An intermediate respiratory care unit (IRCU) is defined as an area for the monitoring and management of patients with acute respiratory failure requiring non-invasive ventilation (NIV)1 and/or high flow oxygen therapy as part of their treatment. These units can care for patients who do not require or will not benefit from admission to a normal ICU, but who are too complex to be appropriately treated in a conventional hospital ward.2 Up to 40% of patients admitted to an ICU do not require intubation, only 40% of cases of acute respiratory failure require invasive mechanical ventilation (IMV), and up to 60% of the time on IMV is dedicated to withdrawal or weaning,1 facts which might suggest that inappropriate use is being made of ICU resources. In Europe, only 9% of IRCUs are physically situated within the general ICU, although that rate is increasing globally.3 Most units are currently either integrated within the respiratory medicine area (59%), or are set up in a separate unit (25%).4,5

In the specific case of Spain, the extent to which IRCUs have been implemented was first defined in 2 surveys conducted by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) in 20046 and 2008.7 These surveys found, in the first place, that the number of these units in the different autonomous communities had increased by approximately 10%, and that 78% of these units were set up as part of the respiratory medicine department.

Secondly, these surveys also showed an increase in the use of NIV and IMV via tracheostomy in these units, in which the average number of beds remained stable at 4 per unit (Fig. 1).

Fig. 1.

Increase in the number of units by autonomous communities. Use and site of non-invasive ventilation, weaning, and extubation (SEPAR surveys 2004 and 2008).

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An analysis of the characteristics of the units that had been created in the intervening 4 years showed that 64% of the new IRCUs did not have internal medicine residents, 68% did not have their own physical therapist, and up to 55% did not have any on-call rosters in place. In 2008, half of the IRCUs lacked monitoring protocols and 87% did not have the recommended equipment at their disposal. Thus, the increase in the number of units was not accompanied by an improvement in human resources or materials (Fig. 2).

Fig. 2.

Staff and infrastructure in Spanish IRCUs (SEPAR surveys 2004 and 2008).

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The implementation of IRCUs is still not universal in our setting, and in the absence of high complexity intermediate care units, many patients who might not need full ICU care continue to be managed in these units. This increases health care spending and limits the use of appropriate resources in each case. The objective of this study was to perform a cost analysis of an IRCU set up within a general hospital, to determine the annual expenditure associated with complexity and potential efficiency in terms of avoided cost. To this end, we analyzed the costs attributable to 2016 and estimated the cost if the patients had been admitted to the ICU of our hospital. Additionally, as secondary objectives, we analyzed the factors most closely associated with expenditure to determine their impact on the final cost, and the mortality rate of the unit in that year and since it was set up, in order to isolate predictors of mortality in the unit.

The study and analysis of patient data were approved by the Ethics Committee of the Hospital Universitario Fundación Jiménez Díaz (HUFJD).

Unit Characteristics

The IRCU of the HUFJD analyzed in this study is a 5-bed unit that can be extended to accommodate 8 beds in periods of greater demand. Fig. 3 shows the unit admission numbers and failures (including death and referral to the ICU) since the year 2004.

Fig. 3.

Admissions and failures (death or rehospitalization in ICU) from 2004 to 2016. Note the polynomial growth and stabilization of mortality at figures close to 6%.

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The cost analysis of the IRCU under study suggest that this type of unit generates economic savings that can be considerable, mainly in terms of avoided costs, while maintaining a low mortality rate.

The IRCU manages highly complex patients, whose main mode of treatment is NIV, IMV via tracheostomy, or high flow oxygen therapy. Costs are avoided by the fact that this type of IRCU averts prolonged or unnecessary ICU stays.

This analysis is based on the concept of “avoided costs”, i.e., savings that are implicit to the appropriate use of different levels of hospital care and management. In 2016, the overall stay of the 250 patients admitted to the IRCU amounted to 1390 days. Due to their complexity, in the absence of an IRCU, those patients would have been admitted to the ICU.

On the other hand, if the ICU resources had not been available, some of these patients would have been treated in a conventional hospital ward. Hospital wards provide care to patients of medium complexity at a level of care clearly inferior to that offered by the IRCU. These patients, therefore, would not receive the level of support that they require.

We do not know the exact cost of a day of stay in the ICU of our hospital. For this reason, we used as a reference the Ministry of Health report, which sets the average associated cost per day of stay in the ICU of public hospitals in Madrid at €805.36 for tier 1 hospitals,11,12 which would apply to our center. Therefore, the analysis of avoided cost is an estimate, and should be taken as a limitation of this study.

According to the data collected, we can conclude that the IRCU saved the hospital a cost of 1390 days of ICU stay, with a theoretical value of €805.36/day. Taking into account the cost of the IRCU itself, the final annual cost avoided would be close to €493417.65/year. The concept of avoided cost should not only be viewed from an economic angle. Consideration should be given to the added value of the potentially improved capacity for ICU admissions and all that this implies in the organization of highly complex medical and surgical activity. This represents an additional benefit that we have not quantified, although it has been described in other studies.13–16

The multivariate models indicate that costs are associated primarily with mean DRG and mortality: in brief, the complexity of the patient. Therefore, we believe that the comparative analysis proposed would not be valid if the average complexity of patients seen in the IRCU were as low as the DRG levels that could be managed in a conventional hospital ward. In short, this study confirms that a high complexity IRCU avoids a greater number of ICU stays and is associated with greater cost savings.

Very few studies have addressed the theoretical efficiency associated with the availability of an IRCU in the care process. A systematic review of the literature identified only 3 studies with economic analyses, all of which reported on respiratory intermediate care units. In one of these studies, the authors concluded that data were insufficient to determine whether IRCUs “are a cost-effective alternative technology to the traditional institution with only ICU and general ward beds”.17 In another more recent prospective study, Bertolini et al.18 reported that in the management of highly complex chronic obstructive pulmonary disease exacerbations, the total cost per patient was lower in a respiratory IRCU than in an ICU. Finally, Byrick et al.19 raised concerns about the increasing numbers of less complex patients being admitted to the ICU and short stays with low nursing workload that occurred when an IRCU in a Canadian hospital was closed for budgetary reasons. These findings were indicative of an inefficient use of staff and resources, and the IRCU subsequently had to be reopened.

The DRG of the IRCU analyzed in our study is very high compared with that of the general respiratory medicine wards of the same hospital (DRG-IRCU 3.5 vs DRG-RMD ward 1.12), and lower than that of the conventional ICU (DRG-IRCU 3.5 vs DRG-ICU 5.8).20 The lowest DRG values recorded in our cohort correspond primarily to patients who were admitted due to the need for continuous monitoring of their vital signs. The average length of stay, quantified at 5.63 days, is very competitive, despite being influenced by patients being referred from the ICU due to slow or complex weaning. These patients account for 16% of the total number of patients admitted and have an average DRG value of between 4 and 5, which represents 19.35% of the overall stay in the unit. In the absence of an IRCU, these patients would have remained in the ICU, and it is precisely this change of setting that is associated with cost savings for the hospital, with no increase in mortality.

In the analysis of any clinical unit, favorable economic data must be accompanied by robust indicators of quality of care. In this study, we also analyzed IRCU mortality. In 2016, 16 of the 250 admitted patients died. These patients had an average severity score of 3.625, according to the 1–4 severity scale (Appendix B, Table 4, additional material) and a probability of death due to complexity of 3.8125 (1–4 mortality scale). The mortality rate for the unit has remained stable since 2009, at an average of 6.4%. This figure is in line with other studies21 that have shown that the existence of an IRCU decreases hospital mortality.22 Data from patients treated with NIV and from those requiring IMV via tracheostomy were analyzed separately, and equally optimistic rates were obtained. A European study published in 2016 describes a mortality rate associated with IMV of 30%,23 while in the IRCU analyzed here, only 15 deaths out of 210 patients (7.14%) occurred for this reason. With regard to tracheostomies and IMV weaning, mortality in this group of patients, according to the latest multicenter study from 2015, was 30%–38%,24 compared to 3.3% (1 of 30 patients) in our IRCU.

Patients are not discharged home from the IRCU, however, and after stabilization and completion of IMV weaning, they return to their original wards, where delayed mortality may occur (Fig. 5). In the cohort of 250 patients analyzed in 2016, follow-up after the IRCU stay revealed that an additional 41 subjects died, implying an overall global mortality of 16%, which is also lower than the European average. When the mortality of each group is analyzed separately, the use of NIV was associated with 34 deaths in 210 subjects, i.e., 16.19% (in Europe, the rate is 30%23); for the 30 cases of weaning after tracheostomy, 7 deaths were recorded (all of them in hospital wards after discharge from the IRCU), i.e., 23%, also below the European average of 30%–38%.24 With respect to predictors of mortality on admission, the Poisson regression found no association among the variables analyzed in this study. A multivariate logistic regression analysis was performed on the 19 clinical variables at admission that reflect a greater mortality in patients with hematologic alterations, tachypnea, and acidosis. These data are consistent with those reported previously in other studies.25

Fig. 5.

Direct and delayed IRCU mortality.

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An IRCU, such as the one analyzed in this study, avoids ICU admission and, as such, generates considerable savings in critical respiratory care. As a result, hospital resources can be better distributed. If the IRCU offers highly complex care, then savings are even more significant. Our study also shows that an IRCU is a safe environment that achieves low mortality rates, despite the complexity of admitted patients.

This study has not received specific support from public sector agencies, or commercial or non-profit organizations.

The authors state that they have no conflict of interests.