Respiratory Intermediate Care Units in the COVID-19 Pandemic

In This Article

Abstract and Introduction

Abstract

Rationale: The SARS-CoV2 pandemic increased exponentially the need for both Intensive (ICU) and Intermediate Care Units (RICU). The latter are of particular importance because they can play a dual role in critical and post-critical care of COVID-19 patients. Here, we describe the setup of 2 new RICUs in our institution to face the SARS-CoV-2 pandemic and discuss the clinical characteristics and outcomes of the patients attended.

Methods: Retrospective analysis of the characteristics and outcomes of COVID-19 patients admitted to 2 new RICUs built specifically in our institution to face the first wave of the SARS-CoV-2 pandemic, from April 1 until May 30, 2020.

Results: During this period, 106 COVID-19 patients were admitted to these 2 RICUs, 65 of them (61%) transferred from an ICU (step-down) and 41 (39%) from the ward or emergency room (step-up). Most of them (72%) were male and mean age was 66 ± 12 years. 31% of them required support with oxygen therapy via high-flow nasal cannula (HFNC) and 14% non-invasive ventilation (NIV). 42 of the 65 patients stepping down (65%) had a previous tracheostomy performed and most of them (74%) were successfully decannulated during their stay in the RICU. Length of stay was 7 [4–11] days. 90-day mortality was 19% being significantly higher in stepping up patients than in those transferred from the ICU (25 vs. 10% respectively; p < 0.001).

Conclusions: RICUs are a valuable hospital resource to respond to the challenges of the SARS-CoV-2 pandemic both to treat deteriorating and recovering COVID-19 patients.

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.

Table 1. Clinical characteristics of the 106 patients with COVID-19 admitted to the RICU
Demographics
Age mean (SD)	66 ± 12
Gender male (%)	76 (72%)
Mean body weight, kg mean (SD)	83 ± 17
Body mass index, kg/m² mean (SD)	29 ± 6
Comorbidity
Systemic arterial hypertension	57 (54%)
Dyslipidemia	30 (28%)
Cardiovascular disease	20 (19%)
Chronic obstructive pulmonary Disease	16(15%)
Diabetes	14 (13%)
Chronic renal failure	14 (13%)
Obstructive sleep apnea	10 (9%)
Cerebrovascular disease	7 (6.6%)
Cancer history	6 (6%)
Organ transplantation	5(5%)
Asthma	3(3%)
Previous treatment
Statins	19(18%)
Angiotensin II receptor blockers	9 (8.4%)
Source of admission to RICU
Intensive care unit (step-down)	65 (61%)
COVID-19 ward (step-up)	27 (26%)
Emergency room (step-up)	14 (13%)

Data is presented as mean (SD) or number of patients (%)

Table 2. Treatments and outcomes
COVID-19 treatment
Hydroxychloroquine	73 (69%)
Systemic corticosteroids	66 (62%)
Azithromycin	60 (57%)
Tocilizumab	51 (48%)
Anakinra	22 (21%)
Siltuximab	5 (5%)
Remdesivir	5 (5%)
Respiratory support in RICU
High flow oxygen nasal cannula	33 (31%)
Non-invasive ventilation	15 (14%)
Days since tracheostomy to decannulation (median [IQR]; n = 31)	25.5 [19–34]
Days since admission to decannulation (median [IQR]; n = 31)	8 [5–12]
NIV duration, days (median [IQR]; n = 14)	4 [1–6.5]
HFNC duration, days (median [IQR]; n = 32)	5 [3–7]
Renal replacement therapy	9 (9%)
Vasopressors	3 (3%)
Destination
Discharge to COVID-19 ward	75 (71%)
Transfer to ICU	17 (16%)
Death	14 (13%)
Outcomes
30-day mortality	15 (14%)
Global mortality at 90 days	20 (19%)
Days since admission to RICU (median [IQR])	13 [4–25.3]
LOS in RICU (median [IQR])	7 [4–11]
LOS (median [IQR])	34 [17–52]
Days since admission to death	27 [12–34]

Data is presented as number of patients (%), median [interquartile range]
LOS length of stay (days)

Table 3. Characteristics of patients by source of admission
	ICU (n = 65)	Non-ICU (n = 41)	p
Age, years, mean	64 ± 11.5	69 ± 13.3	0.048
Body mass index, kg/m², mean (SD)	31 ± 6	27 ± 5	0.002
Comorbidities ≥ 2, n (%)	25 (38.5)	25 (61)	0.029
High flow nasal cannula, n (%)	16 (25)	17 (41)	0.086
Non-invasive ventilation, n (%)	5 (8)	10 (24)	0.022
90-day mortality (%)	16 (25)	4 (10)	< 0.001