Role of Respiratory Intermediate Care Units During the SARS-CoV-2 Pandemic

Mónica Matute-Villacís; Jorge Moisés; Cristina Embid; Judith Armas; Isabel Fárnandez; Montserrat Medina; Miquel Ferrer; Oriol Sibila; Joan Ramón Badia


BMC Pulm Med. 2021;21(228) 

In This Article


Organizational Aspects

Under normal operational conditions, our institution (Hospital Clínic Barcelona) has 850 conventional ward beds and 44 ICU beds of different medical and surgical specialties. During the first wave of SARS-CoV-2 pandemic, the hospital had to re-engineer additional spaces to care for COVID-19 patients. Our Pulmonary Department was asked to transform 2 conventional wards into 2 RICUs (named here A and B) exclusively devoted to the treatment of critically ill COVID-19 patients: unit A had 16 beds and unit B 10 beds. The functional organization of both RICUs sought to minimize the risk of virus spreading among staff (Figure 1). All rooms were for individual use, had a private bathroom and a glass door for external visual control. All were equipped with oxygen and air supply, a video system with centralized continuous (non-invasive and invasive if needed) monitoring, but not with negative pressure. Electrocardiogram recording system (KARDIA), a portable ultrasound (General Electric and Phillips). NIV, HFNC and Cardiopulmonary Resuscitation (CPR) equipment's were available in both units.

Figure 1.

Functional organizational of Unit A. For further explanations, see text

The sanitary personnel of needed in each unit was calculated following local[8] and international recommendations.[9] Briefly, the tiered staffing distribution aimed at: (1) achieving a patient/physician ratio of 4/1, and a patient/nurse ratio of 4/1; and, (2) guaranteeing that each unit has, at least, one highly trained critical care physician and one critical care nurse who directly supervise the rest of staff (who may or may be not trained in RICU care previously). As shown in Figure 2, we assigned to Unit A (16 beds) 2 pulmonologists with critical care expertise, 2 pulmonology residents, 2 nurses with critical care expertise, 2 nurses with previous experience in other areas and 2 respiratory physio-therapists, while in Unit B (10 beds) we assigned 1 pulmonologist with critical care expertise, 4 physicians from other specialties (e.g. nephrology, traumatology, neurology), 1 nurse with critical care expertise, 2 nurses experienced in other clinical areas and 1 respiratory physio-therapist. A pulmonologist was on site in each Unit overnight.

Figure 2.

Organizational pyramid of staff in the two RICUs. Modified from the Ontario Health Plan for an Influenza Pandemic Workgroup. For further explanations, see text

Clinical Performance

Patient Characteristics. During the study period, a total of 2,238 patients were admitted to our Hospital with COVID-19 infection confirmed by Real-Time Polymerase Chain Reaction (RT-PCR) for SARS-CoV-2,[10] among whom, 475 patients (21.2%) required ICU admission.

Table 1 presents the main clinical characteristics of the 106 patients admitted to one of the two RICU investigated here. Mean age was 66 ± 12 years, most of them (72%) were males with a mean body mass index (BMI) of 29 kg/m2. The most prevalent comorbidity was systemic arterial hypertension (54%). The majority of patients (61%) admitted to the 2 RICUs analyzed here were discharged from a hospital ICU (step-down); the rest came from either a hospital ward (26%) or directly from the emergency room (13%). Twenty-eight patients (26%) were admitted with a Do Not Resuscitation (DNR) standing order.

Table 2 details the type of treatment received while in the RICU. Medical treatment followed the recommendations at that time which, unfortunately, were not based on evidence. Thirty-three patients (31%) required HFNC, 15 (14%) NIV and 11 (10%) both (HFNC and NIV). NIV was indicated in patients who deteriorated despite HFNC (as indicated by the presence of severe arterial hypoxemia (PaO2 < 60 mmHg despite elevated FiO2 concentrations (> 80%—60 lpm)), Respiratory Rate (RR) > 30/min, chest incoordination, respiratory acidosis and/or hypercapnia while on HFNC), or who were not candidates for ICU admission due to DNR. The median duration of HFNC and NIV was 5 days [IQR 3–7] and 4 [IQR 1–6.5], respectively. Forty two of the 106 patients (40%) had a tracheostomy when admitted and most of them were decannulated (74%) during their stay in the RICU with a median time from admission to decannulation of 8 [5–12] days.

Table 3 compares the clinical characteristics of patients by source of admission (ICU or non-ICU (ward and ER). The latter were older, had a lower BMI and more comorbidities and required more often HFNC, although NIV was used more frequently in patients admitted from an ICU.

Outcomes. The length of stay (LOS) was 34 days and the LOS in the RICU was 7 days. Table 2. The majority of admitted patients (71%) were discharged from RICU to a COVID-19 Ward, 16% of them were transferred to an ICU and, unfortunately, 14 patients (13%) died during their RICU stay. 3 patients were transferred to the ICU due to the requirement of orotracheal intubation[2] or reconnection to mechanical ventilation through a tracheostomy tube.[1] The mean time since admission to RICU until death was 27 days [12–34 days]. Two deceased patients came from ICU (step-down) and 12 came from the emergency room (ER) or COVID-19 wards (step-up). Most of the 14 deceased patients (50%) had an indication for DNR. We had no readmissions in our RICUs.

Patients were followed up for at least 90 days. Mortality at 30 days was 14% (n = 15). Mortality at 90-days was 19% (n = 20) and, as illustrated in Figure 3, it was higher in patients transferred from ward or ER compared to patients transferred from the ICU (25% vs. 10%, p < 0.001).

Figure 3.

Kaplan Meier 90-day mortality curves in patients admitted to the RICU from an ICU or non-ICU (ward, ER) settings. For further explanations, see text