Skip to main content
Download PDF

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients

Internal and Emergency Medicine volume 1, pages 197–203 (2006)Cite this article

Abstract

Objective

An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation.

Methods

This article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data.

Results

During the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60± years and APACHE II score≥5 and/or APACHE-APS score ≥3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score ⩾=3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness.

Conclusions

The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.

References

  1. Carson SS. The epidemiology of critical illness in the elderly.Crit Care Clin 2003; 19: 605–17.

    PubMed  Article  Google Scholar 

  2. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr, on behalf of the Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?.JAMA 2000; 284: 2762–70.

    PubMed  Article  CAS  Google Scholar 

  3. Mohammedi I, Martin O, Argaud L, St Denis M, Ferry T, Robert D. Patients refused in admission to an intensive care unit. Prospective evaluation of the causes and outcome.Presse Med 2003; 32 (Pt 1): 1738–40.

    PubMed  Google Scholar 

  4. Barbieri S, Feltracco P, Michieletto E, Basso I, Spagna A, Giron G. Demand and availability of intensive care beds. A study based on the data collected at the SUEM 118 Central of Padua from October 1996 to December 2001.Minerva Anestesiol 2003; 69: 625–39.

    PubMed  CAS  Google Scholar 

  5. Campbell SE, Seymour DG, Primrose WR, for the ACMEPLUS Project. A systematic literature review of factors affecting outcome in older medical patients admitted to hospital.Age Ageing 2004; 33: 110–5.

    PubMed  Article  Google Scholar 

  6. Bo M, Massaia M, Raspo S, et al. Predictive factors of inhospital mortality in older patients admitted to a medical intensive care unit.J Am Geriatr Soc 2003; 51: 529–33.

    PubMed  Article  Google Scholar 

  7. Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients.N Engl J Med 1995; 332: 1338–44.

    PubMed  Article  CAS  Google Scholar 

  8. Cucherat M, Bonnefoy E, Tremeau G. Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction.Cochrane Database Syst Rev 2003; (3): CD001560.

    PubMed  Google Scholar 

  9. Wardlaw JM, Zoppo G, Yamaguchi T, Berge E. Thrombolysis in acute ischaemic stroke.Cochrane Database Syst Rev 2003; (3): CD000213.

    PubMed  Google Scholar 

  10. Ram FS, Picot J, Lightowler J, Wedzicha JA. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease.Cochrane Database Syst Rev 2004; (3): CD004104.

    PubMed  Google Scholar 

  11. Nasraway SA, Cohen IL, Dennis RC, et al. Guidelines on admission and discharge for adult intermediate care units. American College of Critical Care Medicine and the Society of Critical Care Medicine.Crit Care Med 1998; 26: 607–10.

    PubMed  Article  CAS  Google Scholar 

  12. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.Crit Care Med 1985; 13: 818–29.

    PubMed  Article  CAS  Google Scholar 

  13. Knaus WA, Wagner DP, Draper EA. Relationship between acute physiologic derangement and risk of death.J Chronic Dis 1985; 38: 295–300.

    PubMed  Article  CAS  Google Scholar 

  14. Rozzini R, Sabatini T, Trabucchi M. The network for elderly care in Italy: only a correct use of acute wards allows an overall functioning of the health care system.J Gerontol A Biol Sci Med Sci 2003; 58: 190–1.

    PubMed  Google Scholar 

  15. Roper N. Definition of nursing: 1.Br J Nurs 1994; 3: 355–7.

    PubMed  CAS  Google Scholar 

  16. Inouye SK, Charpentier MP. Precipitating factors for delirium in hospitalized elderly persons.JAMA 1996; 275: 852–7.

    PubMed  Article  CAS  Google Scholar 

  17. Mahoney FI, Barthel DW. Functional evaluation: the Barthel index.Md State Med J 1965; 14: 61–5.

    PubMed  CAS  Google Scholar 

  18. Charlson M, Pompei P, Ales K, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.J Chronic Dis 1987; 40: 373–83.

    PubMed  Article  CAS  Google Scholar 

  19. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium.Ann Intern Med 1990; 113: 941–8.

    PubMed  CAS  Google Scholar 

  20. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.J Psychiatr Res 1975; 12: 189–98.

    PubMed  Article  CAS  Google Scholar 

  21. Flaherty JH, Tariq SH, Raghavan S, Bakshi S, Moinuddin A, Morley JE. A model for managing delirious older inpatients.J Am Geriatr Soc 2003; 51: 1031–5.

    PubMed  Article  Google Scholar 

  22. Allen KR, Hazelett SE, Palmer RR, et al. Developing a stroke unit using the acute care for elders intervention and model of care.J Am Geriatr Soc 2003; 51: 1660–7.

    PubMed  Article  Google Scholar 

  23. Rozzini R, Sabatini T, Trabucchi M, Ranhoff AH. Stroke units and acute care for elders model of care.J Am Geriatr Soc 2004; 52: 1587–8.

    PubMed  Article  Google Scholar 

  24. Tosteson AN, Goldman L, Udvarhelyi IS, Lee TH. Costeffectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain.Circulation 1996; 94: 143–50.

    PubMed  CAS  Google Scholar 

  25. Elliott MW, Confalonieri M, Nava S. Where to perform noninvasive ventilation?.Eur Respir J 2002; 19: 1159–66.

    PubMed  Article  CAS  Google Scholar 

  26. Confalonieri M, Gorini M, Ambrosino N, Mollica C, Corrado A, for the Scientific Group on Respiratory Intensive Care of the Italian Association of Hospital Pneumonologists. A. Respiratory intensive care units in Italy: anational census and prospective cohort study.Thorax 2001; 56: 373–8.

    PubMed  Article  CAS  Google Scholar 

  27. Pappachan JV, Millar BW, Barrett DJ, Smith GB. Analysis of intensive care populations to select possible candidates for high dependency care.J Accid Ermerg Med 1999; 16: 13–7.

    CAS  Google Scholar 

  28. Geraci JM, Ashton CM, Kuykendall DH, Johnson ML, Wu L. In-hospital complications among survivors of admission for congestive heart failure, chronic obstructive pulmonary disease, or diabetes mellitus.J Gen Intern Med 1995; 10: 307–14.

    PubMed  Article  CAS  Google Scholar 

  29. Hubbard RE, Lyons RA, Woodhouse KW, et al. Absence of ageism in access to critical care: a cross-sectional study.Age Ageing 2003; 32: 382–7.

    PubMed  Article  Google Scholar 

  30. Rozzini R, Sabatini T, Trabucchi M. A silent ageism in access to critical care [letter].Age Ageing 2004; 33: 517.

    PubMed  Article  Google Scholar 

Download references

Author information

Affiliations

  1. Geriatric Research Group, Ullevaal University Hospital, Oslo, Norway

    Anette Hylen Ranhoff

  2. Dipartimento di Medicina Interna e Geriatria, Ospedale Poliambulanza, Via Bissolati 57, 25124, Brescia, Italy

    Renzo Rozzini, Tony Sabatini, Angela Cassinadri, Stefano Boffelli, Marco Ferri, Nicola Travaglini, Antonella Ricci & Alessandro Morandi

  3. Geriatric Research Group, Brescia, Italy

    Renzo Rozzini, Tony Sabatini, Angela Cassinadri, Stefano Boffelli, Marco Ferri, Nicola Travaglini, Antonella Ricci, Alessandro Morandi & Marco Trabucchi

Authors
  1. Anette Hylen Ranhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Renzo Rozzini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tony Sabatini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Angela Cassinadri
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Stefano Boffelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marco Ferri
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Nicola Travaglini
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Antonella Ricci
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Alessandro Morandi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Marco Trabucchi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Renzo Rozzini.

Additional information

The LONATI Foundation in Brescia sponsored the building and equipment of the unit described. The study was partly supported by a grant to the main author from the Faculty of Medicine, University of Oslo, Norway.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Ranhoff, A.H., Rozzini, R., Sabatini, T. et al. Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients. Int Emergency Med 1, 197–203 (2006). https://doi.org/10.1007/BF02934737

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02934737

Key words

  • care units
  • critical care
  • elderly