Experience in the Cohort Intermediate Care Unit Arrangement and Nursing management of patients with COVID-19 at Bangkok Hospital Headquarters

OBJECTIVES: To share experiences for the Cohort Intermediate Care Unit (IMCU) setup description. It also involves the focusing on integrated nursing care in collaboration with Multi-professional team to improve patient outcomes. MATERIALS AND METHODS: We collected and searched many articles from the published medical literature that reported standard protocols for the IMCU and nursing management of SARS-CoV-2 (COVID-19). This study was a collection of data from COVID-19 patients who were confirmed cases with positive real time-PCR test results. They were receiving treatment and admitted at Bangkok Hospital Headquarters (BHQ) from May 1 st - June 30 th , 2021. Descriptive statistics were used to describe the results in frequency, percentage and mean. We compared the average number of days for COVID-19 patients stay between two groups. A confidence interval (CI) was used to explain a different sample proportion and a different interval of hospital mortality rate. RESULT: Among 122 COVID-19 patients, 41 (33.6%) patients were admitted to the Cohort IMCU. The average length of stay (LoS) was 5.1 days, with minimum 1 day and maximum 15 days. Three quarter of them (31/41, 75.6%) had clinical improvement and were transferred to Cohort ward, while a quarter (10/41, 24.4%) had experienced clinical deterioration and were transferred to intensive care unit (ICU). Mortality rate of this group was 4.9% (95%CI -1.7, 11.5). During the same time period, 81 COVID-19 patients were directly transferred to ICU. The average LoS in ICU of 6.2 days. Among them, 8 of 81 patients did not survive. As a result, mortality rate among this group was 9.9% (95%CI 3.4, 16.4). CONCLUSION: In our experience, the Cohort IMCU can reduce mortality rate of the COVID-19 patients and proper management also decrease crowding of ICU.

I t was found a local cluster of pneumonia patients with unknown causes in Wuhan, China in late December 2019. 1 Originally, it was believed that bats were caused the coronavirus and mutated. 2 It was later officially announced by the World Health Organization (WHO) that the disease caused by an infection with SARS-CoV-2 (Severe Acute Respiratory Syndrome CoronaVirus-2), called as the coronavirus disease 2019 or COVID-19. There is an epidemic pattern (Propagated) that spreads of Human to Human transmission. 3 Later on January 30, 2020, the WHO declared the new coronavirus outbreak a Public Health Emergency of International Concern. It was raised to the highest level of alarm, because of the continuous increase in the number of patients as a pandemic. 4 In Thailand, the outbreak of COVID-19 was spread rapidly in all regions. 5 Especially, Bangkok city is the center of the current COVID-19 pandemic. Cumulative number of patients found since 2020 were 165,462 cases, 114,578 cases were recovered, and deaths 1,107 cases. 6 At present, a pandemic has entered stage of the third to fourth wave of the outbreak. 7 There were many patients with COVID-19 who had pneumonia progress to be Acute Respiratory Distress Syndrome (ARDS) and needed more ventilators or special equipment, e.g., Extracorporeal Membrane Oxygenation (ECMO) and Hemodialysis for their life support. 8 The massive increasing of COVID-19 patients affected survival rate especially in ICU. 9 It involved both public and private hospitals.
The BHQ has prepared a Cohort ward (isolated ward) to support this crisis situation. Afterward, the coronavirus that causes COVID-19 has been mutated to a new variant from India, which is called "Delta". 10 It is more easily transmitted and severe than other variants. It was consistent with previous studies that showed 84 patients (41.8%) of COVID-19 patients having a progression of ARDS and 44 patients (52.4%) died. 11 A professional Nursing Organization (NSO) at BHQ was actively responding to this COVID crisis. They prepared facilities and set up the Cohort IMCU for patients with COVID-19. The Cohort IMCU also helps to distinguish patients who have co-morbidity diseases with mild condition from moderate and severe cases with COVID-19. Moreover, patients with co-morbidity diseases should be monitored closely because of progressive clinical to severe stage.
In addition, there was a shortage of doctors and nurses. It associated with the beginning of this pandemic crisis among healthcare providers who closed contact with COVID-19 patients and high-risk groups. Many nurses also had to selfquarantine for 14 days and they must be treated immediately if their COVID-19 test results were positive. It affected human resources planning and health care quality of these patients. 12 Therefore, the objective of this article is to share experiences for the Cohort IMCU arrangement. This article discusses how the idea of the Cohort IMCU has been applied in BHQ, Thailand.

Methods
We collected and searched many articles from the published medical literature that reported standard protocols, review concepts of admission criteria and transfer guidance for the IMCU and nursing management of COVID-19. It was applied from a variety of the specialty guidelines and then adjusted to evidence-based pathway, including this unit applied of new healthcare technology and medical devices to reduce the direct transmission routes to healthcare providers.

A professional nursing organization's responsiveness to the COVID-19 pandemic situation
The NSO at BHQ has organized a working group to set up an Intermediate Care Unit and review guidelines of nursing practice for patients with COVID-19 13 to prevent and control the spread of this illness. It is based on the guidelines of the Department of Medical Services Ministry of Public Health (Thailand), 14-16 COVID-19 guidance of The Centers for Disease Control and Prevention (CDC) 17 and followed the standards of Joint Commission International (JCI) 18 for continuous quality improvement and safety of medical care as detailed below: 1. Set up the Cohort Intermediate Care Unit (Cohort IMCU) 19,20 The Cohort IMCU has developed as specialized unit that providing an intermediate level of care between a Cohort ward and ICU for patients with COVID-19 whose conditions are clinically unstable. Their illness requires continuous vital signs monitoring for ensuring patient safety but no need mechanical ventilation with the following steps:  15 It provides oxygen deliver up to 100% heated for treatment and humidified oxygen at a maximum flow nasal cannula of 60 LPM, therefore it can reduce the endotracheal intubation rates in COVID-19 patients with oxygen deficiency. Furthermore, ancillary department also manage inventory and stock effectively that all medical supplies and devices should be available 24 hours on the unit. iii. Working with Clinical Laboratory. 25 These process was transported blood samples or the nasopharyngeal specimens to the laboratory rapidly for detection and identify infected people or patients who were tested positive for COVID-19. iv. Cooperate with the Facility Management Department. NSO provides work procedures (WP) for "Isolation Precautions" to them and ensure that they are following Hospital protocols and WP. 13

The Human
Resources and preparation of the team 12,29 Shift work in the Cohort IMCU is a 12-hour rotation (morning shift 7.00-19.00 and afternoon shift 19.00-07.00). There is one Internal physician (daytime) and one On-call physician (overnight coverage) for their patients with a multi-professional team, in detail as: 2. 3. Risk of acute respiratory failure 4. Uncomfortable due to symptoms of COVID-19 as acute respiratory illness (e.g., fever, cough, sore throat, fatigue or headache) • Check the ROX score 41 to predict the risk of intubation in hypoxemic respiratory failure and MEWS score 42 such as Systolic blood pressure (mmHg), heart rate, respiratory rate, temperature (°C), conscious level, and any concern about the patient's condition (score 0-21, if score ≥ 4, consider to transferred to the ICU)  43,44,45 Patients at risk of anxiety and lack of knowledge about disease. The roles of nurse, as follows: i. First, nurse should establish a trust relationship with the patients, include: -Offer an opportunity for patients to talk about their disease and express empathy -Paying attention to the patient' needs and ask the patients for clarification with positive communication ii. Provide truthful knowledge and health education to patients, such as advice to keep isolation, precautions during hospitalization and ensure patients are aware of prevent the spread of infectious disease iii. Encourage the patients to have daily activities to self-monitor their symptoms and take care themselves. For example, how to self-examination as fever measurement, vital signs and oxygen saturation monitor through the Tytocare TM device. iv. To support patient's confidence that the nurse is monitoring health conditions of the patient closely 24 hours through the Tele-monitoring system. Nurse support a comfortable environment and easy access to improve effective communication through the hospital telehealth system. They can contact nurses as needs.
v. The depression screening on patients as the Patient Health Questionnaire-9 (PHQ-9) on the first day of admission that use to assess the depression severity. They may consult with a psychologist to recover from mental health problems.
3.3 Psychosocial support for COVID patients 44,46 Some patients were their relatives as family, siblings as well as neighbors, friends or coworker violence. Also, they have concern and worry about economic factors, e.g., unemployment and financial problem. They must adapt to new daily routine as Work from home, closing public places/schools and social isolate. These has impacted on daily life changes very rapidly during COVID-19 situation.
The role of a nurse is provided knowledge, motivation and discussion with the patients and their family or intimate relatives. Nurse is explained about disease and answer questions clearly for relieve stress. Nurse is also encouraging participation to family members involve in the care of patients and continue to recover them at home. This may have positive affected on social adaptation of patients appropriately. In addition, nurse is coordinated with Multidisciplinary care team, including a family meeting before discharge. An attending physician may consult a Psychologist for improving the patients' self-esteem and self-confidence because they may have a negative impact on mental health effects of Covid-19 crisis. It also relates to their long-term quality of life and emotional well-being. 47

Data collection and analysis
This study was collecting data from the COVID-19 patients who were confirmed cases with positive real time-PCR (Poly-

Discussion
The results of this study was consistent with a systematic review from four studies in China and outside China, it was found a median hospital LOS in ICU for COVID-19 patients was 8 days and 7 days respectively. 49 In agreement with previous studies from 10 hospitals in an integrated healthcare system. It was found that the Step Down Unit care was associated with patient outcomes improvement, 50 especially for high-risk patients. The Step Down Unit admission after an ICU discharge was associated with decrease the hospital mortality rate of 2.5%. 51 Furthermore, previous similar study showed the effective utilizations of Intermediate Care Units that can have increased availability of ICU beds 52 and the cost of staffing was lower in the IMCU than ICU as well. 29 Meanwhile, many patients have psychosocial problems affecting them after discharge from an ICU. 53  Descriptive statistics were used to describe the results in frequency, percentage and mean. We compared the average number of days for COVID-19 patients stay and the mortality rate in hospital between two groups. The CI was used to explain a different sample proportion and a different interval of hospital mortality rate. The mortality rate and CI for proportion formulas, 48 as below: consequently the health information technology solution for COVID-19 patients should flexible access and easy to use. Accordingly, the primary role of nurse in the Cohort IMCU should also provide a holistic nursing care and psychosocial support, including sharing the decision making with patients and their families collaboration, which these may improve patients experience and a positive effect on their outcomes. In addition, nurses spend more time with patients with the health assessment, nursing diagnosis, care planning, implementation and patients' evaluation. Therefore, nurses need to prepare both mentally and physically, including their competencies to be ready to respond to this crisis situation that provide excellent and efficient nursing care.
This study aims for sharing our experience among the COVID-19 crisis like a preliminary view. Thus, it may have the selection bias and limitations from the selection of some participants into this study. We compared the LoS of COVID-19 patients between two groups. Some COVID-19 patients were admitted to ICU directly that may have more severe conditions and life-threatening than those who were transferred to the Cohort IMCU. It can be related to prolonged hospitalization. Therefore, hospital mortality rate of ICU was higher than Cohort IMCU. However, further research design should be optimized to reduce bias that could influence study results and further studies are needed more variable which may affect LoS and patient outcomes with COVID-19.

Conclusion
The Cohort IMCU can decrease the mortality rate of the COVID-19 patients. It can also increase the number of ICU beds for COVID-19 patients who require early detection of of the disease's progression needed invasive mechanical ventilation.