International Journal of Environmental Research and Public Health Article Effectiveness of Intermediate Respiratory Care Units as an Alternative to Intensive Care Units during the COVID-19 Pandemic in Catalonia Marina Galdeano Lozano 1,2,3, * , Julio César Alfaro Álvarez 4 , Núria Parra Macías 5 , Rosario Salas Campos 6 , Sarah Heili Frades 7 , Josep Maria Montserrat 8 , Antoni Rosell Gratacós 9 , Jorge Abad Capa 9 , Olga Parra Ordaz 3,10 and Francesc López Seguí 2 1 Unidad de Ventilación y Cuidados Respiratorios Intermedios, Servicio de Neumología, Direcció Clínica Àrea del Tórax, Hospital Universitari Germans Trias i Pujol, IGTP, Universitat Autónoma de Barcelona, Reseau Europén de Recherche en Ventilation Artificielle (REVA), 08193 Barcelona, Spain 2 Unidad de Economía de la Salud, Dirección de Innovación de la Gerencia Territorial Metropolitana Norte, Institut Català de la Salut, 08007 Barcelona, Spain; flopezse.germanstrias@gencat.cat 3 Doctorat de Medicina i Recerca Translacional, Facultat de Medicina, Universitat de Barcelona, 08193 Barcelona, Spain; oparra@ub.edu 4 Servicio de Neumología, Hospital de Viladecans, 08840 Barcelona, Spain; jucealal@yahoo.es 5 Unidad de Innovación Clínica y Promoción de la Salud, Hospital Universitario Sagrat Cor, Grupo Quirón Salud, 08029 Barcelona, Spain; nuriaparramacias@gmail.com 6 Servicio de Medicina Interna, Hospital Universitario Sagrat Cor, Quirón Salud, 08029 Barcelona, Spain; Citation: Galdeano Lozano, M.; Alfaro Álvarez, J.C.; Parra Macías, N.; rsalascampos@yahoo.es 7 Unidad de Cuidados Intermedios Respiratorios, Hospital Fundación Jimenez Díaz, Grupo Quirón Salud, Salas Campos, R.; Heili Frades, S.; Reseau Europén de Recherche en Ventilation Artificielle, 28040 Madrid, Spain; sheili@fjd.es Montserrat, J.M.; Rosell Gratacós, A.; 8 Unidad del Sueño, Servicio de Neumología, Hospital Clínic Provincial Barcelona, Universitat de Barcelona, Abad Capa, J.; Parra Ordaz, O.; 08193 Barcelona, Spain; jcanal@clinic.cat López Seguí, F. Effectiveness of 9 Servicio de Neumología, Direcció Clínica Àrea del Tórax, Hospital Universitari Germans Trias i Pujol, IGTP, Intermediate Respiratory Care Units Universitat Autónoma de Barcelona, 08193 Barcelona, Spain; arosellg.germanstrias@gencat.cat (A.R.G.); as an Alternative to Intensive Care jabadc.germanstrias@gencat.cat (J.A.C.) Units during the COVID-19 10 Unidad de Sueño Servicio de Neumología, Hospital Universitario Sagrat Cor, Quirón Salud, Pandemic in Catalonia. Int. J. Environ. 08029 Barcelona, Spain Res. Public Health 2022, 19, 6034. * Correspondence: mgaldeanol.germanstrias@gencat.cat; Tel.: +34-934661200 (ext. 3603) https://doi.org/10.3390/ ijerph19106034 Abstract: AbstractObjectives: During the COVID-19 pandemic, the risk of collapse for the health system created great difficulties. We will demonstrate that intermediate respiratory care units (IRCU) Academic Editors: Yudong Zhang, Juan Manuel Gorriz and provide adequate management of patients with non-invasive respiratory support, which is particu- Zhengchao Dong larly important for patients with SARS-CoV-2 pneumonia. Methods: A prospective observational study of patients with COVID-19 admitted to the ICU of a tertiary hospital. Sociodemographic data, Received: 11 April 2022 comorbidities, pharmacological, respiratory support, laboratory and blood gas variables were col- Accepted: 13 May 2022 lected. The overall cost of the unit was subsequently analyzed. Results: 991 patients were admitted, Published: 16 May 2022 56 to the IRCU (from a of 81 admitted to the critical care unit). Mean age was 65 years (SD 12.8), Publisher’s Note: MDPI stays neutral Barthel index 75 (SD 8.3), Charlson comorbidity index 3.1 (SD 2.2), HTN 27%, COPD 89% and with regard to jurisdictional claims in obesity 24%. A significant relationship (p < 0.05) with higher mortality was noted for the following published maps and institutional affil- parameters: fever greater than or equal to 39 ◦ C [OR 5.6; 95% CI (1.2–2.7); p = 0.020], protocolized iations. pharmacological treatment [OR 0.3; 95% CI (0.1–0.9); p = 0.023] and IOI [OR 3.7; 95% CI (1.1–12.3); p = 0.025]. NIMV had less of a negative impact [OR 1.8; 95% CI (0.4–8.4); p = 0.423] than IOI. The total cost of the IRCU amounted to €66,233. The cost per day of stay in the IRCU was €164 per patient. Copyright: © 2022 by the authors. The total cost avoided was €214,865. Conclusions: The pandemic has highlighted the importance of Licensee MDPI, Basel, Switzerland. IRCUs in facilitating the management of a high patient volume. The treatment carried out in IRCUs This article is an open access article is effective and efficient, reducing both admissions to and stays in the ICU. distributed under the terms and conditions of the Creative Commons Keywords: respiratory care; COVID; ICU; cost-effectiveness Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Int. J. Environ. Res. Public Health 2022, 19, 6034. https://doi.org/10.3390/ijerph19106034 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022, 19, 6034 2 of 11 1. Introduction In March 2020, the SARS-CoV-2 [1] pandemic was declared in Spain. From 25 February to 28 April 2020, a total of 203,715 cases were confirmed, of which 105,743 were older than 60 years; of these, 15,115 died, and 4353 (4.12%) required admission to an intensive care unit (ICU) [2–6]. The number of ICU beds in Spain is lower than in neighboring countries (approx- imately 3600, equivalent to a ratio of 7.7 beds per 100,000 inhabitants, compared to 29.2/100,000 in Germany) [7–10], and the pandemic exposed the scarcity of this resource. The risk of the health system collapsing, especially during the initial phase of the pan- demic, created major difficulties for the allocation of care resources and sparked a broad ethical debate. Although the majority of people with COVID-19 develop mild symptoms or few com- plications, approximately 14% develop a serious illness that requires hospitalization, and 5% require admission to an ICU [9]. To facilitate difficult decision-making in ICUs during the COVID-19 pandemic, an ethical consensus was created [11,12]. This contained pro- files for admission and location priorities in which semicritical units and/or intermediate respiratory care units (IRCUs) played a leading role. An IRCU is defined as an area for monitoring and providing assistance to patients with acute respiratory failure who require non-invasive mechanical ventilation (NIMV) [13] and/or high-flow oxygen therapy (HFOT) as part of their treatment. Therefore, IR- CUs can be a good alternative to an ICU for the treatment of patients admitted for COVID-19 [14–17] who do not require imminent orotracheal intubation (IOI) or are ex- periencing clinical improvement. The implementation of IRCUs is not yet universal in our health system, with a conse- quent increase in health care expenditure and limitations in the use of adequate resources in each case [18–21]. IRCUs allow for an adequate selection of subsidiary patients who would benefit from invasive mechanical ventilation (IMV) [14,15], while also treating patients with a more advanced age and/or with associated frailty. This characteristic has become more evident in patients with SARS-CoV-2 pneumonia in need of respiratory support [16,17]. Considerable [18–21] economic savings have been described for these units. In this context, our study aims to describe the efficiency of an IRCU at a tertiary hospital, as well as the epidemiological and clinical characteristics and mortality of patients hospitalized in said unit. 2. Methods 2.1. Definitions This is a prospective observational study of patients with COVID-19 admitted to the IRCU of a tertiary university hospital during the first wave of the pandemic (from 25 February to 28 April 2020). Ethical approval was obtained from the Ethics and Re- search Committee. The University Hospital in Barcelona has 295 general ward beds, 10 ICU beds and six IRCU beds. The IRCU is part of the Pulmonology Service and specializes in non-invasive respiratory support (NIRS) and postsurgical recovery from thoracic surgery. This unit has a closed structure with individual rooms; in contrast, the ICU has an open structure. The IRCU’s nurse-to-patient ratio is 1:4 and the main admission criterion is respiratory failure requiring NIRS (when IMV is needed, patients are transferred to the ICU). The IRCU is equipped with a maximum of six individual bays and continuous non-invasive monitoring, ventilators for NIMV (telemetered) and HFOT. The respirators available are V60 and Trilogy 200 Phillips Respironics® . During the first wave of the pandemic, a maximum of 11 bays were made available with these devices. In this period, the manner in which personnel were assigned was modified. Day care was 12 h long with pulmonologists in charge. Continuous night care was provided by intensive care physicians at the center. Staffing in terms of nurses and assistants with expe- rience in non-invasive respiratory support techniques consisted of two nursing graduates Int. J. Environ. Res. Public Health 2022, 19, 6034 3 of 11 and two nursing care technicians. The unit received support from the rehabilitation service in the form of physiotherapy. 2.2. Inclusion and Exclusion Criteria All cases of SARS-CoV-2 pneumonia confirmed by real time polymerase chain reaction (RT-PCR) for SARS-CoV-2 admitted to the IRCU were consecutively included. Admission criteria to the IRCU were as follows: a ratio of arterial oxygen pressure and fraction inspired oxygen (PaFiO2) lower than 50% and oxygen saturation lower than 95%, or respiratory frequency (RR) higher than 25 rpm and PaFiO2 lower than 250. This group of patients included all patients with NIRS needs (experiencing clinical deterioration and possibly requiring admission to the ICU, those making a recovery, dis- charges from the ICU, and patients who had reached a therapeutic ceiling). We consider that not all dying patients have ICU admission criteria (given age and/or associated multiple pathologies), so we present the analysis described below. 2.3. Statistical Analysis Sociodemographic variables (age, gender), clinical variables (Barthel index, Charlson comorbidity index) and chronic and acute comorbidity, obesity and arterial hypertension were collected in addition to home respiratory therapeutic requirements prior to admission and at the time of discharge (NIMV, continuous positive airway pressure (CPAP) and home oxygen therapy); variables of the care process (average length of stay and hospital stay, diagnosis at admission, discharge status), as well as analytical and microbiological parameters, treatments during admission, destination on admission (ICU, IRCU or general ward) and support needs during their stay (NIMV, IMV and IOI, HFOT or CPAP). The costs derived per day of stay were estimated and compared with the costs of an ICU stay. To evaluate the efficiency of the unit, the days of admission to the ICU avoided were considered for patients assessed and taken on by the IRCU at the time of requiring NIRS, as well as post-ICU patients who were discharged early from the unit. The number of stays for patients admitted to the unit was calculated and the theoretical bed cost estimated for the ICU was calculated according to Section 1 of the Spanish Ministry of Health’s classification [20]. The difference between the real cost calculated for the IRCU and the estimated cost for the ICU was considered to be the cost avoided. Results are expressed as the mean and SD for quantitative variables that follow a nor- mal distribution and as the median and IQR otherwise. The variables were described and compared according to their nature and distribution. Qualitative variables are expressed as total number and percentage. With respect to the mortality predictors, a univariate analysis was included in the corresponding multivariable logistic regression backward stepwise model. Strongly correlated variables were excluded from the analyses. All tests were performed with a bilateral significance level of p = 0.05. Statistical analysis was performed using SPSS statistical software (15th version). 3. Results A total of 991 patients confirmed with COVID-19 were admitted during the study period. Of these, 910 were admitted to a general hospital ward and 81 were admitted to a critical care unit. A total of 32 patients (39.5%) were admitted directly to the IRCU and 25 patients (30.8%) were admitted to the UCI. After an average period of 3.5 days (SD 1.8) of hospital stay, 16 patients (66.7%) worsened and required admission to the IRCU. Of the 81 patients admitted to a critical care unit, 56 were admitted to the IRCU (69.13%). Patient flow is outlined in Figure 1. Int. J. Environ. Res. Public Health 2022, 19 4 of 12 Int. J. Environ. Res. Public Health 2022, 19, 6034 4 of 11 Figure 1. Patient flow. The patients admitted to the IRCU had a mean age of 65 years (SD 12.8), a Barthel Index of 75 (SD 8.3), a Charlson comorbidity index of 3.1 (SD 2.2) and the following comorbidities: arterial Figure 1. hypertension Patient flow. accounted for 27%, chronic obstructive pulmonary disease (COPD) was found in 89% of patients, and obesity was found in 24% of patients. Treatment The patientswas soughttodue admitted thetoIRCU cough and/or had a mean dyspnea and/or age of 65 yearsfever greater (SD 12.8), than or a Barthel equalofto75 ◦ C in 65.3% of the cases with an evolution of 7.1 days (SD 4.0), whereas 76.4% 39(SD Index 8.3), a Charlson comorbidity index of 3.1 (SD 2.2) and the following comor- presented bidities: with bilateral arterial infiltrates hypertension according accounted to a chest for 27%, chronicX-ray performed obstructive upon admission. pulmonary disease Upon admission to the IRCU, patients had a sequential organ (COPD) was found in 89% of patients, and obesity was found in 24% of patients. failure assessment (SOFA) score ofwas Treatment 4.5 (SD 2.2),due sought a RRtoofcough 23.1 rpm (SD dyspnea and/or 5.2) and PaFiO2 of 136.2 and/or fever (SD 65.1). greater than For or equal to 39 °C in 65.3% of the cases with an evolution of 7.1 days (SD 4.0), whereaspH the initial arterial blood gas analysis, we obtained mean values upon admission of 7.43 76.4% (SD 0.09), with presented PaO2bilateral 67.5 mmHg (SD 37.5) infiltrates and PaCO2 according 39.7 mmHg to a chest (SD 9.1) (Table X-ray performed upon1). admission. Upon admission to the IRCU, patients had a sequential organ failure assessment Table 1. Characteristics of patients in IRCU, including SOFA (sequential organ failure assessment), (SOFA) score of 4.5 (SD 2.2), a RR of 23.1 rpm (SD 5.2) and PaFiO2 of 136.2 (SD 65.1). For Charlson comorbidity index and Barthel comorbidity index. the initial arterial blood gas analysis, we obtained mean values upon admission of pH 7.43 (SD 0.09), PaO2Variables Clinical 67.5 mmHg (SD 37.5) and PaCO2 Mean 39.7 mmHg (SD 9.1) (Table SD 1). Age 65 12.8 Barthel Score of patients in IRCU, including Table 1. Characteristics 75 8.3 assessment), SOFA (sequential organ failure Charlson Score Charlson comorbidity index and Barthel comorbidity3.1 index. 2.2 SOFA Score 4.5 2.2 Clinical Variables Mean SD 3 Days after Admission to Arterial AgeGasometry Admitted 65 to IRCU 12.8 IRCU Variables (Mean/SD) Barthel Score 75 8.3 (Mean/SD) CharlsonpHScore 7.43/0.09 3.1 7.43/0.13 2.2 pO2 Score SOFA mmHg 67.5/37.5 4.5 77.5/34.4 2.2 pCO2 mmHg Arterial Gasometry Varia- Admitted39.7/9.1 to IRCU 42.8/9.5 to IRCU 3 Days after Admission bles (Mean/SD) (Mean/SD) The description of pharmacological treatment was governed by7.43/0.13 pH 7.43/0.09 the protocol in force pO2 mmHg at our center at all times. A total of 67.5/37.5 68.1% of patients received 77.5/34.4 hydroxychloroquine pCO2 mmHg (100 mg/day), 39.7/9.1 mg/day) and azithromycin lopinavir/ritonavir (200/50 42.8/9.5(500 mg/day). In 9.7% of the cases, boluses of corticosteroids (250 mg/day) were administered, 44.4% wereThe descriptioncorticosteroids administered of pharmacological treatment at 1 mg/kg was governed of weight/day and by thewere 6.9% protocol in force administered at our center at all times. A total of 68.1% of patients received hydroxychloroquine tocilizumab (600 mg in a single dose). A total of 41.7% of the patients received anticoagula- (100 mg/day), tion therapy (1 mg/kg/12 h of enoxaparin or equivalent) due to a high clinical suspicionof lopinavir/ritonavir (200/50 mg/day) and azithromycin (500 mg/day). In 9.7% of the cases, boluses ofevent. a thromboembolic corticosteroids (250 mg/day) were administered, 44.4% were admin- istered corticosteroids The at 1 mg/kg NIRS that patients of weight/day received and 6.9%towere upon admission administered the IRCU tocilizumab consisted of oxygen (600 mg inthrough therapy a singleadose). nasalAcannula total of and/or 41.7% ofVenturi the patients maskreceived anticoagulation (69 patients, 85.2% of thetherapy total), (1 mg/kg/12 NIMV h of enoxaparin (11 patients, 13.6%), or equivalent) CPAP due to (2 patients, a high 2.5%), clinical suspicion high-flow of a thrombo- nasal cannulas (HFNC) embolic event.29.6%) and IOI (39 patients, 48.1%). Prone positioning was performed on (24 patients, 48 patients (59.3% of the total). Patients on a Venturi mask received an average flow of Int. J. Environ. Res. Public Health 2022, 19, 6034 5 of 11 12.13 liters per minute (lpm) with an SD of 6.7 lpm, whereas those on a HFNC received an average flow of 30.96 lpm (SD 12.6 lpm) and 69.50% FIO2 (SD 19.8%). Four simultaneous HFNCs were the only option available. In those patients who received support with NIMV, the mean inspiratory positive airway pressure (IPAP) was 17.64 +/− 3.91 cmH2 O, reaching a maximum of 25 cm H2 O, and the mean expiratory positive airway pressure (EPAP)was 9.27 +/− 2.24 cm H2 O. NIMVs were used for an average of 4.45 days (SD 4.76 days). Patients who needed more days of NIRS use experienced nasal bridge ulcers and some cases of epistaxis. The mortality rate of the 81 patients admitted to the critical care unit was 25%. PaFiO2 at admission, PaO2 , heart rate, RR, levels of lactate dehydrogenase (LDH), potassium, alanine aminotransferase (ALT) and total bilirubin were all significantly associated with higher mortality (Table 2). We did not obtain sufficient sputum cultures to describe the most observed respiratory superinfection. Table 2. Clinical variables and tests associated with mortality. Test Variables Deceased Survivors p LDH (mean [SD]) 649 UI/L [649.7] 327 UI/L [327.0] 0.002 K+ (mean [SD]) 3.8 mEq/L [0.58] 4.5 mEq/L [0.65] 0.025 ALT (mean [SD]) 81.8 UI/L [63.0] 38.6 UI/L [15.47] 0.004 Total bilirubin (mean [SD]) 1.3 mg/dL [0.79] 0.6 mg/dL [0.48] 0.009 Arterial bod gas analyis Deceased Survivors p PaO2 (mean [SD]) 44.5 mmHg [25.3] 78.9 mmHg [34.4] 0.034 PaFiO2 (mean [SD]) 89.7 [26.3] 147.2 [66.0] 0.002 Clinical Variables Deceased Survivors p HR (mean [SD]) 97.5 lpm [20.2] 84.2 lpm [17.187] 0.015 RR (mean [SD]) 28.9 rpm [4.9] 24.4 rpm [6.1] 0.013 A significant relationship (p < 0.05) was found for higher mortality in patients with fever greater than or equal to 39 ◦ C [OR 5.6; 95% CI (1.2–2.7); p = 0.020] at the time of admission, with the use of protocolized pharmacological treatment [OR 0.3; 95% CI (0.1–0.9); p = 0.023] (hydroxychloroquine, lopinavir/ritonavir and azithromycin) and IOI [OR 3.7; 95% CI (1.1–12.3); p = 0.025]. Treatment with intravenous corticosteroids was close to statistical significance for the reduction of mortality [OR 0.3; 95% CI (0.1–1.1); p = 0.0508]. The use of NIMV was not statistically significance and it had a smaller negative impact [OR 1.8; 95% CI (0.4–8.4); p = 0.423] than IOI (Figure 2). Description of the cost avoided was based on the total cost of the unit. A calculation of the hospitalization costs of the IRCU was performed for a total of 56 patients over a period of two months based on the rates detailed in a study carried out at our center prior to the COVID-19 pandemic [21]. The total number of stays amounted to 403.2 days with an average of 7.2 days per admission (range 3.8–11 days) and the following itemized expenses: Personnel costs, taking into account the totality of the existing workforce during all work shifts and the current salary agreement: €52,020. Expenses for the consumption of sanitary material, instruments, clothing, and linen, among others: €5272. Amortization and equipment: Most of the material used in the unit had been pur- chased more than four years earlier, and the remaining material was on loan. No new equipment had been purchased. The equipment inventoried in the unit (not on loan) had a purchase cost of €17,795. None of these expenses are reflected in the period of time that was under study. Int. Int.J.J.Environ. Environ.Res. Res.Public PublicHealth Health2022, 2022,1919, 6034 6 of 6 of1211 Representationofofthe Figure2.2.Representation Figure thesignificant significantassociations associationsof ofqualitative qualitativevariables variableswith withmortality. mortality. Testing andof Description radiology: This costwas the cost avoided wasbased calculated on thebased totalon current cost of thecare unit.protocols rather A calculation than detailed costs for each patient. Three tests were performed as per protocol of the hospitalization costs of the IRCU was performed for a total of 56 patients over a during a patient’s stay (upon admission, at 48 h and at 6–7 days); X-rays were performed upon period of two months based on the rates detailed in a study carried out at our center prior admission and at 48 h. Red blood cell and platelet transfusions were taken into account. to the COVID-19 pandemic [21]. Therefore, the cost amounted to €3816. The total number of stays amounted to 403.2 days with an average of 7.2 days per Pharmacy: An exhaustive comparison was carried out between the drugs prescribed admission (range 3.8–11 days) and the following itemized expenses: in the IRCU and those prescribed in the ICU during the period studied. A dispensing Personnel costs, taking into account the totality of the existing workforce during all cost was obtained per patient during their stay in the IRCU according to the price of each work shifts and the current salary agreement: €52,020. product, and a comparison of expenses with respect to the ICU was performed. In the IRCU, Expenses for the consumption of sanitary material, instruments, clothing, and linen, the average pharmaceutical cost per patient and stay was €91.51 (SD €221.73) compared among others: €5272. to €163.83 in the ICU (SD €150). Figure 3 shows that average expenditure in the IRCU Amortization and equipment: Most of the material used in the unit had been pur- was higher than the ICU; nevertheless, since fewer patients were admitted to the IRCU, chased more than four years earlier, and the remaining material was on loan. No new the figure is based on a smaller dataset. There was no significant difference between the equipment average costhad of been purchased. dispensing The a drug in equipment the ICU andinventoried in the IRCU.in the unit (not on loan) had a purchase cost of €17,795. None of these expenses are reflected in the period of time that was under study. Int. J. Environ. Res. Public Health 2022, 19, 6034 7 of 11 The total pharmacy expenditure amounted to €5124 (some €3713 more than the previ- ous total of €8468 during the pre-pandemic period according to a recent study [21]. The total cost of the IRCU during the study period as the sum of the categories described above amounted to €66,233. When applied to 403.2 days of stay during this period, the cost per day for the IRCU amounted to €164 per day per patient. The IRCU saved the hospital a cost equivalent to 403.2 patient days with a theoretical value of €281,098 according to Section 1 of the Spanish Ministry of Health’s classification for the ICU. The difference between the actual cost calculated for the IRCU and the estimated Int. J. Environ. Res. Public Health 2022, 19 7 of 12 cost for the ICU was considered to be the cost avoided. Therefore, after removing the cost for the IRCU, the actual cost avoided during these two months of the pandemic was €214,865 for 56 patients (Table 3). Testing and radiology: This cost was calculated based on current care protocols ra- ther than Table detailed costs for 3. Hospitalization each costs patient. in the Three IRCU for tests a total were of 56 performed patients as per over a two protocol month perioddur- during ing a patient’s stay (upon admission, at 48 h and at 6–7 days); X-rays were performed the pandemic. upon admission and at 48 h. Red blood cell and platelet transfusions were taken into ac- % Respect Total Cost count. Therefore, theVariables cost amounted to €3816. Cost (€) the IRCU Pharmacy: AnPersonnel exhaustive comparison was carried52,020.95 costs out between the drugs78.54%prescribed in the IRCU and those prescribed Expenses for consumption in the ICU during the period 5272.27 studied. A dispensing 7.96% cost was obtained per patient during their stay in the IRCU according to the price of each Amortization and equipment 0 0 product, and a comparison of expenses with respect to the ICU was performed. In the IRCU, the average Testing and radiologycost per patient and 3816.00 pharmaceutical 5.76% com- stay was €91.51 (SD €221.73) pared to €163.83 in the ICU (SD €150). Figure 3 shows5124.56 Pharmacy that average expenditure7.73% in the IRCU was higher than the ICU; Total cost of the IRCUnevertheless, since fewer patients 66,233.78 were admitted 100% to the IRCU, the figure is based on a smaller dataset. There was no significant difference between Total cost avoided by the IRCU during two the average cost of dispensing a drug in the ICU and in the IRCU. 214,865.16 months of the pandemic for the 56 patients Figure 3. Cont. Int. J. Environ. Res. Public Health 2022, 19 8 of 12 Int. J. Environ. Res. Public Health 2022, 19, 6034 8 of 11 Figure 3. Cont. Int. J. Environ. Res. Public Health 2022, 19 9 of 12 Int. J. Environ. Res. Public Health 2022, 19, 6034 9 of 11 Figure 3. Comparison of pharmacological dispensing cost and number of dispensations per patient Figure 3. Comparison of pharmacological dispensing cost and number of dispensations per patient between between thethe intermediate intermediate respiratory respiratory carecare unitunit (IRCU) (IRCU) andand the the intensive intensive carecare unitunit (ICU). (ICU). 4. Discussion The total pharmacy expenditure amounted to €5124 (some €3713 more than the pre- During the pandemic, the number of ICU beds was insufficient given the increase in vious total of €8468 during the pre-pandemic period according to a recent study [21]. The demand, a situation for which the health system was not fully prepared. Several studies total cost of the IRCU during the study period as the sum of the categories described above and protocols have outlined possible scenarios where it would be necessary to increase the amounted to €66,233. When applied to 403.2 days of stay during this period, the cost per number of ICU [18,19] beds. However, little was published during the first wave of the day for the IRCU amounted to €164 per day per patient. pandemic with regard to NIRS and the need for an intermediary step before reaching the The IRCU saved the hospital a cost equivalent to 403.2 patient days with a theoretical ICU. The IRCU has been working to avoid IOI and/or to assist in early extubations. value of €281,098 according to Section 1 of the Spanish Ministry of Health’s classification During the period analyzed, the IRCU was essential for the organization of both our for the ICU. The difference between the actual cost calculated for the IRCU and the esti- patients and the hospital. Note that 40% of our patients with COVID-19 were admitted mated cost for the ICU was considered to be the cost avoided. Therefore, after removing directly to the IRCU. This percentage is higher than those who were initially admitted to a the cost for the IRCU, the actual cost avoided during these two months of the pandemic general ward or the ICU, and this figure increases to practically 70% of those infected by was €214,865 for 56 patients (Table 3). SARS-CoV-2 when we assess the total number of patients who required IRCU services at any time during their hospitalization. In this way, the IRCU offered support to the ICU Table 3. Hospitalization costs in the IRCU for a total of 56 patients over a two month period during (and the general ward) at a time when admission criteria played a fundamental role. the pandemic. Heili-Frades et al. [20] states that this type of unit represents a very important economic saving in terms of avoided expenses. An IRCU can treat patients % Respect Total of a high Cost complexity Variables Cost (€) whose main axis of treatment is NIMV, IMV by tracheostomy or HFOT. theThe IRCUsavings occur because this type of unitcosts Personnel avoids prolonged or unnecessary 52,020.95 stays in the78.54% ICU and provides supportExpenses to those for patients whose consumption therapeutic ceiling is 5272.27 NIRS. If these resources 7.96% had not been available in the and Amortization IRCU (due to bed shortages), some equipment 0 of these patients would0 have been treated in a general ward. Testing and radiology 3816.00 5.76% In our study, we performed an analysis of the overall consumption of the unit. The Pharmacy 5124.56 7.73% unit’s pharmacy cost also allowed us to make a comparison with that of the ICU, which was lowerTotal cost overall inof the the IRCU IRCU than in the ICU. We 66,233.78 reached the conclusion 100% that the cost of Total cost avoided by the IRCU during two an IRCU bed in our center during the period under study amounted to slightly less than 214,865.16 months €200 perofday. the pandemic The fact thatforpharmaceutical the 56 patients expenditure was higher in the IRCU than the ICU can be attributed to our internal protocol and following current scientific evidence. In the case of NIRS, drugs that have evidence for use are not available to the patient under IoT. Int. J. Environ. Res. Public Health 2022, 19, 6034 10 of 11 However, the concept of avoided cost should not be considered solely from an economic point of view; the added value of a potential improvement in ICU admission capacity should also be considered together with its benefits for the organization of highly complex medical and surgical activities. The values associated with a worse prognosis were mainly onset with high fever and greater gasometric involvement, regardless of age, gender, previous functional status or the presence of comorbidities. A beneficial trend for treatment with corticosteroids (1 mg/kg) and a worse prognosis associated with IOI was observed. NIMV could be proposed as an alternative treatment in some cases, since the use of non-invasive mechanical ventilation, which was not statistically significant, had less negative impact than IOI. Invasive measures such as IMV provide benefits but also drawbacks or deleterious effects. It is essential to determine the exact allocation of patients and avoid ICU stays for those who do not benefit from their stay [14,15]. Up to 40% of patients admitted to an ICU do not require intubation, and only 40% of cases of acute respiratory failure require IMV [13], which highlights issues of inadequate resource management. Reports on hospitalizations due to SARS-CoV-2 pneumonia usually refer to admissions to the ICU, whereas the number admitted to the IRCU is often ignored. Nevertheless, these units have been shown to be effective and efficient given their high degree of specializa- tion. This study looks at the key role played by IRCUs during the start of the pandemic in Catalonia. In conclusion, the COVID-19 pandemic has highlighted the importance of this type of unit in hospitals since they facilitate the management of a high volume of patients with severe respiratory failure and high dependence. In our study, the treatment performed was effective and efficient, reducing both admissions and stays in the ICU. Author Contributions: M.G.L.: Conceived the study and the analysis. Performed the analysis. Coordination. Description of tables and figures. Literature search. Wrote the paper. Reviewed the paper. Translated the paper. J.C.A.Á.: Conceived the study and the analysis. Literature search Performed the analysis. Reviewed the paper. Translated the paper. N.P.M.: Performed the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. R.S.C.: Performed the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. S.H.F.: Conceived the study and the analysis, Performed the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. F.L.S.: Performed the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. J.M.M.: Conceived the study and the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. A.R.G.: Conceived the study and the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. J.A.C.: Conceived the study and the analysis. Description of tables and figures. Wrote the paper. Reviewed the paper. Translated the paper. O.P.O.: Conceived the study and the analysis. Performed the analysis. Reviewed the paper. Translated the paper. All authors have read and agreed to the published version of the manuscript. Funding: This research received no external funding. Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board (or Ethics Committee) Ethics and Research Committee of the Sagrat Cor University Hospital (Barcelona), that this committee has evaluated on 25/05/2021 (nº11/2021). Protocol Code: 2021/32-PNE-HUSC Internal Code: 2021/32- PNE-HUSC. Informed Consent Statement: Not applicable. Data Availability Statement: The results presented are stored in the database of Hospital Universi- tario Sagrat Cor. Acknowledgments: We thank Joan Josep Sopeña and Josep Enric Boada Port for their ongoing support for establishing and maintaining the IRCU. To Antoni Lopez for keeping the closet open. Conflicts of Interest: The authors declare no conflict of interest. Int. J. Environ. Res. Public Health 2022, 19, 6034 11 of 11 References 1. Ministerio de Sanidad Consumo del Govierno de España. España. (Información Inicial Alerta). 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