A pilot study of the use of clinical guidelines to determine appropriateness of patient placement on Intensive and High Dependency Care Units

Background With growing pressure to contain costs without adversely affecting standards of care it is particularly important that expensive High Dependency and Intensive Care facilities are developed and used in a coherent and accountable way. We present a study which examines in detail practice in South Glamorgan Health Authority during a five week period in April-May 1993.

Methods Agreed criteria for admission to High Dependency and Intensive Care were produced by a multidisciplinary group of clinical consultants and senior nurses. These criteria, which were subject to peer scrutiny and subsequently endorsed by the relevant local medical advisory structure, were used as a basis against which to audit current practice.

Results Over the period of the study only 2 . 4 per cent (3/125) of Intensive Care patients were found to be inappropriately placed, However, the use of different types of High Dependency beds was less satisfactory. A Care of the Elderly Unit did not appear to function in a High Dependency role at all, and inappropriate placement on others ranged from 41 per cent (12/29) for a general unit (where half fulfilled the criteria for Intensive Care) up to 76 per cent (13/17) for a cardiac surgical unit (where the majority could have been placed on wards at the time surveyed). Only 0 . 29 per cent (21/7259) of ward patients fulfilled High Dependency criteria and 0 . 03 per cent (2/7259) those for Intensive Care.

Conclusion This study concludes that whereas placement in Intensive Care or on the ward appeared non-controversial, the decision to place patients in a High Dependency Unit was less straightforward. Many patients could more appropriately have been placed elsewhere. The authors suggest that High Dependency bed use could be rationalized by the introduction of professionally derived guidelines and that the current nationwide push to develop more High Dependency facilities should be dependent upon, and tempered by, the development of such clinical consensus.