A prospective study to assess the demand for a high dependency unit (HDU) in a district general hospital based on the guidelines issued by Department of Health (DoH) (NHS Executive) 1996

Abstract

A challenge for doctors is to identify, at an early stage, which patients are most likely to benefit from HDU care.1 2 The NHS Executive (1996) have set guidelines1 to define the main issues to be considered when deciding which patients need HDU care. York District Hospital (YDH) has 838 beds serving a catchment area of approximately 300 000 people. Facilities for an ICU of six beds with no HDU beds or five ICU beds with two HDU beds is provided. Over a period of 20 days (three random and 17 consecutive days) the main surgical and medical wards (total of five wards) were visited daily by one medical investigator identifying patients who might have been considered for admission to HDU, had it been available. The following data were recorded. (a) Date that the patient first fulfilled the criteria for HDU admission. (b) Details of the organ system that required support. (c) Date that HDU was no longer considered necessary. (This may have been due to patient getting clinically better or worsened requiring either a formal admission to HDU or ICU, or death.) (d) Details of patient transfers to other wards or departments, including ICU or other specialist units in nearby hospitals. The two HDU beds were also monitored consecutively for 38 days and the same data were collected. The other medical and surgical wards (17 wards) were not audited, except the number of admission from them into either HDU or ICU. There were 1327 admissions into the adult medical and surgical specialities, of which 687 were elective and 640 emergency admissions. The audited wards had 287 (45%) emergency and 60 (11%) elective admissions. Seventeen patients (six surgical and 11 medical) were identified to qualify for HDU. Out of the 11 medical patients, two (18%) patients were admitted to ICU, of whom one (9%) died. Nine (82%) patients improved. Their mean HDU stay was 3 days. In the surgical audited wards, six patients were identified of whom one (17%) was admitted to ICU. The other 5 (83%) got better and were discharged. Their mean HDU stay was 3.6 days. Two surgical patients, despite being clinically very ill, did not meet any categories in the NHS guidelines. Both patients were admitted to ICU of whom one died. Reviewing their notes, the outstanding biochemical abnormality was presence of severe metabolic acidosis. Five patients were admitted to ICU from the non-audited wards (total 17 wards with 353 (55%) emergency and 627 (89%) elective admissions during the study period). Twenty-seven patients were admitted to the existing HDU in 38 days. These were from theatre (62%), casualty (10%), wards (14%) and from ICU (14%). Four (14%) patients were transferred to ICU, of whom one (3%) died. From the above data, it was predicted that a six bed HDU would be occupied to full capacity for 100% of the time. The guidelines are self explanatory and easy to follow, and therefore should be easily implemented. To increase the specificity of the guidelines, we recommend addition of severe acid base disorders to the guidelines.