Where: Clínica Universidad de Navarra, an academic medical center in Pamplona, Spain.
The issue: Balancing patients' need for complex care with the limited resources of the general ward and the limited space of the intensive care unit (ICU).
“The patients admitted to the [medical] center were increasingly complex and some of them should receive more intensive care and monitoring,” said hospitalist Juan Felipe Lucena, MD. “They were low-risk patients for ICU admission but with significant potential for major complications.”
To provide the appropriate level of care for these patients, the hospital opened a nine-bed intermediate care unit (ImCU) adjacent to the ICU. The ImCU was not a new invention, but the Spanish team put an unusual spin on the concept by having the unit staffed entirely by hospitalists.
How it works
“The unit's work is based on a multidisciplinary co-management model. We think this is the novel concept of our ImCU,” said Dr. Lucena. Patients are admitted to the ImCU by an attending hospitalist, but he or she is joined on rounds by the hospital pharmacist, a nurse, the ImCU resident, and any relevant specialist.
Patients are admitted to the ImCU based on intermediate care criteria established by the Society of Critical Care Medicine. Their most common admission diagnoses, according to a study of the ImCU published online in January by the Journal of Hospital Medicine, were respiratory failure (33.6%), sepsis (19.3%), cardiovascular problems (15.8%) and perioperative care (12.9%).
Each bed on the unit has central monitoring of telemetry, pulse oximetry, arterial blood pressure and central venous pressure, as well as noninvasive pressure support ventilation. The nurse-to-patient ratio is 1:3.
The Spanish team reported on the effects of their new unit in the JHM article. Mortality among the 456 patients treated and studied on the unit was 20.6%, while the expected mortality rate for these patients (based on the Simplified Acute Physiology Score II) was 23.2% (P<0.001), the study found.
“Although it is very difficult to evaluate the results on mortality in a retrospective study, we think the encouraging results were in part due to the continuous assistance of hospitalists through different levels of care from the general ward to the ImCU,” Dr. Lucena said.
The continuity also pleased patients' families, he added. “They receive comprehensive information of the patient's global situation.”
Nurses, who could bring any problems or questions to the attending hospitalist, and specialists, who could focus more on the specialty-specific care, were other beneficiaries of the new system.
Although most of the work in the ImCU was well-suited to hospitalists (“They are the best specialists for the triage as well as for the follow-up of these patients,” said Dr. Lucena), they did lack intensivists' expertise in a few tasks, such as some procedures.
The ImCU hospitalists also had the occasional conflict with their critical care colleagues about the allocation of patients. “Although the ImCU could reduce costs and improves ICU utilization for sicker patients and also potentially decreases ICU readmissions, problems were derived from the overlap with the ICU team in the triage of some acutely ill patients,” Dr. Lucena said.
Further research is needed to support these assumptions about the cost-effectiveness of ImCU care, Dr. Lucena said, since his group did not look at that question and existing evidence is limited. The research team also called for larger, prospective trials to confirm the improvement in outcomes they found.
“It is important to remember that the data were based on prognostic scores, and these scores could also have important limitations predicting mortality,” said Dr. Lucena.
How others benefit
The data did reveal some unexpected advantages to the hospitalist ImCU. Significantly more patients were co-managed by medical and surgical teams at the end of the four-year study than they were at the start (34.9% in 2006-2008 vs. 65.1% in 2008-2010). In addition, the rotation of residents through the unit increased the number of residents being instructed by hospitalists.
“The significant increase in the perioperative co-management model with different surgical teams and also the increase in the number of training residents rotating in the ImCU were wonderful and unexpected results,” said Dr. Lucena. “The creation of an ImCU can serve as an expansion of role for hospitalists, and also many clinicians, trainees and patients may benefit from this unique level of care.”