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

Disclosures

BMC Pulm Med. 2021;21(228) 

In This Article

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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