Special Care Units for the Critically Ill

Providing Key Technology While Also Meeting Emotional/Social Needs

Background & Goal

Chronically critically ill patients need comprehensive, coordinated holistic care that intensive care units often are not designed to provide.

The goal is to continue to provide needed technologic interventions, while also allowing nurses to focus on patients’ emotional and social needs and family needs through the use of nurse-managed “Special Care Units” as a companion to ICUs.

Unit Description

A special care unit for the chronically critically ill is a unit that is physically separate from the regular intensive care unit. Nurse case management is the care delivery system, with medical care delivered by one attending pulmonologist. Patients are transferred to the SCU following a five-day stay in the ICU and remain in the SCU until discharge. It acknowledges that aggressive use of sophisticated technologies is not sufficient to restore an acceptable quality of health to patients who have experienced prolonged periods of critical illness. Instead, it is important to alter the environment, to provide a more balanced approach, tending to social and emotional needs, and explicitly re-evaluate goals of care. The program addresses physical care needs of critically ill patients as well as the psychological impact of critical illness – addressing coping, depression, and life satisfaction after critical illness.

Evidence of Success

• Studies have shown a significant reduction in “cost per survivor,” (that is, effectiveness as measured by the total costs of the program and the number of patients successfully discharged from the hospital) as well as a reduction in early re-hospitalization rates, with no increase in mortality or complications.
• Readmission rates to the hospital within three weeks of SCU care were 8%, compared with 20% where traditional ICU care was involved.
• The average cost per survivor was $109,220 in the SCU, vs. $138,434 in the traditional ICU care

Recent Developments

Since the original trial of the Special Care Unit, hospital discharge patterns for chronically critically ill have changed markedly. The growth in long-term acute care facilities (LTACs) and expansion of the capacity of skilled nursing facilities to care for ventilator-dependent patients have enabled the chronically critically ill to be discharged directly from ICUs, thus reducing the demand for in-hospital special care units. However, this trend created a new need to address the post-discharge care coordination and family support needs for this highrisk, complex, and growing population. Responding to this, we conducted a trial of a post-discharge “Disease Management” program for CCI patients and their family caregivers. This program entailed follow-up and care coordination from an Advanced Practice Nurse for three months post-discharge, regardless of discharge destination. The program demonstrated a significant reduction in post-discharge days of rehospitalization, associated with a significant reduction in cost (Daly et al, Chest 2005; 128: 507-517). Most recently, in response to findings from these previous studies of the very high risk of post-discharge mortality and long-term morbidity in this population, we designed an “intensive communication” intervention to assist family decision makers facing care decisions for their CCI loved one in the ICU (Lilly & Daly, NEJM 2007; 356: 513-14; Daly et al, Chest 2010; 138: 1340-48). We are continuing to investigate the phenomenon of decision making around goals of care for these long-stay ICU patients.