Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study

  1. Olivier Grosgurin
  2. Antonio Leidi
  3. Pauline Darbellay Farhoumand
  4. Sebastian Carballo
  5. Dan Adler
  6. Jean-Luc Reny
  7. Bernardo Bollen Pinto
  8. Anne Rossel
  9. Jacques Serratrice
  10. Thomas Agoritsas
  11. Jérôme Stirnemann
  12. Christophe Marti

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Abstract

<b><i>Background:</i></b> The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. <b><i>Objectives:</i></b> The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. <b><i>Method:</i></b> Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. <b><i>Results:</i></b> One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO<sub>2</sub>/FiO<sub>2</sub> (OR 0.98; 95% CI: 0.96–0.99) and BMI (OR 0.88; 95% CI: 0.78–0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. <b><i>Conclusions:</i></b> IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.

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  1. ScreenIT

    SciScore for 10.1101/2020.07.17.20155929: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board StatementIRB: This observational study was approved by the ethics committee of our institution (CCER 2020-01087).
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    The study protocol was written according the STROBE Statement Checklist and is available on request (https://www.equator-network.org/).
    https://www.equator-network.org/
    suggested: (EQUATOR Network, RRID:SCR_012861)
    Analyses were conducted with IBM SPSS Statistics software (version 25) except for the multivariate model, for which R statistical software (R foundation) was used.
    SPSS
    suggested: (SPSS, RRID:SCR_002865)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Our study has several limitations. First, we used a convenient sample size, limiting the number of event and our ability to exhaustively identify predictors of ICU admission. Second, IMCUs do not exist worldwide, precluding the generalizability of our observation. However, we believe that our experience could be an interesting model in other settings, and may apply to similar structures such as respiratory care or high-dependency units. Third, we used a combination of HFNO, CPAP and self-prone position. The duration of interventions was not systematically recorded, preventing us to analyse the benefit of each modality individually. Finally, our observational design precludes drawing definite conclusion about the beneficial effect of IMCU admission or non-invasive ventilation in the absence of a control group. Further research, including interventional controlled studies, are needed to confirm our findings.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1159/000516329
  3. Version published to 10.1101/2020.07.17.20155929v1 on medRxiv