A Proposal for an Intermediate Care Unit-Quality Measurement Framework

Intermediate Care Units in Internal Medicine

BACKGROUND

Intermediate Care Units (ImCU) have been historically described as an intermediate level of care between standard wards and intensive care units (ICU), and general medical ImCUs have evolved as specifically addressed to high care medical patients. The objective of this study is to explore designs, appropriateness criteria, and quality of care of general medical ImCUs.

METHODS

a comprehensive literature search was performed in electronic database (PubMed/Medline, Embase, Cochrane and Web of Science) up to July 30th 2024 and data about general medical ImCU denominations, settings, processes and outcomes were extracted.

RESULTS

34 studies were included in systematic analyses, the more used nomenclature was ImCU (70.6 %), followed by High Dependency Unit (20.6 %). The median number of beds was 8 [4-11], the nurse-to-patients ratio 1:3.1, and internists involved in comanagement in 40.0 %. Either a step-up from standard wards or a step-down from ICUs role were reported, with a median of 50.8 % [26.2-71.0] of patients directly admitted from Emergency Departments. The main distinctive activities were continuous monitoring and non-invasive ventilation. The median ICU transfer rate was 8.0 % [5.6-12.3], while in-ImCU and in-hospital mortality were 6.2 % [3.6-8.3] and 14.0 % [8.7-19.1], respectively.

CONCLUSIONS

general medical ImCUs are being increasingly recognized as the appropriate setting for high care medical patients but present to date a wide variability of formats. Activity-based admission criteria tailored on each hospital reality could be a process model for adequate patient flow, and quality of care key indicators should consider the functional general medical ImCU role in hospital macro-systems.

The Fenice project to evaluate and improve the quality of healthcare in high-dependency care units: results after the first year

High-Dependency care Units (HDUs) have been introduced worldwide as intermediate wards between Intensive Care Units (ICUs) and general wards. Performing a comparative assessment of the quality of care in HDU is challenging because there are no uniform standards and heterogeneity among centers is wide. The Fenice network promoted a prospective cohort study to assess the quality of care provided by HDUs in Italy. This work aims at describing the structural characteristics and admitted patients of Italian HDUs. All Italian HDUs affiliated to emergency departments were eligible to participate in the study. Participating centers reported detailed structural information and prospectively collected data on all admitted adult patients. Patients' data are presented overall and analyzed to evaluate the heterogeneity across the participating centers. A total of 12 HDUs participated in the study and enrolled 3670 patients. Patients were aged 68 years on average, had multiple comorbidities and were on major chronic therapies. Several admitted patients had at least one organ failure (39%). Mortality in HDU was 8.4%, raising to 16.6% in hospital. While most patients were transferred to general wards, a small proportion required ICU transfer (3.9%) and a large group was discharged directly home from the HDU (31%). The expertise of HDUs in managing complex and fragile patients is supported by both the available equipment and the characteristics of admitted patients. The limited proportion of patients transferred to ICUs supports the hypothesis of preventing of ICU admissions. The heterogeneity of HDU admissions requires further research to define meaningful patients' outcomes to be used by quality-of-care assessment programs.

Assessment of the intermediate care unit triage system

BACKGROUND

An important critique with respect to the utilization of intermediate care units (IMCU) is that they potentially admit patients who would otherwise be cared for on the regular ward. This would lead to an undesired waste of critical care resources. This article aims to (1) describe the caseload at the IMCU and (2) to assess the triage system at the IMCU to determine potentially unnecessary admissions.

METHODS

This cohort study included all admissions at the mixed-surgical IMCU from 2001 to 2015. The Therapeutic Intervention Scoring System-28 (TISS-28) was prospectively collected for all admissions to describe the caseload at the IMCU and to identify medical criteria for admission. These were combined with logistical criteria to assess the IMCU triage system.

RESULTS

A total of 8816 admissions were included in the study. The average TISS-28 was 20.19 (95% CI 18.05 to 22.33), corresponding with 3.57 (95% CI 3.19 to 3.94) hours of direct patient-related work per patient per nursing shift. Over time, this increased by an average of 0.27 points/year (p<0.001). Of all admissions, 6539 (74.2%) were medically considered to be justly admitted, and 7093 (80.4%) were logistically considered to be justly admitted. With these criteria combined, a total of 8324 (94.4%) were correctly admitted.

DISCUSSION

Most admissions to the IMCU are medically and/or logistically necessary, as the majority of admitted patients demand a higher level of nursing care than available on the general ward. Continuous triage is thereby essential. These findings support further utilization of the IMCU in our current healthcare system and has important implications for IMCU-related management decisions.

LEVEL OF EVIDENCE

Level VI.