VCU news

By Jeff Kelley

Serendipity. A deliberate approach. And more than two decades since its creation, a meme.

It’s the story of the Richmond Agitation Sedation Scale — the RASS. Used primarily by intensive-care unit clinicians and researchers, but with the same idea as the patient-friendly Wong-Baker “FACES” pain scale, the RASS has been trusted worldwide for 21 years to describe an ICU patient’s level of alertness and agitation.

“We wanted to understand the consciousness of our ICU patients for a research project, and we looked at what was available in terms of existing scales and decided that none of them were really what we were looking for,” said Curtis N. Sessler, M.D., the Orhan Muren Distinguished Professor in the Department of Internal Medicine at the Virginia Commonwealth University School of Medicine. “So we created our own. It’s not only an assessment tool for the patient, but a communication tool for the providers. Instead of saying, ‘The patient is kind of waking up, but he can’t really talk,’ you simply say, ‘His RASS is -2,’ and everyone is clear on what that means.”

The 10-value scale guides sedation therapy, titration and improves communication among providers. On the scale, “0” is “Alert and Calm” (if you’re reading this, you’re a 0), while “+4” means the patient is combative, violent, and an immediate danger to staff. On the opposite end, “-5” means the patient is unarousable.

Sessler estimates the scale is used millions of times a year, mostly referenced for mechanically ventilated patients in order to avoid over- or under-sedating. Excessive sedation, for example, can delay a patient’s recovery, while under-sedation may leave a person in discomfort.

For his and his team’s work to create the scale, made available in 2002, Sessler was named the 2023 Billy R. Martin VCU Innovator of the Year. The honor was announced by P. Srirama Rao, Ph.D., vice president for research and innovation, at a Richmond ceremony on Nov. 3.

Found by chance, created with collaboration

Sessler said he stumbled on the idea of the scale by serendipity — the market didn’t have an ideal scale, so they made one. But, he said, it was important to be deliberate and collaborate with other ICU providers to ensure whatever they made would be of value for a range of users and be sustainable.

“One of the more important things I've observed over my career is getting different people to look at things from different perspectives,” he said. “It was important that not only doctors participate in creating this scale, but nurses, pharmacists and everybody who works in the care of the patient.” 

Key collaborators included Mary Jo Grap, Ph.D., now retired from the School of Nursing, and Gretchen M. Brophy, Pharm.D., from the School of Pharmacy.

Ivelina Metcheva, Ph.D., assistant vice‌ president ‌for‌ ‌innovation‌ at VCU TechTransfer and Ventures, said Sessler is an excellent example of how VCU staffers who don’t consider themselves researchers can still invent real-world applicable products.

“Dr. Sessler shows that research and innovation at VCU doesn’t mean it has to take place in a laboratory — it just takes intuition and an understanding of your market or your specialty,” said Metcheva, whose office bestows the Innovator of the Year award. “Practicing physicians are hands-on, know their world well, and can develop new ideas to address unmet needs in clinical care.”

The RASS was born out of the VCU School of Medicine, which accounts for almost half of VCU’s sponsored research awards and the majority of its National Institutes of Health funding. Universitywide, sponsored research totaled nearly $465 million in fiscal year 2023.

“Doctors aren’t just healers, they can be innovators too, and who best to find better ways of delivering care than the people on the front line,” said Arturo P. Saavedra, M.D., Ph.D., dean of the VCU School of Medicine. “Dr. Sessler is one of many physicians and health care leaders who are upholding one of the School of Medicine’s strategic priorities to improve health through collaborative science, and I congratulate him on the honor.”

Sessler, who also serves as associate chair for faculty development, said the recognition as Innovator of the Year is “extremely humbling, because of the rich history that VCU has in innovation. There is some marvelous work that has been done here, some really extraordinary inventions — so I truly feel very humbled being part of this group.”

For those with an idea, he said, it’s important to pull a team together, test the idea’s practicality, and rigorously test it in different settings and — in the case of a medical innovation — patient populations. “I think about the first days of putting this scale together. We didn’t have an inkling that this would become a world standard,” he recalled. “It really was a lot of serendipity.”

Copyrighting, commercializing … and a meme

In 2012, ten years after the scale’s development, Sessler worked with VCU TechTransfer and Ventures to copyright the RASS. The protection allows the scale’s free use by health systems, clinicians and researchers (it is easily found online). Meanwhile, pharmaceutical companies must license the scale in clinical trials that are comparing sedative medications.

RASS is used widely around the world — and Sessler is surprised at where it has wound up. ICU nurses have created badge reels, buttons and T-shirts with the phrase, “Calm Your RASS Down!” for sale on sites such as Amazon and Etsy. “ICU nurses have a great sense of humor,” he said. “I’ve enjoyed hearing from people around the world with their interest in RASS, and their clever ideas to incorporate it into their research and patient care. It’s rewarding.”

Even more so, he said, is the satisfaction of knowing the scale a VCU team created helps sick ICU patients become a bit more comfortable and recover faster.

Sessler’s advice to others who have a potential innovation to explore: “Build a good team to look at the idea from all angles, make it practical and easy to use, and rigorously test it in different populations to confirm it measures what you intend it to.”

He has a patent on another product related to airways, and isn’t ruling out someday inventing something else. Up first though? Spoiling grandkids in retirement, which begins on Jan. 1.