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Intermediate care units (IMCUs) have become increasingly important in the care of critical and semi-critical patients, particularly during the COVID-19 pandemic. However, there is still no clear definition of their structural characteristics, specialties, types of patients, and the benefits they provide. The aim of this work is to describe the current state of implementation and operation of IMCUs in hospitals and patient care. To achieve this goal, a systematic review was conducted in the Web of Science, Scopus and CINAHL databases, along with a hand search. The research yielded 419 documents, of which 26 were included in this review after applying inclusion and exclusion criteria. The results were highly diverse and were categorized based on the following topics: material resources, human resources, continuity of care, and patient benefits. Despite the different objectives outlined in the studies, all of them demonstrate the numerous benefits provided by an IMCU, along with the increased relevance of this type of unit in recent years. Therefore, this systematic review highlights the benefits of IMCUs in the care of critical patients, as well as the role of health workers in these units.
Keywords:
intermediate care units, benefits, intermediate care facilities, effectiveness, intensive medicine, patient comfort
The COVID-19 pandemic has adversely affected the functioning of the health system [1]. Intermediate care units (IMCUs) have emerged as a crucial resource in the wake of the COVID-19 pandemic and are a fundamental resource [2]. They provide continuous care to critically ill patients who require constant monitoring of their vital signs and/or frequent nursing interventions [3], ensuring high-quality treatment. An additional benefit of its implementation was the limited availability of intensive care unit (ICU) beds, leading to premature discharge and consequent negative effects on the patient, such as increased mortality rates, re-admissions, and prolonged hospitalization [4].
Generally, hospitals offer two types of care: inpatient units and ICU [3]. However, certain patients have clinical characteristics that require a higher level of care than standard inpatient units, but do not necessitate ICU care [5]. These patients are considered semi-critical and are potential candidates for IMCU beds. As a result, the American College of Critical Care Medicine (ACCCM) has established clinical guidelines and admission criteria that are widely accepted in such units. However, these recommendations must be adapted to the specific needs and environment of each hospital, allowing for some flexibility [3,6]. In accordance with these guidelines, IMCUs should be overseen by a physician with experience in intensive care medicine [6]. According to ACCCM admission criteria for an IMCU, patients must have stable cardiovascular conditions (such as uncomplicated AMI, ACS, arrhythmias, and pacemaker implantation) and respiratory conditions (including failure and ventilated patients) to ensure comprehensive care for a wide range of cases covering cardiac, respiratory, and neurological areas [7].
Additionally, specific criteria exist for determining which patients are transferred to an IMCU [3,6], including those recovering from ICU care, patients from the ward or emergency room experiencing poor outcomes requiring a high level of nursing care, or seriously ill patients. Difficult cases that require non-invasive techniques will receive attention, and patients requiring adjustments in fluid therapy will be seen as well.
However, while considering an official perspective, there is a still a need for clear definition regarding the structural attributes, specialties, and patient categories of IMCUs. Nevertheless, different scientific societies have proposed various models for IMCUs, which vary based on the proposer: parallel model and stand-alone model. Another model that combine both units is the integration model. For example, the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) recommends including an IMCU either within an ICU or as an independent IMCU [7]. Intensive care and intermediate care patients are treated together to increase workforce flexibility in terms of nurse-to-patient ratio and to allow for adaptable treatment adjustments to meet patient requirements. Transfers between units are possible. Furthermore, duplicating monitoring equipment in both the ICU and IMCU may be unnecessary, resulting in significant cost reductions [8,9]. In a parallel model, the ICU and IMCU are situated in distinct regions while remaining adjacent to each other and having equal access to resources. Units following this model will enjoy greater flexibility with nursing staff exchanges and a continuous presence of an intensivist physician. In case of patient transfer between units, information loss will be minimal, guaranteeing outstanding treatment and care continuity. Additionally, the ICU personnel will receive immediate assistance from other ICU staff in the event of medical emergencies [8,9]. Last, a stand-alone IMCU is an autonomous unit in terms of space, organization, and personnel. This model is a suitable solution when there are structural constraints in the ICU. Moreover, it can serve as a treatment unit for hospitals without an ICU if it does not replace the existing ICU. However, this model may impact the continuity of care (transfer of patients), necessitate a complete set of its own resources and staff, and significantly reduce staff flexibility [8,9].
It can be stated that IMCUs are hospital areas provided with sufficient human and material resources to ensure monitoring and care at a level lower than that of ICUs, but much higher than that of conventional hospitalization areas [10]. Restructuring of critical and semi-critical care units can be efficient if it minimizes costs, reduces the consumption of time and resources, without compromising the quality of care for critical and semi-critical patients [11]. Interest in IMCUs has increased in both Europe and the United States. A systematic review has highlighted the positive effects of IMCUs on health systems, including reduced waiting times, improved synchronization of different medical resources, and flexible patient flow [12]. However, it also highlights the challenge of identifying this area of expertise as there is no shared understanding of this type of unit [12].
Given the limited understanding of the global perspective of IMCUs, this work aims to primarily describe the current state of implementation and operation of IMCU both to a hospital and to patient care. Additionally, this study seeks to identify the material and human resources available in an ICU, define the patient profile that can benefit from this intermediate care unit, and analyze the role played by ICUs during the COVID-19 pandemic.
A systematic review of the literature was conducted. This review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology [13]. A protocol was registered with the Open Software Foundation (OSF) (https://osf.io/y2veq/, accessed on 27 December 2023, registration id: osf.io/y2veq/).
The SPIDER tool (Sample, Phenomenon of Interest, Design, Evaluation, and Research strategy) [14] was used to guide the information search process in formulating the following research question. What is the current situation of implementation and operation of Intermediate Care Units (IMCUs) in the global healthcare context, and how does this affect the availability of material and human resources? ( ).
A search of the Web of Science, Scopus, and CINAHL databases was carried out during October–November 2023. Additionally, relevant articles in Intensive and Critical Care Medicine and Nursing were selected with a hand search of major journals, and gray literature was also searched.
To focus the search for information, the following Health Sciences (DeCS) and Medical Subject Headings (MeSH) terms were used: “intermediate care units”, “benefits”, “intermediate care facilities”, “effectiveness”, “intensive medicine”, and “patient comfort”. At the same time, to narrow down the search further, Boolean AND was used.
In each of the databases, several combinations of the above descriptors were made using the Boolean operator AND until the most appropriate combination for the objectives of this study was obtained. The following search equations were used to retrieve the studies: “Intermediate care units” AND benefits, “intermediate care units” AND “intermediate care facilities”, “Intermediate care units” AND “intensive medicine”, “intermediate care units” AND effectiveness, and “intermediate care units” AND “patient comfort”.
All retrieved studies were imported into the Mendeley Desktop bibliographic manager, with duplicate studies being removed. The article selection process was conducted using the following inclusion criteria: articles in English or Spanish and articles with the keyword “intermediate care units” in the title.
Additionally, we excluded articles that were systematic reviews, studies with a pathology-specific focus, and those that referred to the intermediate care unit as an extension unit for chronic patients or home care, rather than as a center for semi-critical patients. No studies were excluded based on their date of publication as this is a topic that has been underexplored, which offers a broader perspective on the relevant subject matter. The studies underwent independent screening by two reviewers, PLJ and MCMF. Any conflicts were resolved through discussion.
A total of 419 articles were retrieved through the search. The process for selecting articles is outlined in , showing the PRISMA diagram. Finally, the systematic review included a total of 19 studies, of which 4 were identified through handsearching.
Open in a separate windowWhen considering the country of origin of the included studies, it is noteworthy that the majority, 36.4%, were published in Spain. Following Spain, the distribution was as follows: U.S.A. (15.4%), Belgium, Italy, Netherlands, and Germany (7.7%, respectively), and Canada, China, Colombia, Brazil, and Turkey (with 3.8%, respectively). This could be attributed to the characteristics of the Spanish healthcare system and the specific interest in investigating the potential of an IMCU. After conducting a comprehensive analysis of the articles, we employed a thematic approach to evaluate the data in reference to the aims and outcomes outlined in . Our analysis yielded significant insights related to four primary elements: material resources, human resources, continuity of care, and patient benefits.
Material resources
IMCUs are viewed as a substitute to traditional hospitalization, allowing for an expansion in the number of beds allocated for critically ill patients [3,29]. It is generally suggested that the number of beds in a unit should not surpass 10–12, as this higher total could prove problematic to manage [7]. Moreover, IMCUs require both invasive and non-invasive monitoring, which can result in additional costs and is often not cost-effective [15]. The use of IMCUs can reduce the burden on ICUs by admitting patients with lower acuity, but it has been found that ICUs have more complex pathologies and higher workloads [25].
Human resources.
Providing a high-quality clinical environment necessitates a multidisciplinary healthcare team [18]. Although IMCUs may be staffed with fewer nurses, research shows that they require the same level of training as ICU nurses [15]. The German Interdisciplinary Association of Intensive Care and Emergency Medicine (DIVI) recommends that at least 20% of IMCU staff possess intensive care knowledge [7], as it will enhance confidence and training, thereby improving patient care quality [20]. According to various critical care associations, maintaining a nurse-to-patient ratio of 1:2 or 1:3 is essential to guarantee quality care [7,17,27]. Respiratory intermediate care units result in a decreased number of hospitalization days compared to patients in internal medicine units, thereby directly affecting the resources and organization of the hospital [22].
Continuity of care.
Reducing the “care gap” between an ICU and an inpatient unit is the primary goal of implementing IMCUs [10]. Additionally, establishing these units decreases the occurrence of premature discharges [3], eliminates the need for transfers to regional hospitals lacking ICUs [18], and minimizes the length of stay in the ICU while still maintaining proper levels of surveillance and monitoring [23] without adversely affecting patient outcomes [17]. Intermediate care units have proven to be a critical asset in managing extremely complicated patients during the COVID-19 outbreak [32,36].
Patient benefits.
The environmental conditions within an IMCU play a crucial role in a patient’s clinical progress. Managing alarms and promoting a culture of silence can reduce noise levels and thus improve patient outcomes [24]. Furthermore, the presence of family members throughout the patient’s stay within the unit provides continuous support and offers psychological benefits to the patient [3]. During the COVID-19 pandemic, respiratory IMCUs prevented almost 50% of critically ill patients [37] from being admitted to ICUs. They also served as a multidisciplinary support for managing COVID-19 patients in critical conditions who required respiratory support and non-invasive monitoring [31].
This systematic review aimed to describe the current state of implementation and operation of IMCUs. It was found that they provide improvements in effectiveness and cost, resource use, and continuity of care for patients who appear to have little chance of complications in the evolution of their disease. The key challenge is how to efficiently allocate resources to meet the needs of non-critical patients who still require potential access to critical care in the future.
Material resources
IMCUs offer a primary benefit as an alternative to ICUs, which increased bed availability for patients with higher levels of severity [3,25], and they also enable ICUs to accommodate more complex patients [25]. Patient mortality risk could be a useful metric for rationalizing and optimizing patient admissions, particularly given the limited capacity of higher levels of care in hospitals [29]. A multicenter study conducted in the US by JL. Vincent and GD. Rubenfeld found that 20% of UCI revenue was being used unnecessary for low-severity critical care, which is clinically inappropriate [23]. Vincent and Burchardi suggest that a minority of severely ill patients utilize a disproportionate amount of ICU resources. Therefore, reducing the number of these patients may have a relatively insignificant impact on the overall expenses of an ICU [15]. In this context, a study suggests an advantage of an IMCU that is physically and administratively independent of the ICU. Hospitals with an IMCU have lower mortality rates than those without one [21]. Another study highlights that a closed IMCU model is also considered desirable [35]. The implementation of an IMCU in a hospital has been observed to lead to increased costs. However, this increase is primarily due to surgical admissions and extended stays of patients within the ICU service. Underutilization of the IMCU may contribute to increased costs as nursing staff are paid without patients to attend to [19]. During the COVID-19 pandemic, ICUMs were a fundamental resource in Spain due to their ability to provide a higher nurse-to-patient and doctor-to-patient ratio compared to traditional critical care units. This was particularly important given the increased demand for critical care. Additionally, they were used to transfer ICU patients who required high-flow nasal cannulae [33].
There is no unanimous agreement on the appropriate IMCU bed capacity, according to scientific evidence. Several hospitals determine their needs using ICU studies (Bridgman formula), different specialization percentages, emergency department pressure, surgical waiting lists, possibility of ICU drainage, as well as the number of refused transfers from other centers [17]. However, in Germany and similar countries, DIVI (the German Interdisciplinary Association for Intensive Care and Emergency Medicine) suggests units of 10–12 beds due to the difficulty of managing very large units of 22–28 beds [7]. Furthermore, while IMCUs have less invasive monitoring equipment, they also require invasive monitoring instruments for potential emergencies, resulting in additional expenses [15].
Human resources
One of the primary economic benefits of IMCUs is the reduction in staff numbers. Nonetheless, recent research indicates that whilst the number of nurses may be smaller, they must receive the same level of training as their ICU counterparts [15]. Additionally, as a multidisciplinary team, there should be space for the involvement of other specialists, including intensivists, anesthesiologists, or experts in the critical management of patients [18].
Ensuring a high-quality clinical environment necessitates critical thinking on the part of nursing professionals. A study conducted by Andrew D. Harding et al. at Morton Hospital in Massachusetts demonstrated that enhancing the education and confidence of nursing staff resulted in improvements to patient care quality [20]. This view is corroborated by the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), which suggests that a minimum of 20% of nurses on the ICU team must receive intensive care training [7]. However, Vincent and Burchardi argue for the importance of not segregating patients based on their severity, which enables staff to maintain their level of attention and interest, and prevents patients from feeling inferior to their colleagues in the ICU [15]. Castillo and colleagues propose the potential for healthcare personnel to adjust the tempo of care delivery by alternating between critically ill patient care and intermediate level care [3].
It is evident that staffing in the IMCU is contingent on patient type, required therapeutic effort, and care team composition. The AACN recommends a nurse-patient ratio of 1:3 or 1:4 [17]. Some countries, like Great Britain, have implemented the 1:3 ratio model, while others, such as Switzerland, advocate for a flexible ratio based on patient severity [7]. These high ratios of nurses to patients permit the admission of patients with more complex requirements, resulting in a greater workload for the nursing staff [27].
Continuity of care
The purpose of IMCUs is to decrease the gap in care between the ICU and hospital wards and ensure uninterrupted care [10]. According to various authors, such as F. Castillo et al. [3], these units reduce the number of premature discharges by allowing patients with decreasing care needs to be transferred to the IMCU for gradual care, thereby avoiding the risk of involuntary and/or inappropriate discharges. Moreover, in regional hospitals lacking an ICU, such as the Hospital Valle del Nalón in Asturias (Spain), these units prevent unnecessary transfers and optimize those that are necessary in the end [18].
Other recent studies, such as the one conducted by JL. Vincent and GD. Rubenfeld, have demonstrated that 20–30% of patients admitted to an ICU are there for less than 24 h for routine surveillance and monitoring [23]. Consequently, the creation of IMCUs would decrease the average ICU stay for patients without negatively affecting their clinical outcomes [17]. If these units were not available, patients of this type would receive treatment directly on an inpatient ward, with care levels significantly lower than what is required, as noted by S. Heili-Frades et al. [28]. However, authors such as J.L. Vincent and H. Burchardi argue that segregating patients into “intensive” and “intermediate” categories could be interpreted as diminishing the importance of the patient as an individual person [15]. During the COVID-19 pandemic, the demand for ICU beds exceeded the supply, and this data are particularly relevant, given the importance of admission criteria. Prior to admission ICU, it is essential to manage critically ill patients for the application of specific drugs or procedures that may impact their outcome during the pandemic period [38]. According to Galdeano et al.’s study, 70% of COVID-19 patients were treated in respiratory IMCUs, highlighting their efficacy as support units [32].
Patient benefits
The main objective of an IMCU is to improve the patient’s environment to allow a better evolution of their pathology. To this end, the environmental dimension in which they find themselves is essential since satisfaction and comfort have a significant impact on the prognosis of their disease. For example, the management of alarms and the promotion of a culture of silence can significantly reduce patient discomfort by reducing the noise in the environment [24].
Objective criteria need to be established for the admission of patients to ICUs and IMCUs. Failure to do so can have negative consequences. For example, admitting a critically ill patient to an IMCU first and then transferring them to the ICU after their condition worsens has been shown to increase mortality [30]. Allocating elderly general surgery patients who do not require organ support therapy in an ICU to an IMCU instead of standard wards can significantly reduce 8.7% of predefined life-threatening postoperative complications [34], along with decreasing patient treatment costs, in this study [16,34]. In addition, F. Castillo et al. show that the stay in an IMCU can be considered as a psychological advantage for the patient. It allows a gradual change from a level of maximum assistance to a lower level, with the possibility of being accompanied by the family at all times, thus increasing their level of comfort [3]. However, it should be noted that IMCUs often treat patients with multiple comorbidities and occasionally with indications for DNR [33].
The crucial role of respiratory IMCUs during the COVID-19 pandemic, which revealed the shortage of ICU beds in the Spanish healthcare system, should be emphasized [32]. As demonstrated by G. Suarez-Cuartin et al., such units enabled the treatment of patients who needed constant monitoring but did not require invasive mechanical ventilation [31], thus preventing almost half of critically ill patients from being admitted to an ICU [37]. Therefore, IMCUs provide safe environments in which more complex care can be administered and require constant evaluation by professionals, and where low mortality rates have been observed compared to critical care [31]. Furthermore, the multidisciplinary teams in the IMCUs have successfully reduced the burden on ICUs when treating patients with COVID-19 [36]. This is aligned with a prior study that highlights the benefits of IMCUs in diminishing mortality, the necessity for ICU admission, and hospital stay duration for patients with intricate respiratory ailments [22]. Furthermore, an IMCU is advantageous for enhancing the management of patients who require complex care but do not need ICU admission.
Several limitations were found in this systematic review. The foremost among them is the challenge of comparing studies conducted in various existing IMCUs due to differences in objectives. In addition, the limited amount of available literature has necessitated the inclusion of articles from a wider timeframe. The body of knowledge on intensive care medical units is complex and varies from country to country. Published studies are often specific to certain interventions, making it difficult to fully understand the potential of IMCUs.
The effectiveness of using IMCUs for the treatment of critically ill patients who, due to their pathologies, are not suitable for or cannot be admitted to a traditional ICU has been established. The characteristics of IMCUs enable high-quality care provision, with emphasis on the patient’s wellbeing and a decrease in the occupancy rate of regular ICU beds. Furthermore, the COVID-19 pandemic highlighted the importance of this unit as it provided necessary care to patients who may not have received the appropriate attention otherwise. In response to the need for beds for more critical patients, however, IMCUs have become increasingly involved in the management of semi-critical patients. Research has demonstrated that while IMCUs may differ in certain aspects, they share similarities in terms of patient profiles and a higher patient-to-staff ratio than traditional ICUs. Additionally, IMCUs are staffed with professionals who are equipped to manage complex patients with diverse pathologies, providing an advantage over standard hospital wards. However, further studies are required to determine the fundamental characteristics of this type of unit, as the current evidence remains scarce.
hait supply professional and honest service.
As a future line of research, this study reinforces the significance of IMCUs in the care of critically ill patients in hospitals that already have an ICU. For hospitals that have not yet implemented IMCUs, this study provides compelling reasons to consider changes in resource allocation or nursing staff training.
This research received no external funding.
Conceptualization, P.L.-J., R.V.-D. and M.C.M.-F.; methodology P.L.-J., R.V.-D. and M.C.M.-F.; software, P.L.-J., M.C.M.-F., R.G.-F. and C.M.-V.; validation, P.L.-J., R.V.-D., R.G.-F., C.M.-V. and M.C.M.-F.; formal analysis, P.L.-J., R.V.-D., R.G.-F., C.M.-V. and M.C.M.-F.; investigation, P.L.-J., R.V.-D. and M.C.M.-F.; resources, P.L.-J., R.V.-D., R.G.-F., C.M.-V. and M.C.M.-F.; writing—original draft preparation, P.L.-J., R.V.-D. and M.C.M.-F.; writing—review and editing, P.L.-J., R.V.-D., R.G.-F., C.M.-V. and M.C.M.-F.; visualization, P.L.-J., R.V.-D., R.G.-F., C.M.-V. and M.C.M.-F.; supervision, R.V.-D. and M.C.M.-F. All authors have read and agreed to the published version of the manuscript.
Not applicable.
The authors declare no conflict of interest.
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