Respiratory intensive care units in Italy: a national census and prospective cohort study

Background-In Italy, respiratory intensive care units (RICUs) provide an in termediate level of care between the intensive care unit (ICU) and the gene ral ward for patients with single organ respiratory failure. Because of the lack of official epidemiological data in these units, a two phase study wa s performed with the aim of describing the work profile in Italian RICUs. Methods-A national survey of RICUs was conducted from January to March 1997 using a questionnaire which comprised over 30 items regarding location, mo dels of service provision, staff, and equipment. The following criteria wer e necessary for inclusion of a unit in the survey: (I) a nurse to patient r atio ranging from 1:2.5 to 1:4 per shift; (2) availability of adequate cont inuous non-invasive monitoring; (3) expertise for non-invasive ventilation (NIV) and for intubation in case of NIV failure; (4) physician availability 24 hours a day. Between November 1997 and January 1998 a 3 month prospecti ve cohort study was performed to survey the patient population admitted to the RICUs. Results-Twenty six RICUs were included in the study: four were located in r ehabilitation centres and 22 in general hospitals. In most, the reported nu rse to patient ratio ranged from 1:2 to 1:3, with 36% of units reporting a ratio of 1:4 per shift. During the study period 756 consecutive patients of mean (SD) age 68 (12) years were admitted to the 26 RICUs. The highest pro portion (47%) were admitted from emergency departments, 19% from other medi cal wards, 18% were transferred from the ICU, 13% from specialist respirato ry wards, and 2% were transferred following surgery. All but 32 had respira tory failure on admission. The reasons for admission to the RICU were: moni toring for expected clinical instability (n=222), mechanical ventilation (n =473), and weaning (n=59); 586 patients needed mechanical ventilation durin g their stay in the RICU, 425 were treated with noninvasive techniques as a first line of treatment (374 by non-invasive positive pressure, 51 by iron lung), and 161 underwent invasive mechanical ventilation (63 intubated, 98 tracheostomies). Ah but 48 patients had chronic respiratory disease, mainl y chronic obstructive pulmonarydisease (COPD; n=451). More than 70% of pati ents (n=228) had comorbidity, mainly consisting of heart disorders. The med ian APACHE II score was 18 (range 1-43). The predicted inpatient mortality risk rate according to the APACHE II equation was 22.1% while the actual in patient mortality rate was 16%. The mean length of stay in the RICU was 12 (11) days. The outcome admitted to in most patients (79.2%) RICUs was favou rable. Conclusions-Italian RICUs are specialised units mainly devoted to the monit oring and treatment of acute on chronic respiratory failure by non-invasive ventilation, but also to weaning from invasive mechanical ventilation. The results of this study provide a useful insight into an increasingly import ant field of respiratory medicine.