nurse-led discharge from high dependency unit

DEVELOPMENTS IN PRACTICE

Nursing in Critical Care 2003 • Vol 8 No 256

Nurse-led discharge from high dependency unitGillian Knight

SUMMARY• High dependency care is a rapidly evolving area of critical care, with high patient turnover, which ultimately leads to high levels

of pressure for beds• There is a growing trend emerging, recognizing the importance and value of nurse-led initiatives in delivering effective nursing care in

acute care settings• One specific nurse-led initiative this author has developed is that of nurse-led discharge (NLD) from the high dependency unit (HDU),

in order to optimize the utilization of critical care beds within the HDU• An audit of the current practice was undertaken, which ultimately led to the implementation of NLD• Early experiences indicate that HDU beds are now being used more effectively

Key words: High dependency care • High dependency unit • Modernisation agency • North Trent Critical Care Network • Nurse-led discharge

HIGH DEPENDENCY CAREThe Audit Commission (1999) defines high dependencycare as an intermediate level of care for patients whono longer need intensive care, but who are not yet wellenough to return to an ordinary ward, or for thoserecovering from major surgery who need close moni-toring. High dependency patients are also characterizedby their need to have support for a single failing organ,or more general support or observation than can beprovided in a ward or in a theatre recovery room (AuditCommission, 1999).

The increased use of critical care beds and thepressures for these beds has been well documented(Department of Health, 1996, 2000; Coad and Haines,1999; Endacott, 1999).

The evolution of high dependency units (HDUs)and high dependency care was one of the responsesinitiated to meet this demand, and it is this author’sbelief that the pressures that were previously seen onintensive care beds are now being replicated in HDU.It is therefore imperative that nurses working withinthis area ensure optimal provision and optimal use ofhigh dependency beds. The implementation of nurse-leddischarge (NLD) from HDU is an attempt to helpnurses meet this goal.

BACKGROUNDThe Sheffield Teaching Hospitals NHS Trust is a memberof the North Trent Critical Care Network (NTCCN),which was established in May 2000 in response to therecommendations in the Department of Health reportComprehensive Critical Care (Department of Health,2000a). The network is a collaborative partnership,which includes the Rotherham, Barnsley, Doncaster,Sheffield, North Derbyshire and North Nottinghamshire(Bassetlaw) Critical Care Units. The network comprisesa network co-ordinator, a network medical co-ordinatorand a network nursing co-ordinator. There is also rep-resentation from clinical audit and finance as and whenappropriate. The afore mentioned staff are members ofthe steering group.

One of the key objectives of the network commis-sioners and providers is to make more collective deci-sions on the planning, procurement and review ofcritical care services for this geographical region. Thenetwork also ensures the effective development ofcollaborative partnerships for the purposes of servicedevelopment, audit, research, recruitment, educationand training. Since February 2001, 29 critical carenetworks have been developed covering the whole ofEngland (Modernisation Agency, 2002).

In February 2001, the NTCCN became involved inthe Modernisation Agency Critical Care ImprovementProgramme. One of the key aims of the ModernisationAgency programme is to make practical and perma-nent improvements in services for people who need ormay need critical care wherever they are in the hospital.Another key aim of this programme is to introduce new

Author: G Knight, RN, SEN, ENB 115, 100, 998, Sister, High Dependency Unit, Sheffield Teaching Hospitals NHS Trust, Northern General Hospital, Sheffield, S. YorkshireAddress for correspondence: High Dependency Unit, Northern General Hospital, Herries Road, Sheffield, S. Yorkshire S5 7AUE-mail: [email protected]

Nurse-led discharge from high dependency unit

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ways of working, whereby services can be redesignedaround patient needs and where improvements can berapidly introduced, tested and put into action.

Each network has a Modernisation Agency ProjectTeam, comprising a full-time service improvementlead and a part-time medical, nursing and alliedhealth professional leads. The NTCCN was involvedwith the first wave of improvement projects, which ledto the evolution of the NLD from the HDU initiative.

The key aim of this improvement project was toempower nursing staff to carry out discharge from theHDU in order to address the current delays in thedischarge process and provide optimal utilization ofbeds in the unit, leading to a reduction of waiting lists.

This project was carried out amidst a growingnational trend, which recognized the importance andvalue of nurse-led initiatives in delivering effectivenursing care in acute care settings (Norton, 2000;Brook, 2001; Harris, 2001; Roberts et al., 2001).

LOCAL PERSPECTIVESThe Northern General Hospital NHS Trust (NGH),now part of the newly merged Sheffield TeachingHospital NHS Trust, is a 900-bedded acute teachinghospital, serving a growing population. This regionalteaching hospital has centralized specialities including:

• Vascular Surgery• Renal Medicine• General Surgery• Burns & Plastics• Spinal Injuries.

The HDU was opened in 1994 as a purpose-built four-bedded unit, which increased its bed capacity to six bedsin 1999 and then to eight beds in 2001. The unit admitsapproximately 900 patients per year, with a largepercentage of these patients being admitted followingelective surgery. Within the HDU, care is providedwith a ratio of one nurse to two patients in accordancewith Guidelines on Admission to and Discharge fromIntensive Care and High Dependency Units (Depart-ment of Health, 1996). In addition to this, the NGHendeavours to provide a nurse in charge of each shift tomeet the recommendations within the same document.The provision of high-quality holistic care is widely feltto be the ideal (Hind et al., 1999), and the managementof the patients’ discharge is an integral part of this. Thisauthor agrees with Harris’ (2001) view that nurses arewith the patient at all times and can be very aware ofthe patient’s condition and progress. It would thereforeseem more appropriate for nurses caring for patients,with the appropriate training, to be able to assesspatients’ readiness for discharge to a general ward.

ASSESSING DISCHARGE PRACTICE PRIOR TO THE NURSE LED INITIATIVEIt was routine in the HDU for the anaesthetist coveringthe unit to review patients for discharge to a ward. Thereview of the patients would commence at approxi-mately 0830 hours and could take up to an hour ormore. Meanwhile, a number of telephone calls wouldbe made to HDU by surgeons enquiring about bedavailability for the patients booked into the HDU postsurgery. Many of the surgical lists are scheduled tocommence at 0800 hours, and the anaesthetists cover-ing the HDU may not know the patients in the unit,therefore the patients’ daily review could be lengthy.This led to delays in commencement of elective surgeryand uncertainty about bed availability.

Mismanagement of critical care services can haveadverse effects on trust wide performance and qualityinitiatives. Examples of this include cancellation ofmajor surgery when critical care beds are full. There-fore, the overall aim of this project was to optimize theutilization of critical care beds within the HDU, pro-viding better access for those patients in need of them.

A multidisciplinary working group was formedincluding Senior Nurses, Consultant Anaesthetists,Project Manager and Network Lead.

The group initially explored the current situationwithin the HDU, which was essentially when thepatient was physiologically ready for discharge the doc-tor made the decision to discharge and then the nurseswould check whether the bed was available in the wardand prepare the patient for discharge. A set of dis-charge criteria were discussed and agreed within thegroup (Appendix 1). One of the concerns expressed bythe group at this time was the need to avoid patientsbeing discharged from HDU and then to begin trig-gering the criteria in the Early Warning Indicator ofCritical Illness Assessment tool (Murch and Warren,2001). Discharge criteria were made sufficiently rigor-ous to avoid this from happening.

SEARCHING THE LITERATUREThe intention of the literature review was to incorp-orate all the arguments regarding NLD from HDU anduse the current information available. Burns and Grove(1997) suggest that the review of the relevant literatureshould be conducted in order to generate a picture ofwhat is known and not known about a particular situ-ation. Review of the relevant literature refers to thosesources that are important in providing in depthknowledge needed to make changes in practice or tostudy a selected problem. The majority of the literatureobtained for this study was collated primarily throughtwo key databases. The Biomed database at http://biomed.niss.ac.uk, using both Medline and Cinahl.



The remaining literature was obtained through furtherincremental searching.

On searching through the literature, there were nospecific articles relating to NLD from HDU; however,there were articles that related to other nurse-ledinitiatives, such as nurse-led weaning from ventilation(Norton, 2000) and nurse-led thrombolysis (Robertset al., 2001). Crookes and Davies (1998) maintain thatincremental searching using cross-referencing techniquesis particularly useful when examining restricted areasof research and practice.

AUDIT OF CURRENT DISCHARGE PRACTICEAn audit of the current discharge practice was under-taken at the beginning of July 2001, where details of allsurgical patients being discharged from HDU werecollected and measured against the discharge criteria.Thirty-seven surgical patients were discharged fromthe HDU during the audit of the current dischargepractice. During this audit, the medical staff continuedto discharge patients from the unit; however, nursingstaff used the NLD criteria to assess whether or not thepatients fulfilled the criteria and documented the timethey would have discharged the patient, had theybeen in a position to do so (Appendix 2).

PILOT OF NLDThe aim of the pilot of NLD was to address any currentdelays in the discharge process. Permission was soughtfrom consultants by letter, providing them with a copyof the discharge criteria and asking them to provide anyconsultant-specific criteria that they wished to add.Post-surgical patients under the management of Vas-cular Surgery, one General Surgical Consultant andthree Orthopaedic Consultants were included in theaudit, as patients under the care of these consultantswere regular users of the HDU.

With the full agreement of the surgeons, the pilotstudy commenced on 30 July 2001. Following discus-sions within the working group, it was agreed thatonly E Grade nurses and above who had completed theHDU/ITU Courses (ENB 100/A75) were authorizedto discharge patients. This decision was made to ensurethat the nurses who were to be involved in the decision-making process remained credible; however, juniorstaff were encouraged to take part in the assessment ofthe patient for NLD, as this was thought to be a goodlearning opportunity for them, in order to developskills in NLD for the future.

It was agreed that if any of the patients assessed fordischarge did not meet any aspect of the strict NLD

criteria, medical opinion, advice or if necessary medicalintervention must be sought.

Patients who were discharged from the HDU underthe NLD criteria were then routinely referred on to theOutreach Team for follow-up care. During the pilot ofNLD, the nursing staff who discharged patients fromthe unit also followed them up. This was done by atelephone call to the ward, 24 and 48h post discharge(Appendix 3).

When discharging patients under the NLD criteria,the nurse would document in the nursing evaluationthat the patient being discharged under NLD has metthe criteria and therefore the discharge process hascommenced. The nurse discharging the patient wouldcomplete the ongoing audit form as safety must bemaintained and be responsible for following up thatpatient in the ward, 24 and 48h post discharge.

RESULTSFollowing the audit of the current discharge practice,results indicated that in some cases, patients werewaiting over 3·5h for a discharge decision and a call tothe bed manager to be made. The median time delaywas 70min, inter-quartile range (IQR) 30–150min. Byeliminating the requirements for a medical review, themedian time to the commencement of the dischargeprocess has been reduced to 15min (IQR 0–40min).The pilot of NLD has demonstrated discharge deci-sions being made between 7·30 and 8·00.

Patient follow-up post discharge at 24 and 48h hasconfirmed that patient outcomes have not been com-promised by the introduction of NLD. All patients dis-charged under NLD continued to improve in the wardand had no adverse effects from being discharged underthe criteria.

Following the above positive outcomes, the nextobjective was to roll out NLD to all surgical patientsadmitted to the HDU.

A letter was sent to all surgical Clinical ManagementTeams, including evidence of its success, asking per-mission to use their patients in the project. All agreedexcept one consultant who wanted two specific typesof patients exempted from the project, as he felt thesepatients were too complex. These were the patientswho were requiring specific endocrine surgery.

It was found that the reason a number of patientsdid not fit the criteria was because their haemoglobin(Hb) was slightly under 10g /dL, i.e. 9·8–9·9g/dL. Afterdiscussion with medical staff and with evidence fromHerbert et al. (1999) as cited by Goldhill et al. (2002),the Hb lower limit was changed to 9·0g/dL. NLD hascontinued to be successful and is now an acceptedpractice within the HDU.



DISCUSSIONAs with any new initiative, this author believes it to beimportant to reflect on the change process and to learnfrom this. In order to facilitate NLD during the pilot,only nurses with the ENB 100/A75 took charge of theunit. This in turn prevented the E grades without thequalification from gaining management experience, andat times this led to a resistance to change in practice.This was identified and addressed within the teamand over a period of time, with increased knowledgeand understanding, a process of shared decision makingbetween 100/A75 certificated and noncertificated staffwas introduced. This ensured that managementopportunities were not compromised.

The anaesthetic staff that cover the HDU weresupportive of the change in practice; however, whena nurse had discharged a patient under NLD criteria,the doctor occasionally still reviewed the patient anddischarged the patient even though the NLD dischargeprocess had begun. This problem was overcome byraising the awareness of the NLD initiative with theanaesthetic staff by informal discussions.

Although the decision to discharge a patient ismade more quickly, there are occasions when thepatient’s transfer time has not been increased, as bedavailability still remains a problem owing to lack ofbeds in the general wards. This initiative, however,has enabled the staff to have a more cohesive approachto the discharge of patients from the HDU.

CONCLUSIONWho better than the nurse at the bedside caring forpatients and having an in-depth knowledge of thatpatient to make a decision as to whether or not thatpatient should be discharged from the HDU.

NLD has proved to be a valuable learning experiencefor all staff in the HDU and has emphasized the import-ance of a thorough assessment of the patient, prior todischarge from critical care. Although the nurse incharge is usually the person who assesses patients forNLD, this is done in conjunction with the nurse caringfor the patient and is therefore a positive educationalexperience for junior nurses.

NLD has been found to be particularly useful out ofhours, for example at weekends and bank holidayswhen there is limited medical cover. Prior to theimplementation of NLD when the HDU was at fullcapacity and patients required admission to the unit,the on call team would be contacted to come and assesspatients for discharge to the general ward. Often thedoctor attending out of hours would not know thepatients and the review and subsequent dischargecould become lengthy. Even if a patient does not fulfil

the NLD criteria, it can be used as a guide for the doctorassessing the patient.

With the implementation of NLD, decisions todischarge patients can be made early and in time fortheatre lists to commence, therefore making moreeffective use of theatre time and critical care facilities.Critical care beds can be freed up to make moreeffective use of HDU, enabling patients in need ofthose beds to have access to them.

NLD has also shown that by empowering nursingstaff to discharge patients within a safe criteria thatmore effective use of critical care beds is beingachieved, which in turn leads to increased autonomyand job satisfaction for nurses.

RECOMMENDATIONS

• Implementing NLD from HDU has beena rewarding and a challenging venture that hasthe potential for adaptation into other HDUs.

• One of the weaknesses of NLD is that it has notbeen formally evaluated, and future studiesshould centre on evaluating the impact of theinitiative.

• Our early experiences of NLD are that this doesreduce pressure on HDU beds; however, it isaccepted that this is purely anecdotal.

ACKNOWLEDGEMENTSI would like to acknowledge the support and encour-agement of the nursing and medical staff on the HDU,Nicola Platt, Project Manager, Mrs Stella Langan, ClinicalServices Manager, Sister Julie Bond, General Intens-ive Therapy Unit. Special thanks to Mr Phil Murch,Lecturer Practitioner, Critical Care, for all his supportand guidance.

REFERENCESAudit Commission. (1999). Critical to Success: The Place of Efficient

and Effective Critical Services Within the Acute Hospital. ANational Report. London: Audit Commission.

Brook N. (2001). Nurse-led discharge planning improves quality ofcare. Nursing Times; 97: 40.

Burns N, Grove S. (1997). The practice of Nursing Research. Conduct,Critique and Utilization (3rd ed). Philadelphia: Saunders.

Coad S, Haines S. (1999). Supporting staff caring for critically illpatients in acute care areas. Nursing in Critical Care; 4: 245–248.

Crookes P, Davies S. (1998). Research into Practice: Essential Skillsfor Reading and Applying Research. Edinburgh: Ballière-Tindallin association with the RCN.

Department of Health. (1996). Guidelines on Admission to andDischarge from Intensive Care and High Dependency Units.London: The Stationary Office.

Department of Health. (2000a). Comprehensive Critical Care: a Reviewof Adult Critical Care Services. London: The Stationary Office.

Department of Health. (2000b). The NHS Plan. London: TheStationary Office.



Endacott R. (1999). Critical care shifting boundaries and openingthe doors. Intensive and Critical Care Nursing; 15: 4–5.

Goldhill D et al. (2002). Anaemia and red cell transfusion in thecritically ill. Anaesthesia; 57: 8–10.

Harris JM. (2001). Weaning from mechanical ventilation: relating theliterature to nursing practice. Nursing in Critical Care; 6: 226–231.

Herbert PC et al. (1999). A multi-center random, controlled clinicaltrial of transfusion requirements in critical care. New EnglandJournal of Medicine; 340: 409–417.

Hind M, Jackson D, Andrewes C, Fulbrook P, Galvin K, Frost S.(1999). Exploring the expanded role of nurses in critical care.Intensive and Critical Nursing; 15: 147–153.

Modernisation Agency. (2002). Bulletin from http://modern.nhs.uk/criticalcare.

Murch P, Warren K. (2001). Developing the role of critical careliaison. Nursing in Critical Care; 6: 221–225.

Norton L. (2000). The role of the specialist nurse in weaningpatients from mechanical ventilation and the develop-ment of the nurse-led approach. Nursing in Critical Care;5: 220–227.

Roberts A, Johnstone J, Miles M. (2001). An evaluation ofnurse-led thrombolysis in the management of patientswith acute myocardial infarction. Nursing in Critical Care;6: 267–272.

APPENDIX 1Criteria for nurse-led discharge from HDUThe following parameters should have been consist-ently met for a minimum of 4 h. However, nurses

should bear in mind the patients’ ‘normal’ parameterswhen considering discharge from HDU.

FiO2, fraction of inspired oxygen; PO2, partial pressure of oxygen; PCO2, partial pressure of carbon dioxide

If the patient does not meet criteria, please write down valueRespiratoryPatent airway Yes No If no, why?

FiO2 <0·6 Yes No If no, what is the value

*PO2 (kPa) >10 Yes No If no, what is the value

*PCO2 (kPa) <6 Yes No If no, what is the value

HCO3 – standard (mmol/L) >19 Yes No If no, what is the value

Respiratory rate 10–20 bpm Yes No If no, what is the valueif no arterial line*O2 saturation >95% Yes No If no, what is the valueComments:

CardiovascularSystolic BP >100 mmHg Yes No If no, what is the value

Heart rate 60–100 bpm Yes No If no, what is the valueComments:

RenalUrine output 1/2 ml/kg Yes No If no, what is the valueComments:

Pain managementPain score 0–1 Yes No If no, what is the valueComments:

Central nervous system

Fully awake and orientated Yes No If no, what is the value

Temperature36–37·5°C Yes No If no, what is the value

Blood testsHaemoglobin >9 g/dL Yes No If no, what is value

U & Es normal? Yes No If no, what is value

Consultant and procedure-specific guidelinesAre the consultant and procedure-specific guidelines met?

Yes No If no, what is the value



APPENDIX 2Audit of the current discharge practice in HDU

APPENDIX 3Patient outcome following nurse-led discharge

Date ........................ Patient Name ............................................................................................... Reg No .....................................................

Please tick whether patient is Elective or Emergency

1 At what time would you have made the decision to discharge the patient?

2 Did the patient meet the criteria for a nurse-led discharge? Yes NoIf no, please state the reasons and discuss with relevant medical staff:

3 At what time did the doctor make the decision to discharge?

4 Did the patient meet the criteria for a nurse-led discharge? Yes NoIf no, please state the reasons and ensure the value of criteria that are not met is identified on the criterion chart:

5 At what time did you make enquiries about bed availability?

6 At what time were you informed that a bed was available?

7 At what time did the ward agree to accept the patient?

Please state the ward:

8 At what time was the patient ready to leave HDU?(patient ready at the point where porters are requested to bring ward bed)

9 At what time did the patient leave the unit?10 If any delays occurred during this process, please state the reasons:

(porters, staffing shortages on ward or HDU, bed alert status, etc.)11 If the discharge was out of hours (after 5 pm Monday to Friday, weekends,

bank holidays), was this owing to HDU/ITU bed pressures?Please comment:

Yes No

12 Has the patient been referred to the Critical Care Liaison Nurse or Outreach Team? Yes No

13 Has the patients’ admitting team been informed of the discharge? Yes No

Section A (to be completed approximately 24 h post discharge)1 Is the patient still in the ward that he/she was discharged to? Yes No

Comments:

2 How is the patient? Improving Same Deteriorating

Comments:

3 If deteriorating, has the patient triggered the Early Warning Indicator tool?

Yes No

Comments:

4 Has the patient been referred to the Outreach Team? Yes No

Comments:

Section B (to be completed approximately 48 h post discharge)1 Is the patient still in the ward that he/she was discharged to? Yes No

Comments:

2 How is the patient? Improving Same Deteriorating

Comments:

3 If deteriorating, has the patient triggered the Early Warning Indicator tool?

Yes No

Comments:

4 Has the patient been referred to the Outreach Team? Yes No

Comments:

nurse-led discharge from high dependency unit

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