Anaesth Intensive Care 2002; 30: 348-354

Review
High Dependency Units: Issues to Consider in Their
Planning
R. BOOTS*, J. LIPMAN†
Intensive Care Facility, Royal Brisbane Hospital, Brisbane, Queensland, Australia

SUMMARY
This review discusses the issues to be considered in establishing new or extending existing high dependency unit
(HDU) services. A defined high dependency service becomes cost-effective when patient care requires more than one
nurse for three patients. Professional guidelines for HDUs vary and there are no national accreditation criteria.
Casemix and service delivery specifications for the HDU need to be defined and agreed upon within the institution.
Establishing a new HDU service requires changes to care delivery. Many potential HDU patients are currently
managed in general wards or in the intensive care unit. The service should be discussed widely and marketed within
the institution, and the development of defined working relationships with the ICU and primary care teams on the
wards is mandatory.
Key Words: HIGH DEPENDENCY UNIT: management; guidelines

The bed closest to the nursing station is tradition- WHAT IS AN HDU?

ally reserved for the seriously ill, “at risk” or compli-
cated patients not admitted to the ICU. Older and
sicker patients now present to hospital requiring
more complex medical management, and better
facilities are needed1. Specialty based units, such as
those focusing on coronary care and bone marrow
transplantation, generally have a defined casemix
with a predictable clinical course. HDUs with a
broader casemix have been proposed as solutions to
bed shortages within ICU and to counteract the loss
of control of surgical patients to intensive care2.
Patient care is increasingly organized according to
care needs and severity of illness rather than tradi-
tional factors such as medical or surgical specialty3.
This review aims to define high dependency care and
to examine the issues that should be considered in the
creation of an HDU.
* F.R.A.C.P., F.J.F.I.C.M., M.Med.Sci., Senior Staff Specialist, Intensive
Care Facility, Royal Brisbane Hospital.
† F.F.A. (Crit Care), F.F.I.C.A.N.Z.C.A., F.J.F.I.C.M., Director, Intensive
Care Faculity, Royal Brisbane Hospital.
Address for reprints: Dr R. Boots, Staff Specialist, Intensive Care Facility,
Royal Brisbane Hospital, Herston Road, Herston, Qld 4029.
Accepted for publication on November 27, 2001.
It is now universally accepted that acutely ill
patients requiring ventilation should be cared for in
an intensive care unit. Beyond this principle, many
models of care have been described for acute clinical
care. No testing has been carried out to determine
which is superior.
The common elements included in definitions of
high dependency care adopted by the British
National Health Service, the Association of
Anaesthetists of Great Britain and Ireland and the
Faculty of Intensive Care of the Australian and New
Zealand College of Anaesthetists are summarized in
Table 1.
Many patients who require increased nursing—for
example, in the form of cardiac rhythm monitoring,
dressings, traction and the mobilization of overweight
patients—do not, we believe, require the level of
service provided by an HDU. The illness of these
patients follows a predictable clinical course and they
are unlikely to require intensive care. They generally
present a stable or chronic single organ malfunction.
The “intermediate” level of care they require
includes expert nursing with a narrow range of
specialist skills such as the monitoring of “flaps” in
plastic surgery. High dependency units do not
normally accept patients requiring mechanical
ventilation.
Anaesthesia and Intensive Care, Vol. 30, No. 3, June 2002
 HIGH DEPENDENCY UNIT MANAGEMENT
TABLE 1
Characteristics of an HDU4,5,6
1. Specifically staffed and equipped section of an intensive care
complex.
2. Provides an intermediate level of clinical care between a
general ward and intensive care.
3. Provides invasive monitoring and support for patients with, or
at risk of developing, acute (or acute on chronic) single organ
failure. (An associated co-morbidity may convert a need for
high dependency care to a need for intensive care. Multi-organ
failure should be managed in the ICU.)
4. Acts as a “step-up” or “step-down” unit between the level of
care delivered on a general ward and intensive care.
5. Admits patients where the predicted risk of clinical
deterioration is high or unknown.
6. Does not normally accept patients requiring mechanical
ventilation.
7. Does not regularly admit patients requiring frequent non-
specialist nursing interventions only, such as non-invasive
clinical observations.
Admission, discharge and referral policies for the
HDU are usually based upon the nature and severity
of an illness, the potential reversibility of the disease
process, the types of therapies required, probability
of long- and short-term survival and the degree of
skill mixes within the hospital7,8. Potentially, every
patient in the ICU is at some time classifiable as an
HDU patient. Only if there is a need for monitoring
for more than 12-24 hours should a patient move
from the ICU to the HDU rather than being
discharged to the ward.
A significant distinction between an ICU and an
HDU would appear to be the ability to provide
mechanical ventilation9. Non-invasive ventilation is
commonly provided in general wards supplemented
by additional nursing staff. It would seem reasonable
to provide this service in an HDU7.
Further work is necessary to develop definitions
that are internationally recognized and endorsed, a
process that will promote consistency in infra-
structure and funding planning.
ISSUES TO CONSIDER IN THE
ESTABLISHMENT OF HIGH DEPENDENCY
CARE
Several issues should be considered to ensure the
provision within the HDU of defined and consistent
staff-management policies and training.
1. Will the HDU lead to improved patient outcomes?
There is some evidence that the existence of an
HDU with defined admission criteria may lead to
improved patient outcomes. The incidence of cardiac
arrests decreased on the medical wards by 39% after
the establishment of an HDU10. No clinical benefit
Anaesthesia and Intensive Care, Vol. 30, No. 3, June 2002
349
from admission to an HDU according to pre-
determined physiological parameters has been
established10,11.
For some 80% of surgical patients with poor out-
comes, a contributory train of events was identified
during the first postoperative 24 hours12. The authors
suggest that high dependency care could have
prevented 17% of deaths and permanent dis-
abilities after surgery and 6% of major postoperative
complications.
Where ICU and HDU care was deemed
appropriate by both the anaesthetist and the surgeon
but was not provided, the fatality rate increased from
1.2% up to 3.1%13. Requests for HDU/ICU admission
tended to be made for ASA class III-IV patients.
Casemix differences between patients admitted to the
HDU/ICU and those remaining on the wards were
not specified.
A mortality audit for deaths occurring after dis-
charge from ICU in the absence of HDU care found
that 26% of patients were expected to die, 54% were
considered at risk of dying and 20% were expected to
survive14. It was suggested that the last two groups
would benefit from intervention.
A further advantage was that the HDU was per-
ceived by patients as a place where there was less
technology, less noise, more privacy, and more open
visiting15.
A study of the impact of an intensivist on the length
of stay and mortality level in the ICU has not yet been
replicated for HDUs16.
Models of deterioration in physiological para-
meters have been created by medical emergency
response teams to prescribe when nursing staff
should call for immediate medical attention17,18. This
may result in improved patient outcomes due to early
intervention17,18,19. Nursing staff follow a specified pro-
cedure to recognize “at risk” patients and summon
appropriate assistance20. It is assumed that similar
early intervention would be available to patients
admitted to an HDU.
At present, the arguments citing improved patient
outcomes as a result of high dependency services do
not clearly define the details of alternative care
arrangements. When patients are clustered in an
area with increased supervision, it is expected that
consistent management and any necessary early
intervention will be facilitated.
2. Will the HDU solve the nursing staff shortage?
There is a shortage on some wards of senior nurs-
ing staff to manage seriously ill patients21. The need to
provide “special nurses” to meet their dependency
350 R. BOOTS, J. LIPMAN
requirements stretches staffing establishments and
their budgets22. It is also difficult to maintain skills
against a background of high staff turnover.
Staff rotation through high dependency and critical
care areas has been proposed as a means of main-
taining skills and raising morale23, and may be an
attractive inducement to recruit staff, especially if it is
linked to specific training and career development.
As yet there are no studies of staff recruitment or
retention related to high dependency services.
3. Will ICU bed shortages be reduced?
The availability of more intensive care beds once
an HDU has been established depends upon whether
patients requiring greater care are presently managed
in the ICU or in the wards24,25. Hospitals with large
numbers of elective ICU admissions have justified the
establishment of an HDU when a significant number
of admission requests have been refused3,24,26. When
an HDU is in place, fewer ICU admissions come
directly from the general wards and both the length of
stay in the ICU and the frequency of cancellation of
elective surgery are decreased24,25. The practice of pro-
tecting HDU beds for elective work at the expense of
emergency work has been documented27.
In many studies the admission policies for HDUs
and ICUs are unclear. Low-risk monitored patients
may comprise up to 40% of ICU admissions28, and
they have less than a 10% risk of requiring active
intensive treatment29. The transfer of these patients to
an HDU should increase bed availability in the ICU.
The value of “step-down” ICUs as an alternative to
the expansion of the ICU is not defined.
4. Can junior doctors care for seriously ill patients in
general wards?
Junior doctors manage public hospital patients
with varying degrees of consultant supervision, and
early recognition of unexpected complications can
be deficient30. The shortage of senior nursing staff,
especially at night, and the quality of care offered by
“on call” junior doctors have been linked to excessive
patient morbidity and mortality30. The National
Clinical Training Portfolio for Junior Doctors
endorsed by the Federal Health Department outlines
the deficiencies in junior doctor training, with par-
ticular emphasis on procedural and acute care skills31.
A fundamental aim of compulsory continuing
medical education and recertification processes
based upon practice reviews is the prevention of
atrophy of clinical skills through disuse32,33. Levels of
morbidity and mortality on the wards may be reduced
by supervised practice in dedicated units.
Occasional care of seriously ill patients is unlikely
to facilitate the maintenance of skill and expertise.
Importantly, a key feature of an HDU is the presence
or immediate availability of senior experienced staff.
When patients are located in dedicated units, staff
training and maintenance of competence is facili-
tated. In planning staff resources, models of practice
will need to take account of factors such as continued
competency, training and availability.
5. What are the requirements of training and
hospital accreditation?
Various professional societies have produced stan-
dards for the HDU5,6,9,34. These will no doubt form the
basis of accreditation standards for hospitals, both
for clinical training and for recognition by health
departments.
6. Will an HDU save hospital costs?
The principal contributor to the cost of care is the
nurse-patient staffing ratio. No studies of HDU
staffing validate staffing formulae. General-ward
staffing formulae are not appropriate for the care
of high dependency patients35. According to the
Therapeutic Intervention Severity Score (TISS), the
average score per patient in an HDU is 16 (40-50 per
nurse per shift is considered reasonable)28. On this
basis, medical patients require a nursing to patient
ratio of 3:1 and surgical patients 4:128. A ratio of 2:1
for patients in the HDU has been recommended6.
Hospital accreditation authorities will determine
the standard when more detailed information is
available; this will be the key cost determinant.
No properly conducted cost-benefit analysis exists
for the establishment of an HDU36, although HDU
care is presumed to be cheaper due to the reduced
nursing staff ratio compared with that of an ICU37.
There is no evidence that patients treated in an HDU
are discharged any more quickly or ultimately experi-
ence lower morbidity or mortality. The real cost of
managing these patients in the general ward if the
same level of care were provided is unknown. Where
an HDU is run during “office hours”, transfers are
almost always made to the ICU38, particularly if the
unit closes over the weekend (to control costs).
The likely cost of the increased morbidity and case
fatalities has not been estimated.
7. What are the roles of the primary care team?
Management of the seriously ill generally requires
a team approach, incorporating expertise from widely
differing disciplines. It is not known whether patient
outcomes improve after patient care is transferred to
Anaesthesia and Intensive Care, Vol. 30, No. 3, June 2002
 HIGH DEPENDENCY UNIT MANAGEMENT 351

an HDU team that is separate from the primary care
team. Where responsibility for high dependency care
remains with the primary care team, specific skills for
the care of the seriously ill are required39,40. Basic
training courses have recently been introduced to
train surgeons in the care of the critically ill41. Various
issues, such as hospital resources, funding and
staffing history and the reluctance of some staff to
share or cede responsibility for patients, need to be
canvassed to determine whether responsibility for
patient care will be divided between the HDU and
the ICU or whether a coordinated, consultative or
supervisory service will be instituted.
8. What are the impacts of different service models?
Most recommendations for an HDU suggest that
it should occupy a geographically distinct unit,
physically separate from but adjacent to the ICU7,9.
The advantages of its physical separation from the
ICU may include the following:
(a) Uniform staffing ratios can be established (com-
pared with the nursing complement needed when
patients requiring lower nursing acuity are
accommodated alongside ICU patients).
(b) Parent teams can locate their patients more
readily.
(c) The medical and nursing skill base is defined.
(d) Infection control is improved, as lengths of stay
are generally shorter than in the ICU.
(e) Cost-centre management may be more readily
defined.
There are four major options for managing high
dependency care based upon the geographical loca-
tion of the unit and the supervising clinician (Table 2).
These general categories serve as a useful model to
discuss individual forms of unit. Any combination of
elements of all of these units is possible in an HDU.
Peripheral specialty-based HDU
This form of HDU potentially provides:
(i) Continuity of care by the primary physician or
surgeon.
(ii) Maintenance of medical and nursing skills in the
general wards.
(iii) Flexibility of bed use between the HDU and the
standard ward.
They generally comprise a defined section of a
general hospital ward.
Multiple speciality-specific HDUs within the hos-
pital may not be justified on financial, staffing or skills
grounds, especially since duplications of service in
many sites and difficulties in providing immediate
consultant cover are likely. Unless there are a certain
number of patients in the HDU every day, it can be
difficult to roster sufficient nursing staff with an
appropriate skill base.
Centralization of high dependency services adja-
cent to the ICU may provide:
(i) Greater economies in the provision of equip-
ment and staff.
(ii) Concentration of nursing, paramedical and
medical expertise for critically ill patients.
(iii) Flexibility of bed use between the unit and the
ICU.
(iv) Uniformity of service and provision of utilities
complying with defined standards.
(v) Regular staff exposure to situations promoting
skill maintenance.

Description of generic HDU descriptions
Type of Unit Supervising Clinician
Peripheral Primary team consultant
Central Open Primary team consultant
Central Combined Multidisciplinary team of
specialists that may
include intensivists
Central Closed Specialists trained in
intensive care
TABLE 2
Unit Location
Often multiple units separate from
the ICU and other critical care units
Adjacent to other critical care units
in a single facility
Adjacent to other critical care units
in a single facility
Adjacent to other critical care units
in a single facility
Description
Specialty based and functions
independently of other critical care
facilities within the institution
Patients have similar care needs. The
involvement of intensive care is as a
consultation or supervisory service.
Direct takeover of care by the ICU is at
the request of the primary team.
Bed control is handled by specialists
trained in intensive care. Specialists are
rostered to the HDU for full-time
periods.
Bed management and direct patient care
are provided by intensivists only, with
input by other specialties based upon
collaboration and consultation.

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352 R. BOOTS, J. LIPMAN
A central open HDU
This form of HDU faces similar staffing problems
to those of a peripheral HDU. A director or coordi-
nator is required to triage admissions and discharges,
which may well become a nursing rather than a
medical responsibility. Standardization of practice by
consensus will be important, and processes for audit
and accountability will need to be clearly defined.
A central combined HDU
In this form of HDU the consultants of the primary
care team must be available for combined rounds
with intensive care staff. Intensivists supported by
members of other disciplines manage the unit, while
a designated specialist coordinates admissions.
Specialists attached to the HDU provide direct
patient care rather than a purely consultative service.
Specialty consultations are requested from outside
the unit as required. Care combined with an increase
in consultant time is provided, accompanied by
continuous cover on the part of senior medical staff.
The central closed HDU
This form of unit is managed in similar fashion to a
closed ICU, with principal care, admission and dis-
charge coordination being provided by the ICU staff.
A consultative approach with the primary team is
undertaken in such a way that continuity of care is
preserved as far as possible, and policy and pro-
cedures, medical staff cover, audit and accountability
are more readily standardized.
Care provided within the ICU is not generally
focused on planning for hospital discharge but rather
on ICU discharge. HDU patients with shorter hos-
pital lengths of stay may need clinical pathways that
more actively include hospital discharge planning,
such as rehabilitation and appropriate discharge
accommodation42. Planning for care within the HDU
may need to incorporate these issues, which are
generally the province of the primary ward team.
As yet, there are no specified recommendations for
performance assessment of an HDU. Patient out-
comes are dependent on pre-HDU and post-HDU
care and the interaction of other external factors,
such as the standardized mortality ratio, patient-
transfer rates, population/per bed ratios, occupancy,
staff to patient ratios and patient stability43.
Several professional organizations have identified
the managerial resources and equipment required for
an HDU5,6,9,44: The equipment and utility require-
ments are similar (apart from invasive ventilation)
to those demanded in any intensive care unit.
Resuscitation facilities must be available, and junior
staff must possess detailed knowledge of the patients.
Senior staff are expected to provide close supervision
and to be available immediately when required,
while the nursing and medical directors should be
specifically trained in critical care. Educational
programs for all staffing grades are required, and
audit and quality improvement programs should
be in place. Twenty-four hour access to the phar-
macy, operating theatres and imaging services and
appropriate access to physiotherapy and allied health
are required.
9. How many patients justify an HDU?
It is important to determine the bed numbers of a
unit at the outset. Inability to accommodate potential
patients satisfying the casemix criteria for admission
has the potential to frustrate the HDU as well as
referring hospital staff. The literature provides no
details on the process of determining the service
requirement. In hospitals where surgical HDU-type
patients are managed on the general wards, perhaps
5% of occupied bed days could be transferred to a
formal HDU45.
Prediction can be made using:
(a) Extrapolation from ICU/HDU data per head of
catchment population from similar hospitals. This
method has the advantage of reflecting the needs
of hospitals of similar size and service delivery.
Referral patterns often differ over time from
those at the beginning of a new HDU service.
(b) In-hospital survey. This has the advantage of
defining the casemix, allowing the HDU to cater
for the needs of the hospital and may need to be
conducted over an extended period, possibly a
year or two, in order to allow adjustment for
seasonal referral patterns. This type of survey
often has to be prospectively managed, since
historical data are often not detailed enough to
assess levels of dependency either from existing
information systems or from the clinical case
notes.
10. Where Does the Money Come From?
Establishing a new high dependency service in a
hospital often requires resources to be diverted from
existing budgets. It may be possible to argue the case
for new seed money as a clinical initiative if the final
cost saving will derive either from income generation
from private practice or from cost efficiencies in the
hospital. It should be clearly noted (and negotiations
should proceed accordingly) that in a hospital where
these patients are cared for within existing budgeted
services, the transfer of patient care from the ward
to an HDU will almost certainly involve a similar
Anaesthesia and Intensive Care, Vol. 30, No. 3, June 2002
 HIGH DEPENDENCY UNIT MANAGEMENT
transfer of the budget allocation for those patients.
This outcome will lead to a loss of revenue for the
parent unit under centralized and closed patient care
models.
CONCLUSION
The establishment of high dependency services in
an appropriately sized hospital offers the potential
advantages of improved patient care, training, main-
tenance of expertise and nursing skills and efficient
use of resources. The development of these services
should be considered when a staff ratio of more than
2-3:1 patients per nurse is required. Clear admission
criteria are required. The specific clinical services
provided in the HDU will depend on the skills within
the hospital, the organizational structure of the HDU
and its relationship to the intensive care and primary
care units of the hospital. Services for the high depen-
dency patient should be developed in the light of
other hospital resources and the pre-HDU and post-
HDU care provided. The model of high dependency
care chosen will vary between individual institutions.
Clinical services must be developed that meet the
needs of patients, maintain training for medical and
nursing staff in a dynamically changing environment
and comply with potential hospital accreditation
requirements.
ACKNOWLEDGEMENT
We would like to thank Mrs Deborah Louw and
Ms Maree Campbell for their assistance in the
preparation of the manuscript.
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