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

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 > or =5 and/or APACHE-APS score > or =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 > or =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.