Introduction
The outbreak of a novel coronavirus SARS-CoV2 causing COVID-19 (coronavirus disease 2019) has led to an unprecedented international health crisis. On March 11
th, the World Health Organization (WHO) declared a global pandemic due to the rapid increase in the number of cases outside China. Since then, healthcare response to the COVID-19 pandemic has been a major concern for public health services and nations around the world [
1].
The high transmissibility of the SARS-CoV-2 [
2] and the fact that 5–15% of all infected patients will develop severe COVID-19 disease rapidly filled up the available Intensive Care Unit (ICU) beds [
3] and led to contingency plans to increase their number by using other ICU beds, such as those normally dedicated to post-operative support (with a parallel reduction in surgical activity) and even to the conditioning of the operating rooms themselves to provide critical care to severe COVID-19. In this scenario, Respiratory Intermediate Care Units (RICU) played an important double role. First, by facilitating the step-down of ICU patients (hence reducing their length of stay in ICU which, in turn, facilitated the care of new critically ill patients), many of them with tracheostomy and ICU-associated myopathy that require expert care including rehabilitation [
4‐
6]. Second, by providing high-flow oxygen therapy via nasal cannula (HFNC) or non-invasive ventilation (NIV) in less severe patients (who may eventually require ICU care too (step-up)) or in those who may not be candidates for mechanical ventilation due to concomitant conditions [
7].
Here, we: (1) describe the setup of 2 new RICUs in our institution to face the SARS-CoV-2 pandemic; and, (2) discuss the clinical characteristics and outcomes of the patients attended there.
Methods
Organizational RICU aspects
To respond to the increased health-care demands caused by the first wave of the SARS-CoV-2 pandemic, our institution built/transform several new ICU and RICUs. We describe here the logistics and organization of two of them, who were designed, lead and managed by members of the Pulmonary Division of Hospital Clinic (Barcelona, Spain).
We analyzed retrospectively the characteristics and outcomes of patients with moderate/severe COVID-19 admitted to these two RICUs from April 1 until May 30, 2020 because: (1) severe respiratory failure with high oxygen requirements (FiO2 > 40%); (2) need of ventilatory support with NIV or HFNC (PaO2 < 60 mmHg, respiratory rate (RR) > 30 bpm, chest incoordination, respiratory acidosis and/or hypercapnia); (3) septic shock; (4) transferred from ICU; and/or (5) not candidates for admission to ICU (do not resuscitate order). In these patients, we analyzed their anthropometric data, comorbidities, previous treatments, treatment received for COVID-19, length of stay (LOS) and mortality.
Ethics
The study was approved by our Institutional Review Board (Comité Ètic d´Investigació Clínica – Hospital Clinic de Barcelona. HCB/2021/0425).
Statistical analysis
Results are expressed as mean ± standard deviation (SD) for quantitative variables that followed a normal distribution, and as median and IQR otherwise. Qualitative variables are expressed as total number and percentage. Fisher exact test was used to compare qualitative variables. Student T-Test or Mann–Whitney U test, as appropriate, were used to compare quantitative variables. Kaplan Meier curves for 90 days mortality was compared by the log-rank test. A two-sided p value lower than 0.05 was considered statistically significant. Analyses were done using SPSS (version 22.0; SPSS Inc, Chicago, Illinois, USA).
Discussion
This study details the setting and operation of two RICUs created
ex-novo to care for COVID-19 patients. Operational results show that RICUs are a viable alternative to increase ICU bed availability maintaining high-quality care. This setting can contribute to a faster recovery process providing specifically dedicated physiotherapy and improving patient care by having a higher doctor-patient/nurse-patient ratio than available in a conventional ward while being a less expensive asset in comparison with the ICU [
11]. The postcritical COVID-19 patient has a variety of active medical problems becoming a highly demanding patient in terms of specific care. Therefore, RICU provides multidisciplinary care that shortens ICU stay and could potentially shorten overall LOS.
RICUs are a valuable asset for either large or smaller hospitals, providing flexibility and a suitable environment of care for many types of patients and clinical situations. However, RICU is still not implemented in many hospitals, COVID-19 pandemic has highlighted the importance of these units in avoiding hospital collapse. Patients with COVID-19 presents with acute severe respiratory failure requiring ventilatory support and continuous monitoring. Given the immediate saturation of ICU beds that occurred during the first pandemic wave, it was critical and urgent to create units that could cope with large numbers of patients, either requiring high care needs or coming from overloaded ICUs.
During the study period, a 2.5-fold increase in the number of RICU beds was achieved in Spain. In a survey conducted by Caballero et al., 41 centres confirmed that at least one RICU was available, with an overall significant increase in the number of RICU beds from 112 to 525. Regarding staff, 95% of these units had at least 1 specialist in pulmonology either involved o directly in charge [
11‐
13].
In our institution, in a short period of time, we achieved a 6.5-fold increase in the number of RICU beds. This milestone was achieved with the involvement of pulmonologists and other professionals with expertise in respiratory medicine. This background provided solid clinical training in the assessment and treatment of respiratory failure, airway management and the management of respiratory support. However, the key to success is in our view, was teamwork and a multidisciplinary approach involving specialized nurses in respiratory care and respiratory therapists in a highly focused environment to guarantee proper functioning and performance. In addition to having the necessary medical equipment and diagnostic tools [
14].
Most of the patients admitted to our RICU came from ICU (61%) and 40% of all (42/106) had a previous tracheostomy performed. Thus, the main role of a RICU during a pandemic was to relieve the high ICU load to allow the high demanding bed’s rate and turn over required under that scenario. The second but not the less is to achieve this target without increasing the risk of related complications because of an early discharge from ICU. RICU as we have described fulfills this function as is shown in terms of 30 and 90-day mortality. Moreover, our purpose during RICU stay was to decannulate all the patients as a mandatory requirement previous the ward discharge to avoid the high risk of cannula complications in a non-monitored ward. The role of respiratory therapists was essential to successfully manage the decannulation process in a short period of time since patients were admitted to our RICU (median 8 [5–12] days). In addition to all the above, the RICUs created were essential to support the 32 wards fully dedicated to caring for COVID patients, both for those worsening in the wards.
In our study, the overall 90-day mortality rate was 18.5%, in contrast with previous publications with slightly higher mortality reported in a different clinical setting, were the majority of patients were included in a step-up setting [
15,
16].
We observed that patients transferred from non-ICU departments were older, had more comorbidities, had a lower BMI and had a statistically and clinically relevant higher mortality. This data is likely attributable to the fact that many of the admissions had standing DNR orders. Thus, HFNC and or NIV were considered in some of these cases the maximum level of respiratory support.
In absence of such limitations, we were very active in avoiding delay in intubation or admission to the ICU and the start of invasive mechanical ventilation in those patients who met the criteria for admission to the ICU.
The present study is descriptive and uncontrolled because of the difficulty of comparing our results with other units and historical data in this unprecedented pandemic situation.
In conclusion, the results of this study show that RICUs are valuable in this health care crisis and have a relevant role in terms of acute respiratory patient management. The success of this type of units should be taken into account when considering organizational changes that can prepare the healthcare system for the current ongoing pandemic and future challenges.
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