Can Pediatric Intermediate Care Optimize PICU Utilization? Outcomes from a Single-Center Study

Can Pediatric Intermediate Care Optimize PICU Utilization? 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Outcomes from a Single-Center Study Francesca Benedetti, Caterina Agosto, El Amiri Oumaima, Andrea Aghi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7861766/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Pediatric Intermediate Care Units (PIMCUs) provide an intermediate level of care for children whose needs exceed those of general wards but do not require Pediatric Intensive Care Unit (PICU) admission. Most PICU-escalated children quickly recover without intubation. Although intensive care overcrowding is documented, the safety of non-invasive ventilation (NIV) outside intensive care in pediatrics remains uncertain. This study aims to analyze admissions to PIMCU, to characterize patients requiring PICU transfer and identify a subgroup who might have been safely managed in the PIMCU. Methods this is a retrospective analysis of admissions to a newly established PIMCU (Nov 2023–Jun 2025). Data collected were demographics, Pediatric Early Warning Score (PEWS), and outcomes. A subgroup analysis defined a “Low-risk NIV Group” (NIV ≤ 5 days, simple interfaces, no or dexmedetomidine-only sedation). A cost simulation compared intensive care costs with projected PIMCU costs for this group. Results a total of 365 children were admitted to PIMCU; 26 (7%) required intensive escalation, mainly for respiratory failure (80%); transferred patients had higher PEWS (median 2 vs. 1, p < 0.001) and shorter PIMCU stays (2 vs. 6 days, p < 0.001). Respiratory disease was an independent predictor of pediatric intensive care transfer (adjusted OR 2.79, 95% CI 1.10–7.06). In intensive care, 81% were managed with NIV; 9 fulfilled “Low-risk NIV” criteria. A cost simulation estimated potential savings of >€50,000 annually. Conclusions most intensive escalations were due to respiratory failure. In low-risk patients, short and mild NIV support was successful. This suggests that, under appropriate conditions, NIV could be safely extended to PIMCUs. Figures Figure 1 Figure 2 Introduction Pediatric Intermediate Care Units (PIMCUs) have emerged as an essential component in the continuum of care for children who require close monitoring and medical interventions that exceed the capabilities of general pediatric wards but do not meet the criteria for admission to a Pediatric Intensive Care Unit (PICU). Despite varying terminology in the literature, PIMCUs are defined by two main features: continuous or near-continuous patient monitoring (both instrumental and clinical) and an intermediate intensity of care between standard hospitalization and intensive care, including the provision of non-invasive organ support (e.g., non-invasive ventilation, NIV)( 1 ). The benefits of establishing intermediate care units are well-documented in both adult and pediatric settings. Notable advantages include a reduction in PICU nursing workload, shorter PICU stays—since patients can be transferred to intermediate care earlier—and prevention of inappropriate PICU admissions( 2 , 3 ). In Italy, the daily cost of a PICU stay is estimated at approximately €2000–2500, highlighting the potential economic impact of implementing intermediate care. Moreover, PICUs are often overcrowded, and patients requiring chronic organ support—such as home NIV or dialysis—are often not accepted by general wards due to their technological dependence( 4 ). As a result, these patients remain in the PICU, occupying beds that could otherwise be reserved for acutely critically ill children. Recent literature indicates that the majority of PIMCU admissions are for respiratory conditions, most often infection related. Similarly, among patients who require escalation to intensive care, the primary reason is the need for increased respiratory support, mainly NIV( 5 , 6 ). NIV refers to the delivery of positive pressure ventilation with or without supplemental oxygen to the respiratory system without the use of invasive airway devices such as endotracheal tubes or tracheostomies( 7 ). Historically, NIV was administered primarily within intensive care settings; however, a considerable proportion of patients receiving NIV do not ultimately require intubation or invasive mechanical ventilation( 8 ). In adult populations, the use of NIV in general wards has become routine practice. In pediatrics, several studies have described the application of NIV in non-intensive settings. Smith et al. observed that the length of stay was shorter for patients receiving NIV in the PIMCU compared to those managed with the same therapy in the PICU( 5 ). Nevertheless, the extent to which NIV can be safely and effectively delivered outside the PICU remains uncertain. We hypothesized that, among children with acute respiratory conditions requiring NIV, a subset presents with identifiable low-risk clinical characteristics that allow for safe and effective management within a PIMCU, leading to reduced PICU admissions without compromising patient outcomes. Among children admitted to a newly established PIMCU who required escalation to the PICU for respiratory distress, this study aims to identify those whose clinical profiles and treatments suggest they could have been safely managed within the PIMCU. Materials and methods Setting: the Department of Women’s and Children’s Health, affiliated with the University of Padova, is a tertiary pediatric hospital serving the northeastern region of Italy, with an independent PICU and a direct-access Pediatric Emergency Department (pED). In November 2023, a PIMCU was established within the 16-bed Acute Patient Ward affiliated with the pED. This area operates under the Co-located Units Model(9, 10) and accommodates up to eight flexible beds. The unit is staffed by the same physicians and nurses as the pED, all of whom have backgrounds in pediatric emergency medicine, intensive care, and general pediatrics. Internal policies were adapted to meet the specific needs of the PIMCU; the admission criteria for the PIMCU were adapted from the AAP Guidelines for PIMCU(1) and are shown in Supplementary Material 1. Study design: this was a retrospective observational study; medical records of all patients aged 0–17 years who were admitted to the PIMCU between November 1, 2023 and June 30, 2025 were reviewed. Data were collected and managed using REDCap electronic data capture tools hosted at Azienda Ospedale Università Padova(11, 12). Collected data : demographics, baseline clinical characteristics (comorbidities, presence of a complex chronic condition - CCC(13), domiciliary devices), admission source, admission diagnoses, pediatric early warning score (PEWS)(14) at admission, length of PIMCU stay. For the patients who needed escalation to PICU the following were also recorded: reasons for PICU transfer, PEWS score at transfer, type of respiratory support needed (none, NIV, invasive mechanical ventilation - IMV), highest NIV settings required during PICU stay (IPAP, EPAP, FiO2), type of NIV interface used, total duration of NIV in days, total duration of IMV in days, length of PICU stay, patient respiratory outcomes (spontaneous breathing, NIV, tracheostomy), disposition. Subgroup analyses were conducted comparing the following two groups: (1) patients requiring escalation to the PICU; (2) patients transferred to a lower-acuity setting (lower-level hospital, general wards, or home). In addition we performed an adjunctive sub-analysis of children who met all of the following criteria: escalated to the PICU for respiratory failure, supported with NIV only (without intubation), NIV duration ≤5 days, use of simple interfaces (nasal cannulas or nasal masks), no sedation or sedation with dexmedetomidine only, and discharge without the need for ongoing domiciliary respiratory support. This subgroup was designated as the Low-Risk NIV Group , as existing literature suggests that children with these characteristics can be reasonably and safely managed outside of intensive care settings(1, 5, 15). Statistical analysis: descriptive statistics were used to summarize the characteristics of the study population. Continuous variables were reported as mean and standard deviation (SD) if normally distributed, or as median and interquartile range (IQR) if non-normally distributed. Categorical variables were summarized as absolute frequencies and percentages. For comparisons of continuous variables between groups, the Mann–Whitney U test or Kruskal–Wallis test was used for non-normally distributed data. Categorical variables were compared using the Chi-square test or Fisher’s exact test, as appropriate. A multiple logistic regression model was used to assess the strength of the association between PICU admission and respiratory disease. Respiratory disease and potential clinical confounders (age, CCC) were individually assessed in univariate logistic regression models and subsequently included together in a multiple model. Firth's penalized likelihood method was employed to obtain robust estimates and address potential separation issues. In logistic models, data were expressed as odds ratio (OR), 95% confidence interval and P-value. Results are presented as forest plots showing odds ratios with corresponding 95% confidence intervals. All analyses were performed using Stata SE 16.1 and R Studio, version 2023.06.0+421. Finally, a cost simulation analysis was performed to estimate the potential financial impact of managing selected low-risk patients with NIV in the PIMCU instead of the PICU. Based on published estimates and institutional benchmarks, the daily cost of a PICU stay was assumed to be approximately €2,000, increasing to a minimum of €2,500 when including NIV and sedation. In contrast, the estimated cost of a PIMCU day was set at €1,000. Using the observed median PICU length of stay for the patients who received only NIV, we calculated the total cost under both care scenarios and estimated the potential savings associated with shifting these cases to the PIMCU: (patients x median PICU stay x PICU day cost) - (patients x median PICU stay x PIMCU day cost) = estimated savings This study was conducted in accordance with the STROBE guidelines (16) and with the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. Ethical approval was obtained by the Regional Ethic Committee Area Centro-Est Veneto (CET -ACEV) with the Protocol n. AOP3948. Results Of the 1678 admissions to the Acute Patient Ward, 365 (22%) were admitted to the PIMCU. A detailed summary of patient characteristics is presented in Table 1 , and the study population flow diagram is depicted in Figure 1 . Table 1: Characteristics of the study population Characteristics Total N = 365 PICU transfer N = 26 Lower acuity care N = 339 p Male, n (%) 186 (51) 13 (50) 173 (51) 0.9 Age at admission, median (IQR) 3 years (9-0.4) 1.8 (6.5-0.2) 4 (9.4-0.6) 0.08 Previously healthy, n (%) 186 (51) 12 (46) 174 (51) 0.6 Number and classification of CCCs, n (%) Neurologic Cardiac, congenital Respiratory Metabolic Gastroenterology Renal Hematology/Oncology Genetic/Chromosomal/Malformations Extreme prematurity 149 (41) 51 (34) 21 (14) - 5 (3) 2 (1.5) 2 (1.5) 39 (26) 19 (13) 10 (7) 11 (79) 5 (46) 2 (18) - - - - 1 (9) 1 (9) 2 (18) 138 (84) 46 (33) 19 (14) - 5 (5) 2 (1) 2 (1) 38 (27) 18 (13) 8 (6) 0.8 Domiciliary devices, n (%) NIV IMV/Tracheostomy NGT/PEG 78 (21) 10 (13) 35 (45) 41 (52) 5 (19) - 3 (60) 3 (60) 73 (21) 10 (14) 32 (44) 38 (52) 0.7 Source of admission, n (%) pED General Ward Other Hospital PICU or NICU 239 (66) 19 (5) 44 (12) 63 (17) 15 (58) 3 (11.5) 5 (19) 3 (11.5) 224 (66) 16 (5) 39 (11) 60 (18) 0.2 Admission diagnoses, n (%) Respiratory Neurologic Hematology Shock/sepsis Gastrointestinal/Hepatobiliary Metabolic/Endocrine Trauma Cardiac Other Renal 192 (53) 71 (19) 40 (11) 21 (6) 11 (3) 11 (3) 10 (2.5) 2 (0.5) 5 (1.5) 2 (0.5) 20 (76) 2 (8) - 2 (8) - - - 1 (4) 1 (4) - 172 (50) 69 (20) 40 (12) 19 (6) 11 (3) 11 (3) 10 (3) 1 (0.3) 4 (2) 2 (0.7) 0.2 PEWS score at admission, median (IQR) 1 (3-0) 2 (4-1) 1 (3-1) < 0.001 Length of PIMCU stay, median (IQR) 6 (8-3) 2 (3-1) 6 (9-3) < 0.001 Abbreviations 1: CCCs = complex chronic conditions; IMV = invasive mechanical ventilation; IQR = inter quartile range; NGT = naso-gastric tube; NICU = neonatal intensive care unit; NIV = non invasive ventilation; pED = pediatric Emergency Department; PEG = percutaneous gastrostomy; PEWS = pediatric early warning score; PICU = pediatric intensive care unit; PIMCU = pediatric intermediate care unit. Three hundred and thirty-nine children were transferred to a lower acuity care or discharged home: 173 were male (51%), median age was 4 years (IQR 9.4-0.6; range, 15 days to 17 years), 138 (41%) were classified as having a CCC. The median length of PIMCU stay was 6 days (IQR 9-3; range, 1–65 days). At discharge, 190 patients (56%) returned home, 138 (41%) were transferred to a general ward, and 11 (3%) to a lower-level hospital. Twenty-six children (7%) needed PICU escalation: 13 (50%) were male and median age was 1.8 years (IQR 6.5-0.2; range, 15 days–15 years). Of this subgroup, 11 (42%) were classified as having a CCC. The majority were admitted from the pED (15, 58%). The primary reasons for PIMCU admission were respiratory diseases (20, 76%). The median length of stay in the PIMCU prior to PICU transfer was 2 days (IQR 3-1; range, 1–14 days). The reasons for PICU admission were escalation of respiratory support (21, 80%), high-risk procedures (3, 11%), shock requiring inotropes (1, 4%), and refractory status epilepticus (1, 4%). The median PICU length of stay was 4 days (IQR 7-3; range, 1–34 days). Among the 21 patients requiring escalation of respiratory support, 4 (19%) were intubated and received IMV for a median duration of 8 days (IQR 1–11). The remaining 17 patients (81%) were managed with NIV, 1 with CPAP and 16 with BiPAP. Among them, 14 (82%) used nasal cannulas (RAM Ⓡ), while others used nasal mask (1, 6%), oro-nasal mask (1, 6%), full-face mask (1, 6%). The maximal NIV settings were: median EPAP 7 cmH2O (IQR 10-7, range 5-12); median IPAP 16 cmH2O (IQR 17-12, range 12-22); median FiO2 0.4 (IQR 0.5-0.3, range 0.21-0.6). The median duration of NIV was 3 days (IQR 4-2, range 1-9). Sedation was not required in three patients, while the remaining 14 (82%) received dexmedetomidine. Of these, 5 (36%) also received ketamine as needed, and 3 (21%) morphine as needed. Regarding respiratory outcomes, of the 21 children with respiratory failure, 20 (95%) returned to spontaneous breathing in room air, whereas 1 (5%) required a tracheostomy. Of the 26 children who required PICU escalation, one died during the PICU stay due to multi-organ failure secondary to splenic sequestration crisis in the context of sickle cell disease. Of the 25 survivors, 16 (64%) were transferred to a general ward and 9 (36%) were returned to the PIMCU. A child died at home following discharge from the PIMCU with an anticipatory disposition of do-not-resuscitate (DNR) order. Children requiring PICU transfer, compared to those who did not need PICU care, tended to be younger, although the difference did not reach statistical significance. There were no significant differences between children transferred to the PICU and those managed in lower-acuity care with respect to sex distribution, prior health status, presence of CCCs, presence of domiciliary devices, source of admission, or admission diagnosis (all p > 0.05). In contrast, children requiring PICU transfer presented with significantly higher PEWS scores at admission (p < 0.001) and had shorter lengths of stay in the PIMCU compared with those managed in lower-acuity care (p < 0.001). In univariate analysis, respiratory disease increased admission odds (OR = 3.06, 95% CI: 1.24–7.59, p = 0.010). Age and CCCs showed no significant associations ( Table 2, Figure 2 ). In multivariate analysis, respiratory disease (adjusted OR = 2.79, 95% CI: 1.10–7.06, p = 0.026) remained independently associated with PICU admission, while age and presence of CCCs were not significant predictors ( Table 2, Figure 2 ). Table 2: Univariate and multiple logistic regression model for identifying predictors for PICU admission. Univariate Multiple Predictors OR CI 95% p OR CI 95% p (Intercept) 0.04 0.02 – 0.08 <0.001 0.05 0.02 – 0.12 0.001 Age 0.94 0.86 – 1.02 0.143 0.96 0.87 – 1.04 0.315 Complex Chronic Condition 1.08 0.49 – 2.39 0.850 1.29 0.55 – 2.95 0.538 Respiratory Disease 3.06 1.24 – 7.59 0.010 2.79 1.16 – 7.57 0.028 Number of patients 365 365 NIV Group – Low-risk patients Nine children fulfilled the criteria for the Low-risk NIV Group (male = 5, 55%), with a median age of 2.5 months (IQR 0.4–0.1 years, range 15 days–6 years). Two patients (22%) had a CCC, while none had domiciliary devices. The main admission diagnoses were bronchiolitis (7, 78%) and pneumonia/parenchymal disorder (2, 22%). Median PEWS at admission was 3 (IQR 4–1, range 0–5), and at PICU transfer remained 3 (IQR 4–2, range 1–6). During their PIMCU stay, eight children (89%) received high-flow oxygen therapy. The median PIMCU length of stay before PICU transfer was 2 days (IQR 2–1, range 1–3), and the median duration of NIV support in the PICU was 3 days (IQR 4–2, range 1–4). Median PICU length of stay was 4 days (IQR 5-3). Three patients required no sedation, whereas the remaining six (67%) were sedated with dexmedetomidine only. With respect to interfaces, eight children were ventilated with nasal cannulas (RAM®) and one with a nasal mask. Maximal NIV settings were as follows: median EPAP 7.5 cmH₂O (IQR 9–6.5, range 5–10), median IPAP 16 cmH₂O (IQR 16–13, range 12–22), and median FiO2 0.45 (IQR 0.5–0.25, range 0.21–0.60). At hospital discharge, all patients achieved spontaneous breathing in room air. NIV Group – Excluded Low-risk patients Among the 17 children managed exclusively with NIV, 8 did not meet the Low-risk criteria (50% male; median age 3.5 months, IQR 1.8-0.2 years). Three (37%) had a CCC, none had domiciliary devices. Most were admitted for bronchiolitis (5, 71%). Median PEWS was 2 at admission and 3 at PICU transfer. Median difference of PEWS between admission to PIMCU and transfer to PICU was 2. Nearly all (87%) received high-flow oxygen therapy during their PIMCU stay. The median PIMCU length of stay before PICU transfer was 2 days (IQR 5.5-1.5), with a median PICU NIV duration of 3 days (IQR 5.5-2). All patients received dexmedetomidine sedation, with additional rescue doses of morphine in 3 cases and ketamine in 5. Interfaces included nasal cannulas (n=6), oro-nasal mask (n=1), and full-face mask (n=1). Median maximal settings were EPAP 7 cmH₂O, IPAP 16 cmH₂O, and FiO2 0.4%. All children were discharged breathing spontaneously in room air. Supplementary material 2 shows the two groups with the met and unmet Low-risk criteria. Cost utility framework The results of the cost simulation strategy analysis show: number of low-risk NIV patients = 9; median PICU length of stay = 4 days/patient = 36 total PICU days; cost per PICU day including NIV and sedation estimated €2500; PIMCU cost per day estimated €1000. If these 9 low-risk patients had received equivalent care in a PIMCU equipped for NIV, the hospital could have potentially saved over €50,000 in direct care costs: (9 x 4 x 2500) - (9 x 4 x 1000) = 90.000 - 36.000 = 54.000 Discussion In this study, we examined the clinical course of children admitted to a newly established PIMCU, focusing on those who ultimately required transfer to intensive care. To our knowledge, this is the first European study to assess children escalated to PICU who could have theoretically been treated in PIMCU. While only a small proportion needed escalation to PICU care, the majority of these cases were related to respiratory deterioration, often managed successfully with NIV. Our findings are consistent with multicenter French data, where respiratory disease accounted for nearly half of PIMCU admissions and represented the main reason for transfer to intensive care( 17 ). Similarly, in 2020 an Italian national survey showed that PIMCUs are primarily utilized for respiratory conditions( 18 ). The pediatric literature has increasingly focused on predictors of PICU transfer in children admitted to PIMCUs( 19 ). In our cohort, children who required PICU escalation were generally younger, although this trend did not reach statistical significance. Acute severity at admission, as reflected by higher PEWS scores, was more closely associated with escalation to PICU, demonstrating the utility of structured early warning systems in identifying children at risk of deterioration. Interestingly, baseline characteristics such as sex, underlying comorbidities, or the presence of domiciliary devices were not significantly different between groups. This suggests that chronic disease alone does not adequately explain the need for PICU escalation, in contrast to what might be intuitively expected. Rather, acute clinical parameters at presentation appear to play a more important role. Both the univariate and multivariate analyses confirmed that the presence of acute respiratory disease represent the principal independent determinant of PICU admission in our cohort. Respiratory disease as a strong predictor aligns with previous reports observing that the need for respiratory support was a significant predictor of PICU transfer( 14 ). This likely reflects the higher risk of decompensation in these patients and confirms the central role of acute respiratory failure in PICU use. Our results stress the importance of vigilant monitoring and the development of more precise predictors of deterioration or oxygen therapy failure, such as high-flow nasal cannula. Our analyses also showed that children who needed escalation had shorter PIMCU stays prior to PICU transfer, reflecting the acute nature of illness and the early recognition of clinical instability that prompted timely transfer. This aligns with Cheng et al., who reported that transfers from intermediate care to PICU typically occurred early in the admission, highlighting the need for close monitoring and rapid decision-making in the first hours of hospitalization( 14 ). The short PIMCU stay of this subgroup of children also suggests the rapid evolution of the acute respiratory disease into respiratory failure, indicating some respiratory conditions may benefit from early NIV initiation in PIMCU. When analyzing the PICU course, we found that many of the children transferred for respiratory deterioration were managed effectively with NIV, and only a small proportion ultimately required invasive mechanical ventilation. The cohort defined as the ‘Low-risk NIV Group’ comprised patients with specific characteristics considered safe, according to existing literature( 5 , 20 – 22 ), for NIV initiation outside intensive care. In this group, ventilatory support was generally of mild intensity and limited duration, and sedation, when required, was provided with dexmedetomidine. The number of patients included was small, owing to strict selection criteria that excluded children that needed to use specific interfaces (i.e. full-face) and those sedated with agents other than dexmedetomidine. Interestingly, among the excluded children, most had only received morphine or ketamine on an as-needed basis. While we believe it was appropriate to exclude these patients for safety reasons, it could be speculated that some of them could have been managed with dexmedetomidine alone in an environment such as the PIMCU, where parental presence and fewer environmental stressors might provide additional reassurance and stability. In addition, for this selected population, we observed that the median difference between PEWS at admission and at PICU transfer was negligible. This finding can be interpreted in two ways. First, it may suggest that although these children were clinically evolving, they remained relatively stable throughout their course—an observation consistent with the ‘no change’ trajectory described by Lampin et al( 17 ). Alternatively, it raises important questions: were these children already critically ill upon admission? Or is there something that PEWS fails to capture—an aspect of clinical deterioration that led to PICU transfer despite stable scoring? Given the estimated cost of PICU day and the known burden of ICU overcrowding in Italy( 4 ), the potential to avoid unnecessary PICU admissions is both clinically and economically significant. Beyond the financial implications, reducing PICU occupancy helps preserve critical care resources for patients with higher acuity needs and alleviates the workload on PICU staff( 15 ). The potential implementation of NIV in PIMCUs could represent a sustainable strategy to balance quality of care with resource efficiency, provided that staff are adequately trained and that the unit is located near a PICU to allow rapid escalation if required. At the same time, our results should be interpreted with caution, as implementing NIV outside intensive care requires substantial investment in staff training, equipment, and policy changes. The associated costs may be considerable, especially when weighed against the relatively limited number of patients who would benefit from it. Ultimately, the safe and effective use of NIV in PIMCUs demands careful planning, ongoing staff education, and continuous quality monitoring to ensure patient safety, clinical outcomes, and optimized resource utilization. In this study, we focused primarily on children with acute conditions, as they represented the largest proportion of those requiring escalation to the PICU. However, according to the AAP guidelines( 1 ), the population eligible for PIMCU admission also includes children with CCCs experiencing acute-on-chronic illness, who are often inappropriate for both a regular ward and the PICU. Although our cohort included children with CCCs, we did not perform a sub-analysis to determine whether acute events affected them differently. Future research should therefore explore the characteristics and outcomes of this special population in the PIMCU setting, with the aim of optimizing their management and minimizing hospital stays. A major strength of this study lies in its real-world, detailed evaluation of a representative PIMCU population, including comprehensive outcome data. The inclusion of cost simulations further enhances its applicability to healthcare policy and operational planning. This study, though, has several limitations. The small number of PICU transfers, particularly within the NIV subgroup, limits the robustness and generalizability of some statistical associations. The retrospective, single-center design further constrains interpretation, as it prevents assessment of causality and may not capture all factors influencing transfer decisions. Moreover, our PIMCU follows a specific organizational model, and differences in structure, staff training, and admission criteria across institutions may restrict external validity. Despite these limitations, our findings are consistent with multicenter reports identifying respiratory disease as the leading cause of PICU escalation and supporting the feasibility of NIV in intermediate care. Future multicenter prospective studies will be necessary to validate these observations and clarify the broader role of PIMCUs in optimizing PICU utilization. Conclusion Our findings indicate that selected pediatric patients requiring non-invasive respiratory support may be safely managed within a well-equipped PIMCU, thereby reducing unnecessary PICU admissions. The successful use of NIV in our cohort highlights its feasibility outside intensive care, provided that appropriate monitoring, trained staff, and proximity to a PICU for rapid escalation are ensured. Future research should focus on evaluating the safety, efficacy, and cost-effectiveness of NIV in PIMCUs, as well as the development of structured protocols to standardize practice. Ultimately, integrating NIV into intermediate care settings has the potential to optimize resource utilization, improve patient safety, and strengthen the continuum of care across pediatric hospital systems. Abbreviations CCCs - Complex Chronic Conditions CPAP - Continuous Positive Airway Pressure EPAP - Expiratory Positive Airway Pressure FiO₂ - Fraction of Inspired Oxygen IMV - Invasive Mechanical Ventilation IPAP - Inspiratory Positive Airway Pressure IQR - Interquartile Range NIV - Non-Invasive Ventilation NGT - Naso-Gastric Tube NICU - Neonatal Intensive Care Unit OR - Odds Ratio pED - Pediatric Emergency Department PEG - Percutaneous Endoscopic Gastrostomy PEWS - Pediatric Early Warning Score PICU - Pediatric Intensive Care Unit PIMCU - Pediatric Intermediate Care Unit REDCap - Research Electronic Data Capture SD - Standard Deviation STROBE - Strengthening the Reporting of Observational Studies in Epidemiology Declarations Ethics approval and consent to participate Ethical approval was obtained by the Regional Ethic Committee Area Centro-Est Veneto (CET -ACEV) with the Protocol n. AOP3948. At the time of admission, patients over 12 years of age and the parents of younger children were asked for permission to be contacted by phone for future research purposes. Families were later contacted by phone, and informed consent forms were sent via email and returned, signed, by mail to the research center. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to concerns regarding patient privacy and confidentiality but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding No funding was received for this project or for the preparation of this manuscript. Authors' contributions FB and CA contributed equally to this work and share first authorship. FB, CA, and TZ conceptualized and designed the study. FB and OA collected the data. FB and AAg curated the data and performed the data analysis. FB and CA drafted the initial manuscript. SC, SB, AAm, and AT provided critical revisions and contributed to the interpretation of data. All authors contributed to the article, revised it for important intellectual content, and approved the final manuscript for submission. Acknowledgements The Authors would like to express deepest gratitude to Prof. Liviana Da Dalt, University of Padua, whose constant dedication to the acute care of children and visionary perspective led to the establishment of our pediatric acute care unit. Her invaluable teachings have guided us in shaping not only this service, but also in envisioning and developing an intermediate care setting for our patients. The Authors (F.B. and C.A.) would like to thank Dr. Maria Fusaro, University of Padua, whose unwavering belief in research and constant support helped us overcome moments of discouragement and motivated us to continue our work. Clinical Trial Number Clinical trial number: not applicable. 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Pediatric Complex Chronic Condition System Version 3. JAMA Netw Open. 2024;7(7):e2420579. Cheng DR, Hui C, Langrish K, et al. Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care. Hosp Pediatr. 2020;10(4):347-52. Tack J, Bruyneel A, Taccone F, et al. Analysis of admissions to intensive care units that could be supported on an intermediate care unit. Nurs Crit Care. 2024. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9. Lampin ME, Duhamel A, Behal H, et al. Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit. Indian J Pediatr. 2023. Sfriso F, Biban P, Paglietti MG, et al. Distribution and characteristics of Italian paediatric intermediate care units in Italy: A national survey. Acta Paediatr. 2020;109(5):1062-3. Lampin ME, Duhamel A, Behal H, et al. Use of paediatric early warning scores in intermediate care units. Arch Dis Child. 2020;105(2):173-9. Caggiano S, Pavone M, Cherchi C, et al. Children with medical complexity and pediatric palliative care: Data by a respiratory intermediate care unit. Pediatr Pulmonol. 2023;58(3):918-26. Brisca G, Strati MF, Canzoneri F, et al. Evaluating treatment and care outcomes for neuromuscular diseases in a pediatric intermediate care setting. Front Pediatr. 2025;13:1539540. Keim G, Nishisaki A. Improving Noninvasive Ventilation for Bronchiolitis: It Is Here to Stay! Pediatr Crit Care Med. 2024;25(3):274-5. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":209133,"visible":true,"origin":"","legend":"\u003cp\u003eStudy population flow-diagram\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-7861766/v1/e28db3b345d063c91cf81c45.png"},{"id":95064460,"identity":"6d4ce87f-e0b6-4b69-8327-c2dff6c7706e","added_by":"auto","created_at":"2025-11-04 01:22:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":61478,"visible":true,"origin":"","legend":"\u003cp\u003eUnivariate and multiple logistic regression model for identifying predictors for PICU admission.\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-7861766/v1/f07f630a1a69a2e72f3b2d3c.png"},{"id":95312247,"identity":"88a1e260-3ffc-4726-bdf3-e9a997df391a","added_by":"auto","created_at":"2025-11-06 15:48:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":755739,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7861766/v1/d8c1d2d3-0645-424a-b332-9362d12dcb99.pdf"},{"id":95064474,"identity":"4899305c-93f0-41d4-9d66-5f9c69017a61","added_by":"auto","created_at":"2025-11-04 01:22:49","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":146960,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7861766/v1/bbe71c5b99da4e94ad751192.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Can Pediatric Intermediate Care Optimize PICU Utilization? Outcomes from a Single-Center Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePediatric Intermediate Care Units (PIMCUs) have emerged as an essential component in the continuum of care for children who require close monitoring and medical interventions that exceed the capabilities of general pediatric wards but do not meet the criteria for admission to a Pediatric Intensive Care Unit (PICU). Despite varying terminology in the literature, PIMCUs are defined by two main features: continuous or near-continuous patient monitoring (both instrumental and clinical) and an intermediate intensity of care between standard hospitalization and intensive care, including the provision of non-invasive organ support (e.g., non-invasive ventilation, NIV)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe benefits of establishing intermediate care units are well-documented in both adult and pediatric settings. Notable advantages include a reduction in PICU nursing workload, shorter PICU stays\u0026mdash;since patients can be transferred to intermediate care earlier\u0026mdash;and prevention of inappropriate PICU admissions(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In Italy, the daily cost of a PICU stay is estimated at approximately \u0026euro;2000\u0026ndash;2500, highlighting the potential economic impact of implementing intermediate care. Moreover, PICUs are often overcrowded, and patients requiring chronic organ support\u0026mdash;such as home NIV or dialysis\u0026mdash;are often not accepted by general wards due to their technological dependence(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). As a result, these patients remain in the PICU, occupying beds that could otherwise be reserved for acutely critically ill children.\u003c/p\u003e\u003cp\u003eRecent literature indicates that the majority of PIMCU admissions are for respiratory conditions, most often infection related. Similarly, among patients who require escalation to intensive care, the primary reason is the need for increased respiratory support, mainly NIV(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNIV refers to the delivery of positive pressure ventilation with or without supplemental oxygen to the respiratory system without the use of invasive airway devices such as endotracheal tubes or tracheostomies(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Historically, NIV was administered primarily within intensive care settings; however, a considerable proportion of patients receiving NIV do not ultimately require intubation or invasive mechanical ventilation(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In adult populations, the use of NIV in general wards has become routine practice. In pediatrics, several studies have described the application of NIV in non-intensive settings. Smith et al. observed that the length of stay was shorter for patients receiving NIV in the PIMCU compared to those managed with the same therapy in the PICU(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Nevertheless, the extent to which NIV can be safely and effectively delivered outside the PICU remains uncertain.\u003c/p\u003e\u003cp\u003eWe hypothesized that, among children with acute respiratory conditions requiring NIV, a subset presents with identifiable low-risk clinical characteristics that allow for safe and effective management within a PIMCU, leading to reduced PICU admissions without compromising patient outcomes.\u003c/p\u003e\u003cp\u003eAmong children admitted to a newly established PIMCU who required escalation to the PICU for respiratory distress, this study aims to identify those whose clinical profiles and treatments suggest they could have been safely managed within the PIMCU.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cem\u003eSetting:\u003c/em\u003e the Department of Women\u0026rsquo;s and Children\u0026rsquo;s Health, affiliated with the University of Padova, is a tertiary pediatric hospital serving the northeastern region of Italy, with an independent PICU and a direct-access Pediatric Emergency Department (pED). In November 2023, a PIMCU was established within the 16-bed Acute Patient Ward affiliated with the pED. This area operates under the Co-located Units Model(9, 10) and accommodates up to eight flexible beds. The unit is staffed by the same physicians and nurses as the pED, all of whom have backgrounds in pediatric emergency medicine, intensive care, and general pediatrics. Internal policies were adapted to meet the specific needs of the PIMCU; the admission criteria for the PIMCU were adapted from the AAP Guidelines for PIMCU(1) and are shown in \u003cstrong\u003eSupplementary Material 1.\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy design:\u003c/em\u003e this was a retrospective observational study; medical records of all patients aged 0\u0026ndash;17 years who were admitted to the PIMCU between November 1, 2023 and June 30, 2025 were reviewed. Data were collected and managed using REDCap electronic data capture tools hosted at Azienda Ospedale Universit\u0026agrave; Padova(11, 12).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCollected data\u003c/em\u003e: demographics, baseline clinical characteristics (comorbidities, presence of a complex chronic condition - CCC(13), domiciliary devices), admission source, admission diagnoses, pediatric early warning score (PEWS)(14) at admission, length of PIMCU stay. For the patients who needed escalation to PICU the following were also recorded: reasons for PICU transfer, PEWS score at transfer, type of respiratory support needed (none, NIV, invasive mechanical ventilation - IMV), highest NIV settings required during PICU stay (IPAP, EPAP, FiO2), type of NIV interface used, total duration of NIV in days, total duration of IMV in days, length of PICU stay, patient respiratory outcomes (spontaneous breathing, NIV, tracheostomy), disposition.\u003c/p\u003e\n\u003cp\u003eSubgroup analyses were conducted comparing the following two groups: (1) patients requiring escalation to the PICU; (2) patients transferred to a lower-acuity setting (lower-level hospital, general wards, or home). In addition we performed an adjunctive sub-analysis of children who met all of the following criteria: escalated to the PICU for respiratory failure, supported with NIV only (without intubation), NIV duration \u0026le;5 days, use of simple interfaces (nasal cannulas or nasal masks), no sedation or sedation with dexmedetomidine only, and discharge without the need for ongoing domiciliary respiratory support. This subgroup was designated as the\u0026nbsp;\u003cem\u003eLow-Risk NIV Group\u003c/em\u003e, as existing literature suggests that children with these characteristics can be reasonably and safely managed outside of intensive care settings(1, 5, 15).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis:\u0026nbsp;\u003c/em\u003edescriptive statistics were used to summarize the characteristics of the study population. Continuous variables were reported as mean and standard deviation (SD) if normally distributed, or as median and interquartile range (IQR) if non-normally distributed. Categorical variables were summarized as absolute frequencies and percentages. For comparisons of continuous variables between groups, the Mann\u0026ndash;Whitney U test or Kruskal\u0026ndash;Wallis test was used for non-normally distributed data. Categorical variables were compared using the Chi-square test or Fisher\u0026rsquo;s exact test, as appropriate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA multiple logistic regression model was used to assess the strength of the association between PICU admission and respiratory disease. Respiratory disease and potential clinical confounders (age, CCC) were individually assessed in univariate logistic regression models and subsequently included together in a multiple model. Firth\u0026apos;s penalized likelihood method was employed to obtain robust estimates and address potential separation issues. In logistic models, data were expressed as odds ratio (OR), 95% confidence interval and P-value. Results are presented as forest plots showing odds ratios with corresponding 95% confidence intervals. All analyses were performed using Stata SE 16.1 and R Studio, version 2023.06.0+421.\u003c/p\u003e\n\u003cp\u003eFinally, a cost simulation analysis was performed to estimate the potential financial impact of managing selected low-risk patients with NIV in the PIMCU instead of the PICU. Based on published estimates and institutional benchmarks, the daily cost of a PICU stay was assumed to be approximately \u0026euro;2,000, increasing to a minimum of \u0026euro;2,500 when including NIV and sedation. In contrast, the estimated cost of a PIMCU day was set at \u0026euro;1,000. Using the observed median PICU length of stay for the patients who received only NIV, we calculated the total cost under both care scenarios and estimated the potential savings associated with shifting these cases to the PIMCU:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(patients x median PICU stay x PICU day cost) - (patients x median PICU stay x PIMCU day cost) = estimated savings\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the STROBE guidelines (16) and with the Declaration of Helsinki and the International Conference on Harmonization Good Clinical Practice guidelines. Ethical approval was obtained by the Regional Ethic Committee Area Centro-Est Veneto (CET -ACEV) with the Protocol n. AOP3948.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 1678 admissions to the Acute Patient Ward, 365 (22%) were admitted to the PIMCU.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA detailed summary of patient characteristics is presented in \u003cstrong\u003eTable 1\u003c/strong\u003e, and the study population flow diagram is depicted in \u003cstrong\u003eFigure 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1: Characteristics of the study population\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 365\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePICU transfer\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 26\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower acuity care\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN = 339\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale, n\u003cem\u003e\u0026nbsp;\u003c/em\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e186 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e173 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge at admission, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 years (9-0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.8 (6.5-0.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (9.4-0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePreviously healthy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e186 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e174 (51)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber and classification of CCCs, n (%)\u003c/p\u003e\n \u003cp\u003eNeurologic\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCardiac, congenital\u003c/p\u003e\n \u003cp\u003eRespiratory\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMetabolic\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGastroenterology\u003c/p\u003e\n \u003cp\u003eRenal\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHematology/Oncology\u003c/p\u003e\n \u003cp\u003eGenetic/Chromosomal/Malformations\u003c/p\u003e\n \u003cp\u003eExtreme prematurity\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e149 (41)\u003c/p\u003e\n \u003cp\u003e51 (34)\u003c/p\u003e\n \u003cp\u003e21 (14)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e5 (3)\u003c/p\u003e\n \u003cp\u003e2 (1.5)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003cp\u003e39 (26)\u003c/p\u003e\n \u003cp\u003e19 (13)\u003c/p\u003e\n \u003cp\u003e10 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (79)\u003c/p\u003e\n \u003cp\u003e5 (46)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e1 (9)\u003c/p\u003e\n \u003cp\u003e2 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e138 (84)\u003c/p\u003e\n \u003cp\u003e46 (33)\u003c/p\u003e\n \u003cp\u003e19 (14)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e5 (5)\u003c/p\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003cp\u003e2 (1)\u003c/p\u003e\n \u003cp\u003e38 (27)\u003c/p\u003e\n \u003cp\u003e18 (13)\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDomiciliary devices, n (%)\u003c/p\u003e\n \u003cp\u003eNIV\u003c/p\u003e\n \u003cp\u003eIMV/Tracheostomy\u003c/p\u003e\n \u003cp\u003eNGT/PEG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78 (21)\u003c/p\u003e\n \u003cp\u003e10 (13)\u003c/p\u003e\n \u003cp\u003e35 (45)\u003c/p\u003e\n \u003cp\u003e41 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (19)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e3 (60)\u003c/p\u003e\n \u003cp\u003e3 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e73 (21)\u003c/p\u003e\n \u003cp\u003e10 (14)\u003c/p\u003e\n \u003cp\u003e32 (44)\u003c/p\u003e\n \u003cp\u003e38 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSource of admission, n (%)\u003c/p\u003e\n \u003cp\u003epED\u003c/p\u003e\n \u003cp\u003eGeneral Ward\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOther Hospital\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePICU or NICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e239 (66)\u003c/p\u003e\n \u003cp\u003e19 (5)\u003c/p\u003e\n \u003cp\u003e44 (12)\u003c/p\u003e\n \u003cp\u003e63 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (58)\u003c/p\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003cp\u003e5 (19)\u003c/p\u003e\n \u003cp\u003e3 (11.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e224 (66)\u003c/p\u003e\n \u003cp\u003e16 (5)\u003c/p\u003e\n \u003cp\u003e39 (11)\u003c/p\u003e\n \u003cp\u003e60 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdmission diagnoses, n (%)\u003c/p\u003e\n \u003cp\u003eRespiratory\u003c/p\u003e\n \u003cp\u003eNeurologic\u003c/p\u003e\n \u003cp\u003eHematology\u003c/p\u003e\n \u003cp\u003eShock/sepsis\u003c/p\u003e\n \u003cp\u003eGastrointestinal/Hepatobiliary\u003c/p\u003e\n \u003cp\u003eMetabolic/Endocrine\u003c/p\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003cp\u003eCardiac\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003cp\u003eRenal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e192 (53)\u003c/p\u003e\n \u003cp\u003e71 (19)\u003c/p\u003e\n \u003cp\u003e40 (11)\u003c/p\u003e\n \u003cp\u003e21 (6)\u003c/p\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003cp\u003e10 (2.5)\u003c/p\u003e\n \u003cp\u003e2 (0.5)\u003c/p\u003e\n \u003cp\u003e5 (1.5)\u003c/p\u003e\n \u003cp\u003e2 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20 (76)\u003c/p\u003e\n \u003cp\u003e2 (8)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e2 (8)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e-\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003cp\u003e1 (4)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e172 (50)\u003c/p\u003e\n \u003cp\u003e69 (20)\u003c/p\u003e\n \u003cp\u003e40 (12)\u003c/p\u003e\n \u003cp\u003e19 (6)\u003c/p\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003cp\u003e10 (3)\u003c/p\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003cp\u003e4 (2)\u003c/p\u003e\n \u003cp\u003e2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePEWS score at admission, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (3-0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (4-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (3-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLength of PIMCU stay, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (8-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 (3-1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 (9-3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations 1: CCCs = complex chronic conditions; IMV = invasive mechanical ventilation; IQR = inter quartile range; NGT = naso-gastric tube; NICU = neonatal intensive care unit; NIV = non invasive ventilation; pED = pediatric Emergency Department; PEG = percutaneous gastrostomy; PEWS = pediatric early warning score; PICU = pediatric intensive care unit; PIMCU = pediatric intermediate care unit.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThree hundred and thirty-nine children were transferred to a lower acuity care or discharged home: 173 were male (51%), median age was 4 years (IQR 9.4-0.6; range, 15 days to 17 years), 138 (41%) were classified as having a CCC. The median length of PIMCU stay was 6 days (IQR 9-3; range, 1\u0026ndash;65 days). At discharge, 190 patients (56%) returned home, 138 (41%) were transferred to a general ward, and 11 (3%) to a lower-level hospital.\u003c/p\u003e\n\u003cp\u003eTwenty-six children (7%) needed PICU escalation: 13 (50%) were male and median age was 1.8 years (IQR 6.5-0.2; range, 15 days\u0026ndash;15 years). Of this subgroup, 11 (42%) were classified as having a CCC. The majority were admitted from the pED (15, 58%). The primary reasons for PIMCU admission were respiratory diseases (20, 76%). The median length of stay in the PIMCU prior to PICU transfer was 2 days (IQR 3-1; range, 1\u0026ndash;14 days).\u003c/p\u003e\n\u003cp\u003eThe reasons for PICU admission were escalation of respiratory support (21, 80%), high-risk procedures (3, 11%), shock requiring inotropes (1, 4%), and refractory status epilepticus (1, 4%). The median PICU length of stay was 4 days (IQR 7-3; range, 1\u0026ndash;34 days).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 21 patients requiring escalation of respiratory support, 4 (19%) were intubated and received IMV for a median duration of 8 days (IQR 1\u0026ndash;11). The remaining 17 patients (81%) were managed with NIV, 1 with CPAP and 16 with BiPAP. Among them, 14 (82%) used nasal cannulas (RAM\u0026nbsp;Ⓡ), while others used nasal mask (1, 6%), oro-nasal mask (1, 6%), full-face mask (1, 6%). The maximal NIV settings were: median EPAP 7 cmH2O (IQR 10-7, range 5-12); median IPAP 16 cmH2O (IQR 17-12, range 12-22); median FiO2 0.4 (IQR 0.5-0.3, range 0.21-0.6). The median duration of NIV was 3 days (IQR 4-2, range 1-9). Sedation was not required in three patients, while the remaining 14 (82%) received dexmedetomidine. Of these, 5 (36%) also received ketamine as needed, and 3 (21%) morphine as needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding respiratory outcomes, of the 21 children with respiratory failure, 20 (95%) returned to spontaneous breathing in room air, whereas 1 (5%) required a tracheostomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 26 children who required PICU escalation, one died during the PICU stay due to multi-organ failure secondary to splenic sequestration crisis in the context of sickle cell disease. Of the 25 survivors, 16 (64%) were transferred to a general ward and 9 (36%) were returned to the PIMCU. A child died at home following discharge from the PIMCU with an anticipatory disposition of do-not-resuscitate (DNR) order.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChildren requiring PICU transfer, compared to those who did not need PICU care, tended to be younger, although the difference did not reach statistical significance.\u003c/p\u003e\n\u003cp\u003eThere were no significant differences between children transferred to the PICU and those managed in lower-acuity care with respect to sex distribution, prior health status, presence of CCCs, presence of domiciliary devices, source of admission, or admission diagnosis (all p \u0026gt; 0.05). In contrast, children requiring PICU transfer presented with significantly higher PEWS scores at admission (p \u0026lt; 0.001) and had shorter lengths of stay in the PIMCU compared with those managed in lower-acuity care (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eIn univariate analysis, respiratory disease increased admission odds (OR = 3.06, 95% CI: 1.24\u0026ndash;7.59, p = 0.010). Age and CCCs showed no significant associations (\u003cstrong\u003eTable 2, Figure 2\u003c/strong\u003e). In multivariate analysis, respiratory disease (adjusted OR = 2.79, 95% CI: 1.10\u0026ndash;7.06, p = 0.026) remained independently associated with PICU admission, while age and presence of CCCs were not significant predictors (\u003cstrong\u003eTable 2, Figure 2\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2: Univariate and multiple logistic regression model for identifying predictors for PICU admission.\u003c/em\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultiple\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ePredictors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCI 95%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003eCI 95%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(Intercept)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u0026nbsp;\u0026ndash;\u0026nbsp;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u0026nbsp;\u0026ndash;\u0026nbsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.86\u0026nbsp;\u0026ndash;\u0026nbsp;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.87\u0026nbsp;\u0026ndash;\u0026nbsp;1.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.315\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eComplex Chronic Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.49\u0026nbsp;\u0026ndash;\u0026nbsp;2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.850\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.55\u0026nbsp;\u0026ndash;\u0026nbsp;2.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.538\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespiratory Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.24\u0026nbsp;\u0026ndash;\u0026nbsp;7.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.16\u0026nbsp;\u0026ndash;\u0026nbsp;7.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNumber of patients\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e365\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e365\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cem\u003eNIV Group \u0026ndash; Low-risk patients\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNine children fulfilled the criteria for the Low-risk NIV Group (male = 5, 55%), with a median age of 2.5 months (IQR 0.4\u0026ndash;0.1 years, range 15 days\u0026ndash;6 years). Two patients (22%) had a CCC, while none had domiciliary devices. The main admission diagnoses were bronchiolitis (7, 78%) and pneumonia/parenchymal disorder (2, 22%). Median PEWS at admission was 3 (IQR 4\u0026ndash;1, range 0\u0026ndash;5), and at PICU transfer remained 3 (IQR 4\u0026ndash;2, range 1\u0026ndash;6). During their PIMCU stay, eight children (89%) received high-flow oxygen therapy.\u003c/p\u003e\n\u003cp\u003eThe median PIMCU length of stay before PICU transfer was 2 days (IQR 2\u0026ndash;1, range 1\u0026ndash;3), and the median duration of NIV support in the PICU was 3 days (IQR 4\u0026ndash;2, range 1\u0026ndash;4). Median PICU length of stay was 4 days (IQR 5-3). Three patients required no sedation, whereas the remaining six (67%) were sedated with dexmedetomidine only.\u003c/p\u003e\n\u003cp\u003eWith respect to interfaces, eight children were ventilated with nasal cannulas (RAM\u0026reg;) and one with a nasal mask. Maximal NIV settings were as follows: median EPAP 7.5 cmH₂O (IQR 9\u0026ndash;6.5, range 5\u0026ndash;10), median IPAP 16 cmH₂O (IQR 16\u0026ndash;13, range 12\u0026ndash;22), and median FiO2 0.45 (IQR 0.5\u0026ndash;0.25, range 0.21\u0026ndash;0.60). At hospital discharge, all patients achieved spontaneous breathing in room air.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNIV Group \u0026ndash; Excluded Low-risk patients\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 17 children managed exclusively with NIV, 8 did not meet the Low-risk criteria (50% male; median age 3.5 months, IQR 1.8-0.2 years). Three (37%) had a CCC, none had domiciliary devices. Most were admitted for bronchiolitis (5, 71%). Median PEWS was 2 at admission and 3 at PICU transfer. Median difference of PEWS between admission to PIMCU and transfer to PICU was 2. Nearly all (87%) received high-flow oxygen therapy during their PIMCU stay. The median PIMCU length of stay before PICU transfer was 2 days (IQR 5.5-1.5), with a median PICU NIV duration of 3 days (IQR 5.5-2). All patients received dexmedetomidine sedation, with additional rescue doses of morphine in 3 cases and ketamine in 5. Interfaces included nasal cannulas (n=6), oro-nasal mask (n=1), and full-face mask (n=1). Median maximal settings were EPAP 7 cmH₂O, IPAP 16 cmH₂O, and FiO2 0.4%. All children were discharged breathing spontaneously in room air.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary material 2\u003c/strong\u003e shows the two groups with the met and unmet Low-risk criteria.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCost utility framework\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the cost simulation strategy analysis show: number of low-risk NIV patients = 9; median PICU length of stay = 4 days/patient = 36 total PICU days; cost per PICU day including NIV and sedation estimated \u0026euro;2500; PIMCU cost per day estimated \u0026euro;1000. If these 9 low-risk patients had received equivalent care in a PIMCU equipped for NIV, the hospital could have potentially saved over \u0026euro;50,000 in direct care costs:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(9 x 4 x 2500) - (9 x 4 x 1000) = 90.000 - 36.000 = 54.000\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we examined the clinical course of children admitted to a newly established PIMCU, focusing on those who ultimately required transfer to intensive care. To our knowledge, this is the first European study to assess children escalated to PICU who could have theoretically been treated in PIMCU. While only a small proportion needed escalation to PICU care, the majority of these cases were related to respiratory deterioration, often managed successfully with NIV. Our findings are consistent with multicenter French data, where respiratory disease accounted for nearly half of PIMCU admissions and represented the main reason for transfer to intensive care(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Similarly, in 2020 an Italian national survey showed that PIMCUs are primarily utilized for respiratory conditions(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe pediatric literature has increasingly focused on predictors of PICU transfer in children admitted to PIMCUs(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In our cohort, children who required PICU escalation were generally younger, although this trend did not reach statistical significance. Acute severity at admission, as reflected by higher PEWS scores, was more closely associated with escalation to PICU, demonstrating the utility of structured early warning systems in identifying children at risk of deterioration. Interestingly, baseline characteristics such as sex, underlying comorbidities, or the presence of domiciliary devices were not significantly different between groups. This suggests that chronic disease alone does not adequately explain the need for PICU escalation, in contrast to what might be intuitively expected. Rather, acute clinical parameters at presentation appear to play a more important role.\u003c/p\u003e\u003cp\u003eBoth the univariate and multivariate analyses confirmed that the presence of acute respiratory disease represent the principal independent determinant of PICU admission in our cohort.\u003c/p\u003e\u003cp\u003eRespiratory disease as a strong predictor aligns with previous reports observing that the need for respiratory support was a significant predictor of PICU transfer(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This likely reflects the higher risk of decompensation in these patients and confirms the central role of acute respiratory failure in PICU use. Our results stress the importance of vigilant monitoring and the development of more precise predictors of deterioration or oxygen therapy failure, such as high-flow nasal cannula.\u003c/p\u003e\u003cp\u003eOur analyses also showed that children who needed escalation had shorter PIMCU stays prior to PICU transfer, reflecting the acute nature of illness and the early recognition of clinical instability that prompted timely transfer. This aligns with Cheng et al., who reported that transfers from intermediate care to PICU typically occurred early in the admission, highlighting the need for close monitoring and rapid decision-making in the first hours of hospitalization(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The short PIMCU stay of this subgroup of children also suggests the rapid evolution of the acute respiratory disease into respiratory failure, indicating some respiratory conditions may benefit from early NIV initiation in PIMCU.\u003c/p\u003e\u003cp\u003eWhen analyzing the PICU course, we found that many of the children transferred for respiratory deterioration were managed effectively with NIV, and only a small proportion ultimately required invasive mechanical ventilation. The cohort defined as the \u0026lsquo;Low-risk NIV Group\u0026rsquo; comprised patients with specific characteristics considered safe, according to existing literature(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), for NIV initiation outside intensive care. In this group, ventilatory support was generally of mild intensity and limited duration, and sedation, when required, was provided with dexmedetomidine. The number of patients included was small, owing to strict selection criteria that excluded children that needed to use specific interfaces (i.e. full-face) and those sedated with agents other than dexmedetomidine. Interestingly, among the excluded children, most had only received morphine or ketamine on an as-needed basis. While we believe it was appropriate to exclude these patients for safety reasons, it could be speculated that some of them could have been managed with dexmedetomidine alone in an environment such as the PIMCU, where parental presence and fewer environmental stressors might provide additional reassurance and stability.\u003c/p\u003e\u003cp\u003eIn addition, for this selected population, we observed that the median difference between PEWS at admission and at PICU transfer was negligible. This finding can be interpreted in two ways. First, it may suggest that although these children were clinically evolving, they remained relatively stable throughout their course\u0026mdash;an observation consistent with the \u0026lsquo;no change\u0026rsquo; trajectory described by Lampin et al(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Alternatively, it raises important questions: were these children already critically ill upon admission? Or is there something that PEWS fails to capture\u0026mdash;an aspect of clinical deterioration that led to PICU transfer despite stable scoring?\u003c/p\u003e\u003cp\u003eGiven the estimated cost of PICU day and the known burden of ICU overcrowding in Italy(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), the potential to avoid unnecessary PICU admissions is both clinically and economically significant. Beyond the financial implications, reducing PICU occupancy helps preserve critical care resources for patients with higher acuity needs and alleviates the workload on PICU staff(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe potential implementation of NIV in PIMCUs could represent a sustainable strategy to balance quality of care with resource efficiency, provided that staff are adequately trained and that the unit is located near a PICU to allow rapid escalation if required. At the same time, our results should be interpreted with caution, as implementing NIV outside intensive care requires substantial investment in staff training, equipment, and policy changes. The associated costs may be considerable, especially when weighed against the relatively limited number of patients who would benefit from it. Ultimately, the safe and effective use of NIV in PIMCUs demands careful planning, ongoing staff education, and continuous quality monitoring to ensure patient safety, clinical outcomes, and optimized resource utilization.\u003c/p\u003e\u003cp\u003eIn this study, we focused primarily on children with acute conditions, as they represented the largest proportion of those requiring escalation to the PICU. However, according to the AAP guidelines(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), the population eligible for PIMCU admission also includes children with CCCs experiencing acute-on-chronic illness, who are often inappropriate for both a regular ward and the PICU. Although our cohort included children with CCCs, we did not perform a sub-analysis to determine whether acute events affected them differently. Future research should therefore explore the characteristics and outcomes of this special population in the PIMCU setting, with the aim of optimizing their management and minimizing hospital stays.\u003c/p\u003e\u003cp\u003eA major strength of this study lies in its real-world, detailed evaluation of a representative PIMCU population, including comprehensive outcome data. The inclusion of cost simulations further enhances its applicability to healthcare policy and operational planning.\u003c/p\u003e\u003cp\u003eThis study, though, has several limitations. The small number of PICU transfers, particularly within the NIV subgroup, limits the robustness and generalizability of some statistical associations. The retrospective, single-center design further constrains interpretation, as it prevents assessment of causality and may not capture all factors influencing transfer decisions. Moreover, our PIMCU follows a specific organizational model, and differences in structure, staff training, and admission criteria across institutions may restrict external validity. Despite these limitations, our findings are consistent with multicenter reports identifying respiratory disease as the leading cause of PICU escalation and supporting the feasibility of NIV in intermediate care. Future multicenter prospective studies will be necessary to validate these observations and clarify the broader role of PIMCUs in optimizing PICU utilization.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur findings indicate that selected pediatric patients requiring non-invasive respiratory support may be safely managed within a well-equipped PIMCU, thereby reducing unnecessary PICU admissions. The successful use of NIV in our cohort highlights its feasibility outside intensive care, provided that appropriate monitoring, trained staff, and proximity to a PICU for rapid escalation are ensured. Future research should focus on evaluating the safety, efficacy, and cost-effectiveness of NIV in PIMCUs, as well as the development of structured protocols to standardize practice. Ultimately, integrating NIV into intermediate care settings has the potential to optimize resource utilization, improve patient safety, and strengthen the continuum of care across pediatric hospital systems.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCCCs - Complex Chronic Conditions\u003c/p\u003e\n\u003cp\u003eCPAP - Continuous Positive Airway Pressure\u003c/p\u003e\n\u003cp\u003eEPAP - Expiratory Positive Airway Pressure\u003c/p\u003e\n\u003cp\u003eFiO₂ - Fraction of Inspired Oxygen\u003c/p\u003e\n\u003cp\u003eIMV - Invasive Mechanical Ventilation\u003c/p\u003e\n\u003cp\u003eIPAP - Inspiratory Positive Airway Pressure\u003c/p\u003e\n\u003cp\u003eIQR - Interquartile Range\u003c/p\u003e\n\u003cp\u003eNIV - Non-Invasive Ventilation\u003c/p\u003e\n\u003cp\u003eNGT - Naso-Gastric Tube\u003c/p\u003e\n\u003cp\u003eNICU - Neonatal Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eOR - Odds Ratio\u003c/p\u003e\n\u003cp\u003epED - Pediatric Emergency Department\u003c/p\u003e\n\u003cp\u003ePEG - Percutaneous Endoscopic Gastrostomy\u003c/p\u003e\n\u003cp\u003ePEWS - Pediatric Early Warning Score\u003c/p\u003e\n\u003cp\u003ePICU - Pediatric Intensive Care Unit\u003c/p\u003e\n\u003cp\u003ePIMCU - Pediatric Intermediate Care Unit\u003c/p\u003e\n\u003cp\u003eREDCap - Research Electronic Data Capture\u003c/p\u003e\n\u003cp\u003eSD - Standard Deviation\u003c/p\u003e\n\u003cp\u003eSTROBE - Strengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained by the Regional Ethic Committee Area Centro-Est Veneto (CET -ACEV) with the Protocol n. AOP3948.\u0026nbsp;At the time of admission, patients over 12 years of age and the parents of younger children were asked for permission to be contacted by phone for future research purposes. Families were later contacted by phone, and informed consent forms were sent via email and returned, signed, by mail to the research center.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to concerns regarding patient privacy and confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this project or for the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFB and CA contributed equally to this work and share first authorship. FB, CA, and TZ conceptualized and designed the study. FB and OA collected the data. FB and AAg curated the data and performed the data analysis. FB and CA drafted the initial manuscript. \u0026nbsp;SC, SB, AAm, and AT provided critical revisions and contributed to the interpretation of data. All authors contributed to the article, revised it for important intellectual content, and approved the final manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Authors would like to express deepest gratitude to Prof. Liviana Da Dalt, University of Padua, whose constant dedication to the acute care of children and visionary perspective led to the establishment of our pediatric acute care unit. Her invaluable teachings have guided us in shaping not only this service, but also in envisioning and developing an intermediate care setting for our patients. The Authors (F.B. and C.A.) would like to thank Dr. Maria Fusaro, University of Padua, whose unwavering belief in research and constant support helped us overcome moments of discouragement and motivated us to continue our work.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Trial Number\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEttinger NA, Hill VL, Russ CM, et al. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics. 2022;149(5).\u003c/li\u003e\n\u003cli\u003eLopez-Jardon P, Martinez-Fernandez MC, Garcia-Fernandez R, et al. Utility of Intermediate Care Units: A Systematic Review Study. Healthcare (Basel). 2024;12(3).\u003c/li\u003e\n\u003cli\u003eGeneslaw AS, Jia H, Lucas AR, et al. Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both. J Crit Care. 2017;41:268-74.\u003c/li\u003e\n\u003cli\u003eMinardi C, Conti G, Moscatelli A, et al. Shortage of paediatric intensive care unit beds in Italy. Lancet. 2023;402(10412):1525.\u003c/li\u003e\n\u003cli\u003eSmith A, Kelly DP, Hurlbut J, et al. Initiation of Noninvasive Ventilation for Acute Respiratory Failure in a Pediatric Intermediate Care Unit. Hosp Pediatr. 2019;9(7):538-44.\u003c/li\u003e\n\u003cli\u003eRuss CM, Agus M. Triage of Intermediate-Care Patients in Pediatric Hospitals. Hosp Pediatr. 2015;5(10):542-7.\u003c/li\u003e\n\u003cli\u003eRivera R, Tibballs J. Complications of endotracheal intubation and mechanical ventilation in infants and children. Crit Care Med. 1992;20(2):193-9.\u003c/li\u003e\n\u003cli\u003eLazner MR, Basu AP, Klonin H. Non-invasive ventilation for severe bronchiolitis: analysis and evidence. Pediatr Pulmonol. 2012;47(9):909-16.\u003c/li\u003e\n\u003cli\u003ePlate JDJ, Leenen LPH, Houwert M, et al. Utilisation of Intermediate Care Units: A Systematic Review. Crit Care Res Pract. 2017;2017:8038460.\u003c/li\u003e\n\u003cli\u003ePrin M, Wunsch H. The role of stepdown beds in hospital care. Am J Respir Crit Care Med. 2014;190(11):1210-6.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208.\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-81.\u003c/li\u003e\n\u003cli\u003eFeinstein JA, Hall M, Davidson A, et al. Pediatric Complex Chronic Condition System Version 3. JAMA Netw Open. 2024;7(7):e2420579.\u003c/li\u003e\n\u003cli\u003eCheng DR, Hui C, Langrish K, et al. Anticipating Pediatric Patient Transfers From Intermediate to Intensive Care. Hosp Pediatr. 2020;10(4):347-52.\u003c/li\u003e\n\u003cli\u003eTack J, Bruyneel A, Taccone F, et al. Analysis of admissions to intensive care units that could be supported on an intermediate care unit. Nurs Crit Care. 2024.\u003c/li\u003e\n\u003cli\u003evon Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61(4):344-9.\u003c/li\u003e\n\u003cli\u003eLampin ME, Duhamel A, Behal H, et al. Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit. Indian J Pediatr. 2023.\u003c/li\u003e\n\u003cli\u003eSfriso F, Biban P, Paglietti MG, et al. Distribution and characteristics of Italian paediatric intermediate care units in Italy: A national survey. Acta Paediatr. 2020;109(5):1062-3.\u003c/li\u003e\n\u003cli\u003eLampin ME, Duhamel A, Behal H, et al. Use of paediatric early warning scores in intermediate care units. Arch Dis Child. 2020;105(2):173-9.\u003c/li\u003e\n\u003cli\u003eCaggiano S, Pavone M, Cherchi C, et al. Children with medical complexity and pediatric palliative care: Data by a respiratory intermediate care unit. Pediatr Pulmonol. 2023;58(3):918-26.\u003c/li\u003e\n\u003cli\u003eBrisca G, Strati MF, Canzoneri F, et al. Evaluating treatment and care outcomes for neuromuscular diseases in a pediatric intermediate care setting. Front Pediatr. 2025;13:1539540.\u003c/li\u003e\n\u003cli\u003eKeim G, Nishisaki A. Improving Noninvasive Ventilation for Bronchiolitis: It Is Here to Stay! Pediatr Crit Care Med. 2024;25(3):274-5.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7861766/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7861766/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePediatric Intermediate Care Units (PIMCUs) provide an intermediate level of care for children whose needs exceed those of general wards but do not require Pediatric Intensive Care Unit (PICU) admission. Most PICU-escalated children quickly recover without intubation. Although intensive care overcrowding is documented, the safety of non-invasive ventilation (NIV) outside intensive care in pediatrics remains uncertain. This study aims to analyze admissions to PIMCU, to characterize patients requiring PICU transfer and identify a subgroup who might have been safely managed in the PIMCU.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003ethis is a retrospective analysis of admissions to a newly established PIMCU (Nov 2023\u0026ndash;Jun 2025). Data collected were demographics, Pediatric Early Warning Score (PEWS), and outcomes. A subgroup analysis defined a \u0026ldquo;Low-risk NIV Group\u0026rdquo; (NIV\u0026thinsp;\u0026le;\u0026thinsp;5 days, simple interfaces, no or dexmedetomidine-only sedation). A cost simulation compared intensive care costs with projected PIMCU costs for this group.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ea total of 365 children were admitted to PIMCU; 26 (7%) required intensive escalation, mainly for respiratory failure (80%); transferred patients had higher PEWS (median 2 vs. 1, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and shorter PIMCU stays (2 vs. 6 days, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Respiratory disease was an independent predictor of pediatric intensive care transfer (adjusted OR 2.79, 95% CI 1.10\u0026ndash;7.06). In intensive care, 81% were managed with NIV; 9 fulfilled \u0026ldquo;Low-risk NIV\u0026rdquo; criteria. A cost simulation estimated potential savings of \u0026gt;\u0026euro;50,000 annually.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003emost intensive escalations were due to respiratory failure. In low-risk patients, short and mild NIV support was successful. This suggests that, under appropriate conditions, NIV could be safely extended to PIMCUs.\u003c/p\u003e","manuscriptTitle":"Can Pediatric Intermediate Care Optimize PICU Utilization? Outcomes from a Single-Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-04 01:22:38","doi":"10.21203/rs.3.rs-7861766/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-31T19:21:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-30T18:22:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-28T16:42:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58019470994200079600156233118279522835","date":"2025-10-28T13:16:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-25T18:52:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"7837732732876524521642855123545990043","date":"2025-10-22T20:51:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138693551769468016337652163214276146292","date":"2025-10-22T19:37:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-22T16:38:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-20T06:34:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-18T09:01:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-18T09:00:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-10-14T20:08:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9e299d67-1a95-49bf-8281-9fe904727cc6","owner":[],"postedDate":"November 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T09:10:51+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-04 01:22:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7861766","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7861766","identity":"rs-7861766","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}