ABSTRACT
Rationale: Significant capacity constraints brought on by the COVID-19 pandemic have underscored the need for novel staffing models that offload ICUs while still providing appropriate standard of care for high acuity patients. Intermediate Care Units (IMCs) provide one such outlet that have not been extensively examined, particularly during the COVID-19 era. Here we describe a quality improvement project focused on the creation of a mixed IMC with critical care support at our institution during the COVID-19 pandemic. Methods: With the support of institutional leadership, an interprofessional working group spanning critical care, surgery, hospital medicine, nursing, and respiratory therapy was convened to establish the staffing model, determine inclusion/exclusion criteria, and track IMC progress. The initial model entailed a medical-surgical service unit staffed by intermediate care-trained nurses, primary teams comprised of hospitalists or surgical teams, and an intensivist who rounded daily. All medical patients received an automatic critical care support consult;all surgical patients had the option of this consult. The maximum census was three. A retrospective chart review was conducted at the end of the initial phase to evaluate process, outcome, and balancing measures. Data were reported using simple descriptive statistics. Results: From August 9th to October 15th 2021, 36 patients - 21 medical and 15 surgical - were admitted to the IMC. The average age was 62.4, 17 (47.2%) were female, and 11 (30.5%) were admitted for COVID-19. The most frequent indications were hypoxemia (15, 71.4%) for medical patients and post-operative monitoring (12, 80%) for surgical patients. The average length of stay was 2.5 days. Most patients stepped down from an ICU or PACU rather than stepping up from a general ward or emergency department. A total of 577 ICU bed-hours were made available by admitting patients to the IMC who would have otherwise occupied an ICU bed. Seven medical patients (33.3%) required transfer back to an ICU and one medical patient (4.8%) transitioned to hospice. The remaining 13 (61.1%) medical and 14 (93.3%) surgical patients were discharged to a general ward. One patient was intubated within 48 hours of triage to the IMC, and zero patients expired while admitted to the IMC.Conclusions: Creation of an IMC provided a means to care for high acuity patients while creating ICU capacity. Subsequent phases will expand on inclusion criteria and maximum census while assessing the effect of critical care support consults on patient safety and hospitalist and intensivist workloads.
ABSTRACT
INTRODUCTION: Beth Israel Lahey Health (BILH) formed in March 2019 incorporating 2 legacy systems and 3 independent hospitals. In March 2020, during the surge of COVID-19 in MA, BILH formed a Critical Care Group (CCG) to assist patient load balancing and equipment leveling across all 12 hospitals. METHODS: CCG members included ICU leaders from 3 tertiary hospitals and the BILH Chief Medical Officer. The team huddled twice daily, and developed ICU bed and ventilator surge plans, and pathways for balancing across the network. Requests for transfers from referring hospitals were redirected to BILH hospitals with capacity. CCG made strategic decisions to transfer patients within BILH so that no single hospital became overwhelmed. CCG invited 3 Safety Net Hospitals (SNHs) to the huddles;each SNH was in a COVID ?hotspot,? and the CCG accommodated their transfers. RESULTS: The CCG enabled BILH to flex to 238% of the system's baseline 224 licensed ICU beds. At peak, BILH's tertiary hospital ICUs had an occupancy at 157% of baseline, with 73% of ICU patients on ventilators. From 3/1-6/30, one of the tertiary BILH hospitals accepted 81 SNH ICU transfers;support for SNHs was critical for the overall State response to the surge. Unexpected benefits of the CCG included providing a platform for communication and knowledge sharing;discussions included standardization for tracheostomy procedures, management of ECMO resources, avoidance of pitfalls using anesthesia machines as ventilators, and protocols for proning. As a new system, these strengthened relationships between legacy hospital systems. In addition, MA developed a similar CCG, with the aim of the state's largest hospitals having awareness of how other hospitals' ICUs were managing the surge. CONCLUSIONS: CCG was essential to the BILH system as it facilitated a real-time adaptive response to the surge. Key elements included: 1) Creating a team of senior Critical Care leadership, all of whom were closely in tune with their respective ICU's current status and needs 2) CCG relied on a dashboard that provided daily data on ICU capacity at each hospital, allowing for real-time decision-making 3) Early planning prior to the influx of patients;the CCG formed when the COVID critical care census system-wide was 5, relative to a census of 190 at peak surge.