Evaluation of an integrated intensive care service in a department of geriatrics

Objective

Transferral of multimorbid elderly patients from a geriatric ward to an intensive care unit for deterioration for vital function may be associated with some serious problems: (1) environmental changes may lead to acute disorientation in geriatric patients, (2) the invasiveness of an extended ICU therapy may be felt to be inappropriate by the patient and his relatives in relation to multimorbidity and prognosis. However, abstaining from transferral to an ICU and witholding extended therapy may be inappropriate as well. Therefore, extended therapy including ICU service which is adjusted to the individual prognosis and needs of the elderly patients is required in a geriatric clinic. For economic reasons, this implemented extended therapy cannot include the more invasive and costly services of an ICU (eg respirator treatment, continuous hemofiltration). We report our experience with the implementation of extended therapy in a department of geriatrics.

Patients and methods

The nurses of the Department of Geriatrics (University Teaching Hospital) received special training in intensive care. Forty geriatric patients with multimorbidity and acute deterioration of their health state (eg impairment of renal function, severe pneumonia, pulmonary embolism, sepsis, cardiac arrhythmia with circulatory instability, unstable angina pectoris and contraindication for interventions) were included in the study. Therapy extension included continuous monitoring of ECG, RR, O₂-saturation and fluid balance, mask CPAP ventilation, intensified bronchial suctioning, continuous drugs (eg dopamine, norepi-nephrine, epinephrine, furosemide, theophylline, insulin, heparin). Evaluation included outcome, necessity of transferral to an external ICU, geriatric assessment (Barthel index, up-and-go test, Tinetti test as well as APACHE III score on admission and discharge) and acceptance of intensive care treatment implemented in the geriatric clinic by the patient and/or his relatives.

Results

In all 40 cases, the suggestion of extended therapy within the Department of Geriatrics was accepted by the patients themselves or their relatives. Eight patients had to be transferred to an ICU for extended ICU treatment (intubation and ventilation, continuous hemofiltration, surgical interventions). Eighteen patients did not survive. This treatment approach was highly appreciated by the patients and their relatives.

Conclusion

Extended therapy including services normally provided by an ICU which are implemented in a geriatric clinic may be an appropriate alternative or adjunct to transferral to an external ICU in multimorbid geriatric patients with a limited prognosis of survival. However, all decision-making in a deteriorating geriatric patient has primarily to depend on the decision of the patient himself and his relatives. Transferral of geriatric patients to an external ICU may be prevented by an implemented extended therapy in a substantial number of patients.