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AGNOLETTI V, RUSSO E, CIRCELLI A, BENNI M, BOLONDI G, MARTINO C, SANTONASTASO DP, BROGI E, PRATICÒ B, COCCOLINI F, FUGAZZOLA P, ANSALONI L, GAMBERINI E. From intensive care to step-down units: Managing patients throughput in response to COVID-19. Int J Qual Health Care 2021; 33:mzaa091. [PMID: 32780867 PMCID: PMC7454682 DOI: 10.1093/intqhc/mzaa091] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/15/2020] [Accepted: 08/03/2020] [Indexed: 11/19/2022] Open
Abstract
QUALITY PROBLEM OR ISSUE The on-going COVID-19 pandemic may cause the collapse of healthcare systems because of unprecedented hospitalization rates. INITIAL ASSESSMENT A total of 8.2 individuals per 1000 inhabitants have been diagnosed with COVID-19 in our province. The hospital predisposed 110 beds for COVID-19 patients: on the day of the local peak, 90% of them were occupied and intensive care unit (ICU) faced unprecedented admission rates, fearing system collapse. CHOICE OF SOLUTION Instead of increasing the number of ICU beds, the creation of a step-down unit (SDU) close to the ICU was preferred: the aim was to safely improve the transfer of patients and to relieve ICU from the risk of overload. IMPLEMENTATION A nine-bed SDU was created next to the ICU, led by intensivists and ICU nurses, with adequate personal protective equipment, monitoring systems and ventilators for respiratory support when needed. A second six-bed SDU was also created. EVALUATION Patients were clinically comparable to those of most reports from Western Countries now available in the literature. ICU never needed supernumerary beds, no patient died in the SDU, and there was no waiting time for ICU admission of critical patients. SDU has been affordable from human resources, safety and economic points of view. LESSONS LEARNED COVID-19 is like an enduring mass casualty incident. Solutions tailored on local epidemiology and available resources should be implemented to preserve the efficiency and adaptability of our institutions and provide the adequate sanitary response.
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Affiliation(s)
- Vanni AGNOLETTI
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Emanuele RUSSO
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Alessandro CIRCELLI
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Marco BENNI
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Giuliano BOLONDI
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Costanza MARTINO
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Domenico P SANTONASTASO
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Etrusca BROGI
- Department of Anesthesia and Intensive Care, University of Pisa, Via Piero Trivella, 56124, Pisa, Italy
| | - Beniamino PRATICÒ
- Department of Internal Medicine, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Federico COCCOLINI
- Department of Surgery, University of Pisa, Via Piero Trivella, 56124, Pisa, Italy, and
| | - Paola FUGAZZOLA
- General, Emergency and Trauma Department, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Luca ANSALONI
- General, Emergency and Trauma Department, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
| | - Emiliano GAMBERINI
- Department of Anesthesia and Intensive Care, M Bufalini Hospital, Viale Ghirotti 285, 47521, Cesena, Italy
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Mitra AR, Griesdale DEG, Haljan G, O'Donoghue A, Stevens JP. How the high acuity unit changes mortality in the intensive care unit: a retrospective before-and-after study. Can J Anaesth 2020; 67:1507-1514. [PMID: 32748188 DOI: 10.1007/s12630-020-01775-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE High acuity units (HAU) are hospital units that provide patients with more acute care and closer monitoring than a general hospital ward but are not as resource intensive as an intensive care unit (ICU). Nevertheless, the impact of opening a HAU on ICU patient outcomes remains poorly defined. We investigated how the creation of a HAU impacted patient outcomes in the ICU. METHODS This historical cohort study compared ICU patient in-hospital mortality, ICU length of stay (LOS), and hospital LOS before and after the creation of a HAU in a tertiary-care hospital with a medical/surgical ICU between 1 January 2013 and 31 December 2017. RESULTS Data from 4,380 patients (984 in the pre-HAU group and 3,396 in the post-HAU group) were analyzed. In this cohort of ICU patients, 360 (37%) died in the pre-HAU group before the creation of a HAU, and 1,074 (32%) died in the post-HAU group after the creation of a HAU. The creation of a HAU was associated with lower relative risk of in-hospital mortality (adjusted risk ratio, 0.80; 95% confidence interval [CI], 0.72 to 0.89; P < 0.001). The creation of a HAU was also associated with reduced ICU and hospital LOS with a 12% increase in the rate of ICU discharge (adjusted sub-distribution hazard ratio [SHR], 1.12; 95% CI, 1.02 to 1.23; P = 0.02) and a 26% increase in the rate of hospital discharge (adjusted SHR, 1.26; 95% CI, 1.14 to 1.39; P < 0.001), when accounting for the competing risk of death. CONCLUSIONS These data support the hypothesis that the creation of a HAU may be associated with reduced in-hospital mortality, ICU LOS, and hospital LOS for ICU patients.
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Affiliation(s)
- Anish R Mitra
- Division of Critical Care Medicine, Department of Medicine, Surrey Memorial Hospital, Surrey, BC, Canada.
- Department of Medicine and Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada.
- Intensive Care Unit - Surrey Memorial Hospital, 13750, 96th Ave, Surrey, BC, V3V 1Z2, Canada.
| | - Donald E G Griesdale
- Department of Medicine and Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Gregory Haljan
- Division of Critical Care Medicine, Department of Medicine, Surrey Memorial Hospital, Surrey, BC, Canada
- Department of Medicine and Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ashley O'Donoghue
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Laws L, Lee F, Kumar A, Dhar R. Admitting Low-Risk Patients With Intracerebral Hemorrhage to a Neurological Step-Down Unit Is Safe, Results in Shorter Length of Stay, and Reduces Intensive Care Utilization: A Retrospective Controlled Cohort Study. Neurohospitalist 2020; 10:272-276. [PMID: 32983345 DOI: 10.1177/1941874420926760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Purpose Patients suffering intracerebral hemorrhage (ICH) are at risk for early neurologic deterioration and are often admitted to intensive care units (ICU) for observation. There is limited data on the safety of admitting low-risk patients with ICH to a non-ICU setting. We hypothesized that admitting such patients to a neurologic step-down unit (SDU) is safe and less resource-intensive. Methods We performed a retrospective analysis of patients with primary ICH admitted to our SDU. We compared this cohort to a control group of ICH patients admitted to a neurologic-ICU (NICU) at a partner institution. We analyzed patients with supratentorial ICH ≤15 cc, Glasgow Coma Scale ≥ 13, National Institutes of Health Stroke Scale ≤ 10, and no to minimal intraventricular hemorrhage. Primary end points were (re-)admission to an NICU and rates of hematoma expansion (HE). We also compared total NICU days and hospital length of stay (LOS). Results Eighty patients with ICH were admitted to the SDU. Only 2 required transfer to the NICU for complications related to ICH, including 1 for HE. Seventy-four SDU patients met inclusion criteria and were compared to 58 patients admitted to an NICU. There was no difference in rates of NICU (re-)admission (7 vs 2, P = .17) or rates of HE (3 vs 5, P = .28). Median NICU days were 0 versus 1 (P < .001). Step-down unit admission was associated with shorter LOS (3 vs 4 days, P = .05). Conclusions Select patients with ICH can be safely admitted to an SDU. This may reduce LOS and ICU utilization. We also propose criteria for admitting patients with ICH to an SDU.
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Affiliation(s)
- Lindsay Laws
- Department of Neurology, Washington University in St. Louis, MO, USA
| | - Flavia Lee
- Department of Neurology, St. Louis University, MO, USA
| | - Abhay Kumar
- Department of Neurology, St. Louis University, MO, USA
| | - Rajat Dhar
- Department of Neurology, Washington University in St. Louis, MO, USA
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Vantomme K, Siddiqui M, Cossette M, Lyster K. Medical surveillance unit: patient characteristics, outcome, and quality of care in Saskatchewan, Canada. BMC Res Notes 2020; 13:87. [PMID: 32085764 PMCID: PMC7035728 DOI: 10.1186/s13104-020-04951-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Intermediate care units provide a high level of care to complex patients and are becoming increasingly popular in North America. Despite the growing popularity of Intermediate care units, very little is known about them. This study explored a typical Intermediate care unit, identifying patient characteristics including demographics, comorbidities, length of stay, as well as primary and secondary diagnosis and mortality. RESULTS A total of 200 patients chart were reviewed, of which, 102 were male, and 89 patients were younger than 65 years old. Diabetes, hypertension, and chronic obstructive pulmonary disease were common among patients with a prevalence of 33.5%, 56%, and 32.5%, respectively. Alcohol use disorder, asthma, liver disease and IV drug abuse were much more common in patients younger than 65 years. The average length of stay was 5.31 days regardless of age. Almost two-thirds of the patients in the Intermediate care unit were admitted directly from the emergency room. The mortality rate among the patients studied was 9.5%. The most common admitting diagnosis was respiratory diseases such as chronic obstructive pulmonary disease or Pneumonia (38.0%), followed by cardiac disorders which were predominantly arrhythmias and congestive heart failure (27.0%).
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Affiliation(s)
- Karl Vantomme
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Muhammad Siddiqui
- Department of Research, Saskatchewan Health Authority, Regina, SK, Canada.
| | - Marlee Cossette
- Medical Surveillance Unit, Pasqua Hospital, Saskatchewan Health Authority, Regina, SK, Canada
| | - Kish Lyster
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.,Medical Surveillance Unit, Pasqua Hospital, Saskatchewan Health Authority, Regina, SK, Canada
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