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and Cost Of Stay
Abdul Hamid Alraiyes, M.D.
Manju Pillai, M.D. Samer Alhindi, M.D. Khalid Alokla, M.D.
Joseph Sopko M.D., F.C.C.P
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
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.
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.
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.
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 highintensity 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.
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.
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. (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 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) 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.
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 onsite 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 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,
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 REFERENCES
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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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