Intermediate care unit helped surgical, COVID-19 patients

Background

To keep up with a growing volume of surgery patients, clinicians at BIDMC wanted to both create a space for patients with intermediate care needs after surgery and free up ICU beds. Then the pandemic hit, and as at many hospitals across the country, the latter need became more pressing.

"When the COVID-19 pandemic set in and the dire consequences around ICU capacity arose, the pre-existing idea for the intermediate care unit was adapted to expand into medical patients," not just surgery patients, said Emmett Kistler, MD, MHQS, a fellow at BIDMC at the time and now a pulmonary and critical care specialist at Mount Auburn Hospital in Cambridge, Mass.

In August 2021, an interprofessional team put this idea into action, adapting an existing 16-bed medical ward and opening an intermediate care unit for medical and surgical patients.

How it works

An interdisciplinary working group of surgeons, hospitalists, ICU doctors, nurses, and respiratory therapists created admission criteria for the unit based on the institution's needs and patient safety. The initial maximum census was three patients.

The medical patients on the unit were seen by hospitalists, while surgical patients were cared for by their surgeons. The nurses had been trained in intermediate medical-surgical care, and there was a lower nurse-to-patient ratio than on a regular medical ward, although sometimes nurses saw patients on both wards.

The first group of patients admitted to the unit required frequent monitoring and labs, but after several months, criteria expanded "to eventually include patients who had been on a stable amount of high-flow nasal cannula and noninvasive respiratory ventilation," said Dr. Kistler. The broadened criteria and growing demand for care led the census to rise to a maximum of six.

Results

A total of 230 patients were admitted to the unit during its pilot period, freeing up 1,023 ICU bed-days. Of those admitted, 141 were medical and 89 were surgical patients. The average daily census was 2.8, according to a study of the unit published by Critical Care Explorations in October 2023.

"The way we approached [calculating the primary outcome] was that if the intermediate care unit did not exist at our institution, the patients who were admitted to the intermediate care unit otherwise would have been admitted to the intensive care unit," explained Dr. Kistler.

Most patients (74%) were transferred to the general ward following a stay on the intermediate care unit. Within 48 hours of admission to the unit, 8% of patients were transferred to the ICU, 2% were intubated, and 1% died.

Patients admitted to the unit for respiratory support had the highest risk of adverse events, specifically those requiring high-flow nasal cannula or noninvasive positive-pressure ventilation. This included some patients with COVID-19, and it was difficult to determine whether the adverse events would have taken place regardless, "recognizing that [for] conditions like COVID-19 and pneumonia, there's going to be a certain percentage of patients that progress despite the optimal level of care," Dr. Kistler said.

Notably, having the intermediate care unit situated within the general ward allowed for easier de-escalations of care for some patients, he and his colleagues reported.

Challenges

One key challenge was adapting a general ward to provide intermediate care. For example, intermediate care rooms required specific oxygen hookups and suctioning, and the assigned staff had to be trained to care for these patients.

Another issue was the difficulty finding appropriate dispositions after intermediate care; three patients stayed in the unit for more than 50 days, accounting for nearly one-third of all ICU bed-days saved.

Next steps

The intermediate care unit at BIDMC has evolved to meet the institution's needs, explained Dr. Kistler. As the pandemic waned, "the census actually collapsed [because] there was less of a demand for ICU beds and more of a demand for general ward telemetry beds," he said. However, if there were to be another COVID-19 surge, the hospital would be prepared to put the ward back to use for intermediate care, Dr. Kistler said.

In his current role at Mount Auburn, he serves as medical director of the stepdown unit, which is evaluating criteria for intermediate care admission.

"I've been able to borrow and learn a lot from what we did at Beth Israel as we're trying to improve our own stepdown unit," said Dr. Kistler.

Going forward, multicenter retrospective studies are needed to identify which patients benefit most from intermediate care, as are analyses of adverse events and cost-effectiveness, he said.

Lessons learned

Creating an intermediate care unit requires an institutional leader who can serve as a sponsor of the project, along with an interdisciplinary group of leaders, advised Dr. Kistler.

Establishing admission criteria is key, as these determine not only the educational needs for physicians, nurses, and respiratory therapists, but also the actual physical space requirements, along with supplies and materials needed, he said.

Words of wisdom

As with any change, positive outcomes may not be immediate. "Expect this to be a gradual, long-term process," said Dr. Kistler, who recommended that unit leaders start with "realistic expectations and a specific subset of patients for whom there's the highest chance of safe, effective care."