Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity

Emmett A Kistler; Elaine Klatt; Jesse D Raffa; Phyllis West; Jacqueline A Fitzgerald; Jennifer Barsamian; Scott Rollins; Charlotte M Clements; Shelby Hickox Murray; Michael N Cocchi; Julius Yang; Margaret M Hayes

doi:10.1097/CCE.0000000000000994

Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity

Crit Care Explor. 2023 Oct 18;5(10):e0994. doi: 10.1097/CCE.0000000000000994. eCollection 2023 Oct.

Authors

Affiliations

¹ Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
² Fellowship in Patient Safety and Quality, Harvard Medical School, Boston, MA.
³ Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA.
⁴ Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, MA.
⁵ Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
⁶ Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA.
⁷ Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

Abstract

Objectives: ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity.

Design: Descriptive report with retrospective cohort review.

Setting: Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds.

Patients: Adult inpatients who were admitted to the IMC.

Interventions: An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies.

Measurements and main results: The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers.

Conclusions: Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.

Keywords: critical care; intensive care unit capacity; intermediate care; respiratory failure.