How the Acute Respiratory Care Unit Improves Care for Complex Patients

Written by Sudhir Krishnan, MD; Eduardo Mireles-Cabodevila, MD; and Hassan Khouli, MD,

The COVID-19 pandemic was a watershed moment in critical care history, and the experience left an indelible mark on those of us who served in the ICUs. The management of refractory acute lung failure combined with protracted ventilator therapy was a hallmark of this malady. Cohorting severely ill patients with a similar disease in a designated geographical location and investing in a multidisciplinary team that specializes in lung failure helped us navigate some of our most challenging cases. The lessons learned during this very difficult phase led to the creation of the Acute Respiratory Care (ARC) Unit.

We face an era of rapid technological advancements, an increasing severity of disease in an aging population, and new and complex treatments. Patients survive otherwise unsurvivable diseases thanks to transplants, medications or the use of extracorporeal life support. The complexity of these patients and their treatments requires specialized knowledge. This is a transformative paradigm shift in critical care delivery.

Our approach has been to create subspecialist intensive care units (ICUs) that operate within our Medical Intensive Care Unit but focus on a specific patient population or diseases. In this case, ARC was created to care for patients with severe respiratory failure — a super-specialized unit within the medical intensive care unit (MICU) to diagnose, assess and treat patients with complex pulmonary pathology faster and more efficiently.

Overview of the program

Cleveland Clinic’s ARC is a 12-bed unit within the MICU. It is led by a group of experienced critical care physicians to manage complex respiratory failure and extracorporeal life support. The unit provides interprofessional and multidisciplinary care to our most vulnerable patients. These patients require intensive medical attention as well as timely and targeted clinical interventions for those with severe and complex respiratory failure. The ARC team offers care for patients being evaluated or who have received extracorporeal life support.

Our multidisciplinary approach is the cornerstone of our comprehensive and holistic care philosophy, as each member brings unique expertise and insight into patient management. A dedicated group of intensivists, pulmonologists, transplant physicians, nurses, respiratory therapists, pharmacists, physical therapists and advanced care practitioners form a team trained and focused on complex, severe respiratory failure. The team collaborates across all disciplines and works closely with our cardiothoracic surgeons to help transition them to and from extracorporeal life support. The ARC focuses on advanced physiologic monitoring, application of respiratory support devices and technology, evaluation for extracorporeal life support, and recovery from the effects of severe respiratory failure.

Our team and our priorities

The goal of the ARC is to have the ability to personalize care to the needs of the patient’s condition. The team members of the ARC collaborate and share ideas and expertise to find new ways to achieve that goal; the team meets several times to discuss cases and develop new approaches and best practices.

For instance, a group of patients may benefit from less intense extracorporeal life support, called extracorporeal removal of carbon dioxide (ECCO2R). The ARC team recognized several groups of patients for which this level of support may avoid the full institution of ECMO. This led to a process to implement the ECCO2R program at the ARC. The systematic process included networking and collaborating within and across the institution, establishing guidelines and procedures, creating a training program, and developing standard operating procedures. Like all initiatives, iteration, and revaluation lead to improvement in delivery.

Another one of our priorities is to train and graduate the best leaders in critical care medicine. We believe that the skills our residents, fellows and advanced practice providers develop from training in the ARC will prepare them to be future leaders in the highly challenging field of critical care. Although the ARC is unique due to the available resources and sheer patient volume at Cleveland Clinic, we believe the experiential learning our critical care team members acquire here through ARC will be lifelong lessons that can be applied wherever their career path takes them. Through caring for these patients in highly interprofessional and interdisciplinary environments, we believe we are giving our care team the tools and experience in their journey to become future leaders in critical care.

Valuable research

In addition to providing and optimizing care, research is another important focus of the ARC. Cohorting patients in the ARC increases the ability to implement interventions and assess and improve their effects. The ARC is a fertile ground for conducting multicenter clinical and translational trials and beta testing innovative medical devices. The generation of systemic knowledge is vital to improve the care of future patients. Several ongoing or planned trials will assess respiratory physiology, new ways to ventilate patient, and implementation of goal-directed mechanical ventilation and diaphragm stimulation.

We are still a young and ambitious ICU and continuing to develop plans around clinical research. Clinical trials related to respiratory issues and therapies will be preferentially hosted in the ACR. Prospective observational studies evaluating morbidity and mortality outcomes in patients with complex respiratory failure admitted to the ARC are also on the horizon. Our focus for this upcoming year is navigating operational and clinical challenges while trying our best to cohort those who would benefit from being admitted to the ARC.

In summary, the ARC highlights the unique approach of the Medical Intensive Care Unit at the Cleveland Clinic to improve patient care. That is, by cohorting patients in a geographic area and cared for by a highly skilled multidisciplinary team, we seek to optimize care of the patients with complex respiratory failure to minimize their time requiring life support (mechanical ventilation or extracorporeal life support), achieve a timely diagnosis, and implement therapies to save lives and improve their quality of life. The ARC team will provide standardized state-of-the-art care to patients, research their problems, and educate those who serve to improve outcomes if patients with complex respiratory failure.