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

admissions are admitted during off-hours3 also (ICU) is
Levels of cognitive function are often compromised an area where outcome of patients is affected by
with increasing levels of stress and fatigue, as is often providing the right treatment at the right time4-5; delays
the norm in certain complex, high-intensity fields of in such treatment have been demonstrated to have
work. Aviation, aeronautics, and product negative consequences.
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

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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
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
P- Value = 0.795
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 hospitalists13to 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
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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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