Data collected were

analyzed using ANOVA analysis in order to compare the differences between the 3 groups in the APACHE II score

at 24 vs. 48 hrs, the ICU cost and length of stay. RESULTS

Admissions to ICU with APACHE II score ≥ 20 were randomly distributed to the three groups of residents per the

call schedule and the (ROS) protocol was used by one ICU team. By using the APPACHE II score as an indicator

for clinical improvement and patient illness prognosis (outcome), the change of this score in 24 and 48 hours was

statistically significant with P-value 0.005 comparing to other residents teams that didn‟t utilize the ROS protocol.

ANOVA analysis didn‟t show a statistically significant reduction neither in cost nor length of stay.

CONCLUSION

ROS checklist is a useful tool that improves outcome and reduce human errors in many industrial carriers such as

aviation. We showed that Review of System (ROS) protocol is a tool that can organize orders on admission and

daily round in open ICU system and improve sick patients‟ outcome. This protocol may shorten the stay in the ICU

and lower the cost of stay.

Keywords: Review of systems. ICU. Outcome. Length of stay. Cost of stay.

INTRODUCTION

Levels of cognitive function are often compromised

with increasing levels of stress and fatigue, as is often

the norm in certain complex, high-intensity fields of

work. Aviation, aeronautics, and product

manufacturing have come to rely heavily on checklists

to aid in reducing human error. Despite demonstrated

benefits of checklists in medicine and critical care, the

integration of checklists into practice has not been as

rapid and widespread as with other fields1. Many

studies compared the application of checklists in high-

intensity fields such as aviation proves the

improvement in quality and efficiency2.

The checklist is an important tool in error management

across all these fields, contributing significantly to

reductions in the risk of costly mistakes and improving

overall outcomes.

Such benefits also translate to improving the delivery

of patient care. And since Studies have demonstrated

that 66% to 69% of intensive care unit (ICU)

admissions are admitted during off-hours3 also (ICU) is

an area where outcome of patients is affected by

providing the right treatment at the right time4-5

; delays

in such treatment have been demonstrated to have

negative consequences.

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Two out of six interventions from the 100,000 Lives

Campaign which applied by the institute of healthcare

improvement are Prevention of Central Line Infections

and Ventilator-Associated Pneumonia which proved to

save 100K lives6 .

Review Of Systems (ROS) protocol (figure1) “see the

attached protocol” is simply a check list used on

admission and daily ICU rounds that adapted the

principles from above tools which applied in open ICU

system with no 24/7 in-house intensivist coverage7.

(Figure 1)

(ROS) used by the ICU call team in an open ICU

system8-9

where the patient care is handled by primary

care physician and multiple subspecialty teams with

different daily orders and plans using (ROS) is

important to keep ICU team with subspecialty teams on

one page which is the case in closed ICU system10,11

.

METHODS AND MATERIALS

Over 4 months ICU rotations 81 patients with inclusion

criteria of (1) diagnosis of shock on admission “either

cardiac or septic” (2) APACHE II (Acute Phase and

Chronic Health Evaluation II) score ≥ 20 (3) stayed in

ICU for more than 72 hours were admitted to ICU and

randomly distributed to three on-call groups per

monthly call schedule; the (ROS) protocol was applied

on one ICU team‟s patient were the other two teams

didn‟t use the (ROS) protocol; the three groups were

compared based on APACHE II score at 24 hrs and 48

hrs, cost and length of stay (LOS) in the ICU. Our

hypothesis is to find a difference in the mean of the

above collected data between the (ROS) group of

patients and the other 2 groups.

Data collected were analyzed using multi-way

ANOVA analysis in order to compare the difference

between the 3 groups in the APACHE II score at 24 vs.

48 hrs, the ICU cost and length of stay. Box plot

graphics done for each variable and P value calculated.

Patients‟ age and APACHE II score on admission were

equal in the (ROS) group and control groups (table 1).

RESULTS

Admissions to ICU were randomly distributed to the

three groups of residents per call schedule and the

(ROS) protocol was applied to one ICU team

admissions with APACHE II score ≥ 15. The three

group‟s patient outcome measured by improvement of

APACHE II score plus length and cost of stay were

compared using multi-way ANOVA analysis.

Outcome of the patients was compared between the

(ROS) group and other groups by assessing the

difference in the APACHE II at the 24 hr and 48 hr and

showed a statistically significant result with P-value

<0.005 mean reduction in APACHE II score at the

(ROS) group comparing with the other 2 groups.

ANOVA analysis showed a reduction in the ICU length

of stay for the (ROS) group comparing with the other

groups but it was not statistically significant. Although

there was a significant reduction in the mean cost,

statistically there was no significant reduction in the

ICU cost in the (ROS) group (Figure-2)

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(Figure 2)

P- Value < 0.05 P- Value = 0.189 P- Value = 0.795

DISCUSSION

Checklists have been recently promulgated as a method

to enhance patient safety and improve outcomes for the

critically ill patients especially in open11

ICU system.

Open ICU system run by multiple care givers providing

the care with multiple plans, orders and procedures

which put the patient at risk because of lack of

communication between different teams. This system

has the tendency to increases the load of work on the

front line caregivers such as nurses and residents12

.

Recent evidence suggests that having continuous on-

site 24/7 coverage by qualified intensivists7 helps in

ensuring consistency of care which is not the case in

many intensive care units due to the shortage of

intensivist. The lack of this coverage put the hospitals

under pressure of using hospitalists for ICU coverage

in non-teaching hospitals and might increase the work

hours for residents in teaching hospitals. A checklist

“such as (ROS) protocol” will be a great tool for us as

residents or future hospitalists13

to use when we are

doing intensive care rotations.

Intensive care is one of the toughest careers that

demands high levels of cognitive function and stress

tolerance. Without proper communication between the

patient‟s care givers and without the systematic review

of the patient problems, more improper repeated orders

and procedures may delay the diagnosis which will

extend the patient stay in the ICU and eventually

affects outcome. We believe that applying a checklist

in our ICU as residents will improve the outcome in

patient care.

While preparing this ROS checklist, we made sure to

discuss it with residents, internal medicine staff,

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subspecialty staff, nurses and respiratory therapists

before utilizing it in our ICU. This approach was made

to cover all significant points that affect patient

outcome, plan of care and above all coordination

between all teams.

After applying the (ROS) protocol randomly on a

group of patient with APACHE II score of ≥ 20 and

comparing with control groups, a statistically

significant improvement in patient outcome translated

as improvement in APACHE II score noticed with less

influence on the cost and length of stay.

We did not expect that (ROS) protocol is going to

improve the cost since more tests will be ordered

secondary to full review of all systems. At the same

time we found improvement in the ICU length of stay

that wasn‟t statistically significant because of the lack

of 24/7 intensivist in our ICU7 which delay patient‟s

transfer to regular nursing floor until daily morning

round done by the primary care physician14

who will

make the transfer decision.

CONCLUSION

Review Of System (ROS) Protocol is a tool that can

organize orders on admission and daily round in ICU

especially in open ICU system that prove to improve

sick patients outcome “patients with APACHE II ≥20”

and might help shorten the stay in the ICU and lower

the cost of stay.

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