Critical care in internal medicine department: EBM approach and new organizational model for Italian National Health Service

Abstract

During the last decade the number of over-60 patients with multiple organ dysfunction admitted in the Departments of Internal Medicine in Italy has considerably increased. Many of these patients are critically ill and needs to be treated by trained medical staff with experience in internal medicine and an olistic approach. Several studies carried out in ICUs show that prognosis of elderly patients affected by multiple organ dysfunction is related to the number and severity of comorbidity regardless of age. Furthermore many survived patients dismissed from ICUs cannot reach the previous level of performance and global quality of life. One randomized controlled trial on chronically critically ill patients compared performances of traditional intensive care units with low technology 'Special Care Unit' managed by specialist in internal medicine, supported by sub-intensive nursing. These units obtained comparable clinical outcomes (mortality, complications) and better value (economic cost, stay of hospitalization). On the basis of these data and the characteristics of Italian National Health Service, we created in our Department of Internal Medicine a 'protected area' for critically ill patients affected by internistic diseases with complex comorbidities needing continuous monitoring of vital parameters and therapies. Medical staff working in this area have been trained in emergency medicine and are supported by nurses ACLS (Advanced Cardiac Life Support) certified. This unity is constituted by four beds with monitoring of EKG, non-invasive blood pressure, pulse, oximetry, body temperature, connected with a central computerized unit. Moreover, in this room are available ABG, ph-metry, and CPR equipment. Currently in Italy, this kind of patients are admitted in ICUs, often with unappropriated use of resources or in Department of Internal Medicine with inadequate quality of care. We are planning a case-control study to compare the outcomes of patients admitted in our new 'protected area' with those of matched patients previously admitted in our Department of Internal Medicine. The results of this investigation could supply data to support the creation of other 'protected areas' in Departments of Internal Medicine in our country. Furthermore this new approach could promote the renaissance of the role of Internal Medicine in Italian National Hospital System and help to release resources for the ICUs and other specialties.