La cura della persona anziana nella rete
dei servizi: dall’ospedale al territorio.
Sabato 10 giugno 2006
S.Angelo Lodigiano
L’anziano nell’ospedale per acuti
Marco Ferri
Dipartimento di Medicina Interna e Geriatria
Fondazione Poliambulanza-Istituto Ospedaliero
Cos’è Poliambulanza?
Ospedale per acuti sorto
nel 1997 per volonta
dell’Ordine Religioso
“Ancelle della Carità” di
Brescia.
Nel 2005 è diventato
Fondazione
Poliambulanza Istituto
Ospedaliero.
Cos’è Fondazione Poliambulanza?
Quale utenza? Quali risposte?
Quale utenza? Quali risposte?
Dipartimento di Medicina Interna e Geriatria
Fondazione Poliambulanza-Istituto Ospedaliero
Current and Projected Workforce Requirements for Care of the Critically Ill
and Patients With Pulmonary Disease (JAMA. 2000;284:2762-2770)
Forecast of Supply and Demand for Intensivists and Pulmonologists Through 2030
L’acuzie dei malati attualmente ospedalizzati, richiederebbe sempre
più spesso l’ammissione a reparti di Terapia Intensiva, per malattie di
tipo internistico in una elevata percentuale di pazienti (per oltre il
30% dei casi cardiache, vascolari, neurologiche, polmonari, emorragie
gastroenteriche, sepsi).
Nelle Divisioni di Medicina Interna (MI) si concentrano sempre più malati
anziani, pluripatologici, in certe fasi clinicamente instabili e “chronically
critically ill” (CCI). I malati CCI sono caratterizzati da insufficienza acuta
mono-organo potenzialmente reversibile, insufficienza acuta mono- o multiorgano a lento recupero, insufficienza irreversibile mono-organo.
Essi richiedono una prolungata degenza in terapia intensiva, che nel caso
degli anziani raramente garantisce un soddisfacente recupero. Infatti tali
pazienti, che rappresentano il 5-10% dei ricoveri in Terapia Intensiva,
presentano un’età elevata (per oltre il 50% hanno più di 65 anni), un’elevata
mortalità soprattutto nei pluripatologici, hanno ridotta sopravvivenza,
determinano un elevato impiego di risorse, possono essere gestiti al meglio
in strutture di terapia semiintensiva, che potrebbero essere le stesse
Divisioni Internistiche. La gestione ottimale di una struttura di Medicina
semiintensiva perquesti malati è infatti da collocare nell’ambito della
Medicina Interna.
Bollettino della Società Italiana di MEDICINA INTERNA n. 4 - Dicembre 2003
Sub-Intensive Care Unit for the
elderly-SICU
A new multicomponent model of care for
the critically ill elderly
Combines a high level of care with the ACE
principles
Un numero crescente di anziani sono ricoverati in
ospedale per patologie “critiche”.
Il “gap” fra la disponibilità strutture e la domanda
sta diventando un problema crescente. Per cercare
di affrontare questo problema nella nostra
Divisione di Geriatria (24 letti) sono stati dedicati 4
letti alla cura “sub-intensiva” (UCSI).
E’ dedicata ai pazienti anziani, ma non solo,
che, per la loro gravità, richiedono una intensività
di cure che non può essere affrontata in una
comune Divisione di Medicina.
Tale unità ha iniziato ad operare nel Gennaio 2004.
I 4 letti dedicati alla UCSI (SICU) sono integrati al
centro del reparto proprio di fronte alla sala
infermieristica.
E’ una stanza unica nella quale i 4 letti sono separati
da tende provvedono ad assicurare la “privacy” ai
pazienti.
La stanza è illuminata da luci che garantiscono una
illuminazione adeguata a provvedere ad una corretta
sorveglianza notturna senza interferenza con il riposo
dei pazienti. La luce diurna è anche fornita da due
ampie finestre.
Ciascuno dei letti è dotato di sistema di
monitoraggio, anche telemetrico, dei parametri
vitali cardiaci e respiratori.
Nella stanza sono presenti tre ventilatori (2
Bipap Vision e 1 portatile mod. Esprit) che sono
adatti ai diversi tipi di ventilazione meccanica
non invasiva.
All’ingresso della stanza è presente il carrello
per le per la intubazione e la defibrillazione
d’emergenza.
Admission and discharge guidelines for the Subintensive Care Unit for the elderly
I. Admission Criteria
A. Cardiac system
1. Low probability for ST-elevation myocardial infarction.
2. Hemodynamically stable myocardial infarction.
3. Any hemodynamically stable dysrythmia.
4. Congestive heart failure without shock (NYHA classes III-IV).
5. Hypertensive urgency without evidence of end-organ damage.
B. Pulmonary system
1. Hemodynamically stable patients with respiratory failure requiring NIV.
2. Patients who require frequent monitoring of vital signs.
C. Neurologic disorders
1. Patients with stroke who require frequent neurologic assessments or
frequent suctioning or turning.
2. Patients with chronic, but stable neurologic disorders, who require
frequent nursing interventions.
D. Drug ingestion and drug overdose
1. Any patient requiring frequent neurologic, pulmonary, or cardiac
monitoring for drug ingestion or overdose who is hemodynamically stable.
E. Gastrointestinal (GI) Disorders
1. GI bleeding with minimal orthostatic hypotension responsive to
fluid therapy.
2. Variceal bleeding without evidence of bright red blood by gastric
aspirate and stable vital signs.
3. Acute liver failure with stable vital signs.
F. Endocrine
1. Diabetic ketoacidosis patients requiring constant intravenous
infusion of insulin, or frequent injections of regular insulin during
early regulation phase after recovery form diabetes ketoacidosis.
2. Hyperosmolar state with resolution of coma.
3. Thyrotoxicosis, hypothyroid state requiring frequent monitoring.
G. Miscellaneous
1. Appropriately treated and resolving early sepsis without evidence
of shock or secondary organ failure.
2. Patients requiring closely titrated fluid management.
3. Any patient requiring frequent nursing observation or monitoring
of vital signs who does not fall under the above categories may be
considered for admission (i.e.: Addison’s disease, renal failure,
delirium, hypercalcemia or other electrolyte disturbances).
II. Patient who are usually not
appropriate for admission
A. Complicated acute myocardial infarction with temporary
pacemaker, angina, hemodynamic instability, significant pulmonary
edema or significant ventricular dysrythmias.
B. Patients requiring heavy nursing loads and titrated patient care 1224 hrs/day.
C. Patients with acute respiratory failure who are intubated or at
imminent risk of requiring intubation.
D. Patients requiring invasive hemodynamic monitoring with a
pulmonary artery or left atrial catheter or an intracranial pressure
monitor.
E. Patients in status epilepticus.
F. Patients with catastrophic brain illness or injury who are not to be
resuscitated and are not candidates for organ donation.
G.Patients from whom aggressive modalities of care are being
withheld or have been withdrawn, such that they are receiving only
for comfort measures.
III. Discharge of patients from the SICU shall take place:
A.When a patient’s physiological status has stabilized and the
need for intensive patient monitoring is no longer necessary and
the patient can be cared for on a general unit.
B. When a patient’s physiological status has deteriorated and
active life support is required or highly likely, the patient should
be transferred to the Intensive Care Unit per unit-specific
protocol.
C. Patients from whom, during their stay in the SICU, aggressive
modalities of care are being withheld or have been withdrawn,
such that they are receiving only for comfort measures.
Process of care for patients admitted to the SICU
In Emergency Room or other referring department:
· Social anamnesis (civil status, living conditions, formal and informal care etc.)
· Physiologic anamnesis (previous diseases, surgical&medical treatment)
· Actual problem-orientated anamnesis
· Physical examination (check list)
· Assessment of severity (APACHE II score)
In SICU/ACE-unit:
· Comprehensive geriatric assessement at admission
-IADL and Barthel Index two weeks prior to admission and at admission
-screening for delirium with CAM
-nurse assessment (communication, ADL, elimination, mood and sleep)
· Review of medical care (main diagnoses, comorbidity, adverse events,
medication, examinations and procedures)
· Patient-centered care plans (prevention of pressure sores, delirium and falls)
· Define expected clinical goals
· Discharge planning
· Visit of patients (twice daily): Review of medical care, patient-centered care plans,
clinical goals and plan for discharge
· Assessment at discharge: MMSE, Geriatric Depression Scale, IADL and BI.
Sub-Intensive Care Unit for the elderly: a
new model of care for critically ill frail
elderly medical patients.
Internal and Emergency Medicine, Submitted
I pazienti ammessi in UCSI (=SICU)
sono stati confrontati con pazienti di
analoga gravità che erano stati curati
nel nostro reparto prima che l’unità
subintensiva fosse aperta.
Characteristics of patients 60+ years admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=1380) (A), of selected patients with APACHE II
score >/=5 and/or APACHE -APS =/>3 admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=125)(B), and patients with APACHE II score
>/=5 and/or APACHE -APS =/>3 admitted in the Sub-Intensive Care Unit (SICU) for
the elderly (n=401)(C).
A
B
C
ACE severe
ACE–MU ACE-MU (sev)
SICU
vs SICU
n=1380
n=125
n=401
Characteristics
M+SD
M + SD
M + SD
p*
Age
Gender (female), n (%)
Living alone, n (%)
Vision impairment, n (%)
Heavy alcohol use, n (%)
IADLs lost two wks prior
Barthel Index two wks prior
Barthel Index on adm.
Barthel Index at disch
78.8 +9.3
911 (66.0)
52 (37.7)
293 (21.2)
83 (6.0)
3.3 +2.7
84.9 +24.6
75.0 +28.2
78.8 +26.2
82.3 +6.8
49 (56)
37 (29.6)
33 (26.4)
6 (4.8)
4.5 +2.9
65.6 +33.9
36.6 +35.9
47.5 +38.2
78.1 +8.8
196 (49)
102 (25.4)
116 (29.0)
20 (5.0)
3.4 +3.0
72.8 +33.0
28.8 +35.2
49.3 +39.4
p<.05
NS
NS
NS
NS
NS
NS
NS
NS
Characteristics of patients 60+ years admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=1380) (A), of selected patients with APACHE II
score >/=5 and/or APACHE -APS =/>3 admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=125)(B), and patients with APACHE II score
>/=5 and/or APACHE -APS =/>3 admitted in the Sub-Intensive Care Unit (SICU) for
the elderly (n=401)(C).
A
B
ACE–MU ACE-MU (sev.)
n=1380
n=125
C
SICU
ACE severe
vs SICU
n=401
p*
Main diagnoses, n (%)
Respiratory failure
Cardiac disease
Stroke
GI bleeding
Cancer related problems
Acute renal failure
Others
255 (18.5)
264 (19.1)
171 (12.4)
197 (14.3)
127 (9.2)
36 (2.6)
527 (38.2)
35 (28.0)
28 (22.4)
15 (12.0)
12 (9.6)
18 (14.4)
7 (5.6)
6 (4.8)
172 (42.9)
111 (27.7)
44 (11.0)
27 (6.7)
23 (5.7)
16 (4.0)
8 (1.9)
p<.001
NS
NS
NS
p<.01
NS
NS
Characteristics of patients 60+ years admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=1380) (A), of selected patients with APACHE II
score >/=5 and/or APACHE -APS =/>3 admitted in the Acute Care for the Elderly
(ACE) medical unit during 2002 (n=125)(B), and patients with APACHE II score
>/=5 and/or APACHE -APS =/>3 admitted in the Sub-Intensive Care Unit (SICU) for
the elderly (n=401)(C).
A
B
C
ACE severe
ACE–MU ACE-MU (sev.)
SICU
vs SICU
n=1380
n=125
n=401
p*
Characteristics
M (%)
M (%)
M (%)
MMSE score (0-30)
22.6 +7.2
Charlson Index (0-33)
6.9 +2.5
APACHE II score (0-71)
6.7 +2.8
APACHE -APS (0-33)
2.1 +2.6
S-Albumin (g/dl)
4.0 +0.6
S-Cholesterol (mg/dl)
205.2 +51.4
Drugs (n)
4.2 +3.2
Delirium, n (%)
95 (6.9)
Bladder catheter, n (%)
170 (12.3)
NIMV n (%)
--LOS in SICU (hours)
--LOS (days)
6.1 +3.2
Mortality in SICU, n (%)
--Mortality (in Hosp), n (%)
50 (3.6)
17.0 +10.7
8.9 +2.9
17.9 +5.7
8.8 +3.6
3.5 +0.6
175.8 +49.8
5.0 +2.2
27 (21.6)
45 (36.0)
7.7 +5.2
24 (19.2)
19.1 +11.0
6.5 +2.0
14.5 +6.0
9.0 +5.7
3.3 +0.6
174.2 +49.7
7.6 +3.2
128 (31.2)
228 (56.9)
87 (21.7)
61.8 +62.4
6.0 +4.9
31 (7.7)
50 (12.5)
ns
p<.05
p<.05
ns
ns
ns
p<.05
p<.01
p<.01
NS
p<.05
Comparing patients of same illness
severity (APACHE-APS >/=3 ) (n=125),
patients treated in the SICU had lower inhospital mortality than those treated in
the ordinary ward (12.5% versus 19.2%).
Low hospital mortality supports the
usefulness of this model.
Sub-Intensive Care Unit for the
elderly-SICU
A new multicomponent model of care for
the critically ill elderly
Combines a high level of care with the ACE
principles