As technology developed and monitoring became more sophisticated the rapid development of intensive care units somewhat overshadowed the development of formal high dependency units. Over the years highly dependent patients have been cared for in many areas within the hospital setting, including intensive care and acute ward areas with an increased nurse: patient ratio.

It remains difficult to distinguish between intensive care, high dependency care and care provided on wards, as services will differ from hospital to hospital. The general agreement is that high dependency care does fall between the level of care which can be provided in intensive care and on the wards.

In June 2000, following the recommendations by the Department of Health, a project group was formed to plan and set up a surgical high dependency unit at The Royal London Hospital. The group was led by the Heads of Nursing and consisted of nursing representatives from all wards within the Surgical and Muscoskeletal directorate, the Acting General Manager, anaesthetic and surgical consultant representatives, physiotherapists and pharmacists and a medical technical officer. Valuable contributions were made by A & E and ITU staff and the Patient at Risk Nurse Consultant.

In order to provide a high dependency service, access to experienced and suitably trained staff from a multidisciplinary team is necessary, with resources to assist in providing such a level of care. As refurbishment work commenced on Harrison ward, costings for the project were prepared and taken to the Critical Care Board. An inventory of equipment was agreed and ordered. Equipment needs will vary from one high dependency unit to another, depending on the type and speciality of patients the service is aimed at. The main expenditure necessary is for a monitoring system to meet the patients needs on and off the unit when transferred. Other expenses included humidification circuits, re-warming devices and emergency equipment including a transport ventilator.

Nursing activity on a high dependency unit will be predictably more costly than a ward area. It is recommended that there is a nurse to patient ratio of 1:2 in HDU areas. Skill mix also needs to be considered to ensure safe and quality care is provided and training and development available to all grades of clinical staff. With an agreed nursing establishment, job descriptions were written and initial recruitment was led by the Heads of Nursing, with the assistance of nursing staff across the directorate. Members of the project group visited other high dependency units. The medical management for high dependency patients was debated and operational issues discussed within the project group. This resulted in an agreed operational policy that patients would remain under the management of a surgical consultant whilst in the high dependency unit and included specific admission criteria.

In order to provide a quality service in a clinical area, it is imperative that staff are developed and supported. Most nursing staff commenced work a month before the HDU opened. With the challenge of developing the nurses ability to care for highly dependant patients in a relatively short period of time, work books were used as a theoretical learning resource for staff starting in a new speciality. High-dependency study days and daily teaching introduced new skills and developed staffs existing knowledge. Since the unit has opened there continues to be a structured teaching programme. More recently the HDU hosted a national open and study day. Case presentations were incorporated into lectures and presented by members of the HDU team. There were a large number of external visitors from across the country, and the day was deemed a success.

In a new and demanding environment the need for a positive and productive learning environment is important. All staff have quarterly personal development plan meetings with a preceptor. A resource of learning materials is being built up. More recently a competency based development programme has been introduced for staff in the HDU. Outside of the unit good relationships are being developed with City University School of Nursing and Midwifery who run an ENB course in High Dependency Nursing. Senior nursing staff from the unit will be teaching on future courses and for the first time all candidates on the course will have an opportunity to work in a designated high dependency area with clinical tutors.

With patients' length of stay on HDU ranging from 1-13 days, the average length of stay is 2 days. Most patients (88%) are discharged to the wards from the HDU. Only 7% of patients have been transferred to the intensive care unit. Mortality on the unit is 3.5%. At the end of February 64% of patients admitted to the HDU since December were discharged home from hospital. The remaining patients (24%) were reportedly recovering well on wards.

Project work currently in progress by the nursing staff on HDU includes the development of local policies and guidelines for care. A review of documentation including assessment tools and care planning is currently under way. To compliment the existing development for staff, there will be a programme of study days on High Dependency care for nursing staff this summer. As recruitment continues after the success of the national open day, the unit will soon be opening more beds. Working with the senior nurses and Heads of Nursing from the directorate, opportunities are being explored for rotational programmes for nursing staff.

The high dependency unit is part of a hospital wide approach to critical care. The unit is a resource that supports and interacts with a range of departments and personnel across the Trust. Many of those people were involved in the design and initial planning of the unit as well as the recruitment of staff. To all those people including the Special Trustees who made available generous funding for the rebuilding of the HDU, we would like to extend our thanks. In the future the unit looks forward to the challenge of providing a level of critical care to surgical patients at The Royal London.

2.  Sheppard M. High Dependency Nursing, Ballilere TindallI/ RCN 2000.

3.  Department of Health. Comprehensive Critical Care: A Review of Adult Critical Care Services. 1999.

4. East London Region Intensive Care Audit; December 2000 - February 2001.

Nursing Progress: Issue 10: June  2001.