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High-dependency unit

A high-dependency unit (HDU), also referred to as an intermediate care unit or step-down unit, is a specialized hospital ward that delivers an intermediate level of patient care and monitoring positioned between a standard general ward and an intensive care unit (ICU).^[1]^[2] These units focus on patients requiring enhanced observation, frequent nursing interventions, and support for vital functions without the need for invasive mechanical ventilation or multi-organ life support typical of ICUs.^[3] The primary purpose of an HDU is to bridge gaps in care continuity, serving as a step-up facility from general wards for acutely ill patients or a step-down from ICUs for those recovering but still needing close supervision.^[4]^[2] Typical patients include those with single-organ dysfunction, such as respiratory distress requiring non-invasive ventilation, circulatory instability managed with vasoactive drugs, postoperative recovery after major surgery, or conditions like acute cardiac failure and renal impairment that demand vigilant monitoring but not full critical care escalation.^[3]^[4] Admission criteria often involve physiological indicators, such as oxygen saturation below 94% or significant deviations in blood pressure, ensuring timely intervention to prevent deterioration.^[4] HDUs operate 24 hours a day with multidisciplinary teams, including intensivists, medical officers, specialized nurses, and support staff like technicians and physiotherapists.^[4]^[2] Nursing staffing follows a standard ratio of one nurse per two patients, allowing for individualized care while optimizing resources compared to the one-to-one ratio in ICUs.^[4]^[2] Essential equipment encompasses multi-parameter physiological monitors, non-invasive ventilatory support devices (e.g., BiPAP or CPAP), infusion pumps, defibrillators, suction apparatus, and crash carts for emergency resuscitation, all integrated into a design that prioritizes visibility from central stations and infection control measures like negative-pressure isolation rooms.^[4]^[2] The development of HDUs traces back to the early 20th century, with postoperative high-dependency recovery areas emerging in hospitals during the 1920s alongside advances in surgical techniques, evolving into formalized units by the mid-20th century as part of broader intensive care innovations to improve patient outcomes and hospital efficiency.^[5] Their expansion accelerated in the late 20th and early 21st centuries, particularly in response to resource constraints and pandemics like COVID-19, which highlighted the need for scalable intermediate care to alleviate pressure on ICUs.^[6]^[4]

Overview

Definition

A high-dependency unit (HDU) is a specialized hospital area that provides intermediate-level care positioned between intensive care units (ICUs) and general wards, catering to patients who require more intensive monitoring and nursing support than standard ward care but not the full spectrum of invasive interventions such as mechanical ventilation or advanced hemodynamic support.^[4]^[7] This setup allows for the management of patients with single-organ dysfunction or those stabilizing after critical illness, without the need for constant life-support systems.^[4] Key characteristics of HDUs include elevated nurse-to-patient ratios relative to general wards—typically 1:2 to 1:4—enabling continuous physiological observation and prompt response to deteriorations.^[4]^[7]^[8] Facilities in these units support access to advanced diagnostics, such as frequent arterial blood gas analysis and electrocardiography, while emphasizing non-invasive therapies like continuous positive airway pressure.^[4] Terminology for these units varies by region and healthcare system; they are also commonly known as step-down units, intermediate care units, or progressive care units.^[9]^[7]

Purpose and Role

High-dependency units (HDUs) primarily function to bridge the continuum of care between intensive care units (ICUs) and general hospital wards, offering intermediate-level monitoring and support for patients whose needs exceed those of standard ward care but do not require full ICU resources. Key objectives include stabilizing patients recovering from critical illness post-ICU discharge, preventing acute deterioration among at-risk individuals transferred from general wards (often termed "step-up" admissions), and delivering timely interventions to mitigate the need for escalation to ICU-level care. This structured approach ensures continuous oversight for patients with single-organ dysfunction or moderate instability, optimizing transitions and reducing risks associated with abrupt care level changes.^[10] In enhancing hospital efficiency, HDUs play a vital role by alleviating ICU overcrowding through appropriate step-down placements for recovering patients, which facilitates faster bed turnover and shortens overall hospital lengths of stay. By accommodating medium-acuity cases that might otherwise occupy scarce ICU beds, these units promote resource allocation that balances demand across care levels, ultimately supporting more cost-effective delivery of hospital services without increasing adverse events. For instance, the availability of dedicated HDU capacity has been shown to improve ICU bed utilization, allowing hospitals to manage higher volumes of elective procedures while maintaining operational flow.^[10] Empirical evidence underscores these benefits, with studies reporting a 20% reduction in ICU admissions following the implementation of an obstetric HDU, primarily for conditions like hypertensive disorders and hemorrhage that do not necessitate full critical care. The opening of an adult HDU has similarly led to more efficient ICU occupancy, rising from 63.7% to 73.4%, alongside a halving of the proportion of ICU beds used by high-dependency patients (from 21.6% to 11.2%), thereby decreasing readmissions and enhancing overall unit appropriateness. Broader access to intermediate care facilitated by HDUs has also correlated with a 25% decrease in general ward mortality rates, highlighting their impact on survival for vulnerable populations.^[11]^[12]^[13]

Patient Management

Admission Criteria

Admission to a high-dependency unit (HDU) is guided by standardized criteria aimed at identifying patients who require intermediate-level care between general wards and intensive care units (ICUs), typically involving close monitoring and support for a single failing organ system without the need for advanced life support. Patients suitable for HDU admission often present with conditions such as respiratory distress requiring non-invasive ventilation like continuous positive airway pressure (CPAP), circulatory instability managed with low-level inotropic support, or the need for frequent vital sign assessments every 1-2 hours due to risks like altered consciousness or oxygen saturation below 94% on room air. Post-operative patients recovering from high-risk procedures, such as major elective surgeries in those with comorbidities, who need intravenous therapies but maintain stable hemodynamics, also qualify for admission to ensure timely intervention if deterioration occurs.^[4]^[14]^[15] Scoring systems play a key role in objective triage for HDU admission, with the Modified Early Warning Score (MEWS) commonly used to detect early physiological deterioration. A MEWS threshold of 4 or higher has demonstrated 75% sensitivity and 83% specificity for identifying surgical patients requiring transfer to HDU or ICU, prompting escalation of care through increased monitoring or specialist review. While clinical judgment remains essential alongside these tools.^[16]^[17]^[18] Exclusion criteria ensure appropriate resource allocation, directing patients with multi-organ failure, requirements for invasive mechanical ventilation, or hemodynamic instability necessitating vasopressors to an ICU instead. Those who are hemodynamically stable without ongoing organ support, having resolved their acute issues for 12-24 hours, are typically stepped down to general wards. Specialized populations, such as neonates, obstetric cases, or major trauma patients, may be excluded from general HDUs in favor of dedicated units to optimize care delivery.^[4]^[14]^[15]

Common Conditions Treated

High-dependency units (HDUs) primarily manage medical conditions characterized by intermediate acuity, where patients require enhanced monitoring and support for single-organ dysfunction without the need for invasive mechanical ventilation or multi-organ failure intervention. Respiratory disorders, such as moderate exacerbations of chronic obstructive pulmonary disease (COPD) or community-acquired pneumonia necessitating supplemental oxygen therapy, are among the most common admissions, allowing for close observation of oxygenation and respiratory effort.^[4] Cardiac conditions, including post-myocardial infarction monitoring in hemodynamically stable patients without persistent arrhythmia or shock, also feature prominently, focusing on arrhythmia surveillance and cardiac function assessment.^[4]^[19] Surgical conditions treated in HDUs typically involve postoperative recovery from major procedures, where patients need vigilant oversight for complications but are not critically unstable. Examples include recovery after cardiac surgeries like coronary artery bypass grafting or abdominal operations such as colectomy, emphasizing fluid balance and pain control in the immediate postoperative period.^[20]^[21] Trauma patients with stable injuries, such as isolated fractures or minor head trauma without neurological deterioration, are often admitted for serial assessments and mobilization support to prevent secondary complications.^[22]^[23] Special populations in HDUs include oncology patients experiencing complications from chemotherapy, such as tumor lysis syndrome or neutropenic fever requiring isolation and hydration monitoring.^[4] Elderly individuals with delirium, often precipitated by acute illness or medication effects, benefit from the unit's structured environment for behavioral observation and reorientation, particularly when baseline frailty elevates acuity risks.^[4]^[24]

Operational Aspects

Staffing and Training

High-dependency units (HDUs) require specialized nursing staff to manage patients with intermediate acuity levels, typically maintaining nurse-to-patient ratios of 1:2 for general adult care, though this may adjust to 1:3 or 1:4 based on patient dependency and shift demands, as recommended by health authorities; ratios vary internationally, with recent U.S. guidelines for progressive care suggesting 1:3 or 1:4 as of 2025.^[4]^[25] Registered nurses in HDUs must hold qualifications in critical care or equivalent, with mandatory training in advanced life support (ALS) protocols to handle potential deteriorations, and units operate with 24-hour coverage including senior nurse oversight for decision-making and quality assurance.^[4] The multidisciplinary team in an HDU comprises intensivists or rotating specialist physicians (such as cardiologists or pulmonologists) for medical oversight, typically at a ratio of one medical officer per 10 patients, alongside physiotherapists who support early mobility and respiratory rehabilitation, and pharmacists responsible for medication reconciliation and dosing adjustments in complex cases.^[4] This collaborative structure enhances patient outcomes by integrating expertise across disciplines, with daily or regular rounds to coordinate care plans. Training for HDU staff emphasizes competency in key areas, including mandatory certifications for electrocardiogram (ECG) interpretation to detect arrhythmias promptly, management of non-invasive ventilation for respiratory support, and early recognition of sepsis through protocols like the Surviving Sepsis Campaign guidelines.^[4]^[26] Initial training often involves a minimum of seven days at a tertiary facility, covering basic and advanced life support (BLS/ALS), while ongoing education utilizes simulation-based scenarios to practice intermediate acuity interventions, ensuring staff preparedness without redeployment from critical roles.^[4]^[27]

Equipment and Monitoring

High-dependency units (HDUs) are equipped with a range of specialized devices to facilitate close surveillance and intervention for patients requiring level 2 care, bridging the gap between general wards and intensive care units (ICUs). Essential monitoring equipment includes multi-parameter monitors that provide continuous cardiac monitoring via electrocardiography (ECG), pulse oximetry for oxygen saturation (SpO2), non-invasive blood pressure (NIBP) measurement, and temperature assessment.^[4]^[28] These devices enable real-time tracking of vital signs, with central consoles allowing staff to oversee multiple patients from a nursing station.^[28] Additionally, portable ultrasound machines are available for bedside vascular assessments and procedural guidance, supporting rapid diagnostic evaluations without patient transport.^[4]^[29] Infusion and syringe pumps are standard for precise administration of medications, fluids, and vasopressors, ensuring controlled delivery to maintain hemodynamic stability.^[28]^[30] Unlike ICUs, HDUs typically do not include full mechanical ventilators for invasive support but provide non-invasive respiratory aids such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) masks, along with high-flow nasal oxygen systems for patients with acute hypoxemic respiratory issues.^[4]^[30] Supportive technologies further include defibrillators with automated external defibrillator (AED) capabilities and transcutaneous pacing, crash carts stocked for emergencies, and central suction systems for airway management.^[4]^[28] Monitoring protocols in HDUs emphasize frequent and continuous assessment to detect deterioration early. Vital signs are typically recorded hourly or more often based on patient acuity, incorporating telemetry for arrhythmia detection through ECG leads and integration with early warning systems like the National Early Warning Score 2 (NEWS2) linked to electronic health records.^[29]^[30] These systems trigger alerts for abnormalities, such as heart rate irregularities or oxygen desaturation, prompting immediate review. Escalation protocols mandate transfer to an ICU if parameters worsen despite interventions, for instance, if SpO2 falls below 90% on supplemental oxygen or if hemodynamic instability requires increasing vasopressor support.^[30]^[31] Trained nursing staff, operating under a 1:2 nurse-to-patient ratio, manage these protocols to ensure timely responses.^[29] Point-of-care testing, including arterial blood gas analysis and glucometers, supports protocol-driven care by allowing rapid evaluation of respiratory and metabolic status without delaying treatment.^[4]^[29] All equipment undergoes regular servicing and calibration to maintain reliability, with emergency call systems enabling swift staff mobilization during alarms.^[28] This setup prioritizes non-invasive yet intensive surveillance, optimizing resource use in HDUs while preventing unnecessary ICU admissions.^[30]

Facility Design and Guidelines

Physical Layout

High-dependency units (HDUs) typically feature a compact layout designed to balance patient monitoring with efficient staff workflow, often comprising 4 to 12 beds arranged in semi-private bays or individual rooms separated by privacy curtains.^[2]^[4] A central nursing station is positioned for direct line-of-sight visibility to all beds, facilitating rapid response to patient needs, while decentralized sub-stations may support smaller pods of up to 14 beds.^[2] At least two isolation rooms per pod, equipped with negative pressure ventilation and anterooms, are included for infection control, particularly for patients with contagious conditions.^[2]^[4] These units are strategically located in close proximity to intensive care units (ICUs), operating theaters, emergency departments, and general wards to enable seamless patient transfers.^[2]^[4] Environmental design in HDUs prioritizes patient comfort and recovery while minimizing stressors, incorporating noise-reduction materials such as cushioned vinyl flooring to maintain sound levels below 45 decibels during the day and 20 decibels at night.^[2]^[4] Adjustable lighting systems provide at least 300 lux at the bedside for clinical tasks, with provisions for dimming to support rest, and a minimum of 50% of beds access natural daylight to promote circadian rhythms.^[2]^[4] Dedicated family visitation areas, often adjacent to gown-up/gown-down rooms, allow for controlled access without compromising the unit's sterile environment.^[2] For infection prevention, select rooms feature high-efficiency particulate air (HEPA) filtration within air handling systems maintaining 10-12 air changes per hour, positive pressure, and temperatures of 23±2°C with 45-65% humidity.^[2]^[4] Space allocation in HDUs ensures adequate room for clinical activities and equipment, with a minimum of 20-25 m² per bed in bays or enclosed rooms, including 1.2 meters of clearance around each bed and 3.5 meters between beds for safe maneuvering.^[2]^[4] Integrated storage solutions, such as dedicated rooms for sterile supplies, linen, and critical equipment, prevent clutter in patient areas.^[2]^[4] Hand hygiene stations, including sinks and alcohol-based rubs, are mandated at unit entries, nursing stations, and every 2-4 beds to uphold infection control protocols.^[2]^[4]

Standards and Regulations

High-dependency units (HDUs) are subject to oversight by professional bodies and national health authorities to ensure safe, standardized care for intermediate-level patients. In the United Kingdom, the Faculty of Intensive Care Medicine (FICM) outlines guidelines in the Guidelines for the Provision of Intensive Care Services (GPICS), recommending at least one critical care bed, including HDUs providing Level 2 care, for every 35 acute hospital beds to meet demand and avoid non-clinical transfers. Similarly, the National Health Service (NHS) England specifies that HDUs must integrate with intensive care units (ICUs) and contribute to overall critical care capacity, with units submitting bed availability data twice daily to national systems for coordinated resource management.^[32] In Australia, the College of Intensive Care Medicine (CICM) mandates a minimum of four beds in HDUs, which must be geographically and operationally linked to a Level II or III ICU to facilitate seamless patient progression.^[14] The Society of Critical Care Medicine (SCCM) in the United States provides frameworks for ICU admission, discharge, and triage that extend to intermediate care settings like step-down units, emphasizing evidence-based criteria to optimize resource use without specific bed ratios. Accreditation for HDUs typically falls under broader hospital standards, with processes requiring periodic on-site evaluations, compliance audits, and data submission. Joint Commission International (JCI) accreditation for hospitals includes requirements for specialized services such as intensive and intermediate care, mandating established admission and discharge criteria, along with ongoing monitoring of infection risks and healthcare-associated infection rates through surveillance and reporting. In the UK, FICM recommends peer-review inspections coordinated through Critical Care Networks, with units required to participate in national audits like the Intensive Care National Audit & Research Centre (ICNARC) to verify adherence to standards. Australian HDUs undergo CICM accreditation reviews that assess linkage to ICUs, formal audit programs, and infection control protocols, including isolation procedures.^[14] NHS specifications further require demonstration of strategies to minimize infections, such as publishing central venous catheter-related bloodstream infection rates.^[32] Quality indicators for HDUs focus on patient outcomes, staffing competence, and operational efficiency to drive continuous improvement. Key targets include avoiding readmission to critical care within 48 hours of discharge, with units monitoring and reporting these rates through national databases like ICNARC.^[32] Infection control metrics emphasize low rates of hospital-acquired infections, supported by mandatory care bundles and annual audits. Staffing quality is gauged by nurse certification, with UK guidelines requiring at least 50% of registered nurses to hold post-registration qualifications in critical care nursing and limiting agency staff to under 20% per shift. Timely transfers are prioritized, with NHS standards aiming for discharges to wards within four hours of the decision (ideally between 07:00 and 19:59), and FICM mandating audits of delayed discharges and nighttime transfers to enhance safety.^[32] Patient satisfaction scores are integrated into broader governance reviews, though specific HDU targets vary by jurisdiction.^[14]

Comparisons and Variations

Differences from ICU

High-dependency units (HDUs) provide an intermediate level of care for patients requiring more observation and intervention than a general ward but less intensive support than an intensive care unit (ICU), typically involving single-organ system support such as continuous positive airway pressure (CPAP) or non-invasive ventilation, whereas ICUs manage patients with multi-organ failure through advanced interventions like mechanical ventilation, invasive vascular lines, and deep sedation.^[32]^[33] HDUs focus on stabilizing patients with isolated organ dysfunction or those recovering from acute events, avoiding the comprehensive multi-organ resuscitation characteristic of ICUs, which handle life-threatening conditions demanding constant, high-acuity monitoring and support across multiple systems.^[32]^[33] In terms of resource allocation, HDUs operate with lower nurse-to-patient ratios, typically 1:2, compared to the 1:1 staffing in ICUs, reflecting the reduced need for continuous one-on-one oversight and enabling more efficient use of specialized personnel for stabilization rather than ongoing acute interventions.^[32] This staffing difference allows HDUs to prioritize enhanced monitoring and basic support without the full spectrum of ICU resources, such as dedicated intensivist coverage for every patient or advanced life-support equipment, thereby optimizing hospital capacity for higher-acuity cases.^[32] Patient outcomes in HDUs demonstrate benefits for appropriate step-down cases, with studies showing that dedicated HDU care can reduce ICU length of stay by approximately 1 day—from 7.0 to 6.0 days on average—through earlier transfers and decreased reliance on level 3 beds, potentially saving significant bed-days annually.^[34] For patients suitable for HDU-level care, such as those post-stabilization, mortality rates show a favorable trend, dropping from 31% to 19% in ICU transfers following HDU implementation, alongside lower risks of complications like the need for renal replacement therapy, which decreased from 32% to 16%.^[34] These improvements underscore HDUs' role in enhancing recovery trajectories without escalating to full ICU demands, provided patient selection aligns with single-system needs.^[34]

Differences from General Wards

High-dependency units (HDUs) differ markedly from general wards in their monitoring capabilities, providing continuous telemetry for vital signs such as heart rate, blood pressure, oxygen saturation, and respiratory rate, often through multi-parameter monitors connected to central stations for real-time oversight.^[4] In contrast, general wards rely on intermittent vital signs checks, typically conducted every 4 to 8 hours depending on patient stability, which can delay detection of subtle deteriorations.^[35] This continuous monitoring in HDUs is supported by dedicated rapid response teams that enable immediate intervention, reducing the risk of adverse events compared to the periodic assessments on wards where nurses handle broader patient loads.^[36] Regarding intervention scope, HDUs are equipped to deliver advanced therapies that exceed general ward resources, including invasive arterial lines for precise hemodynamic monitoring and low-dose vasopressors to maintain blood pressure in patients with mild instability.^[1] These capabilities allow for proactive management without immediate escalation, whereas general wards lack such specialized equipment and protocols, often requiring patient transfer for any non-basic interventions like simple oxygen therapy or oral medications.^[4] For instance, HDUs can initiate non-invasive ventilation or central venous access under close supervision, bridging care gaps that would otherwise overwhelm ward staff.^[37] Patient acuity levels further distinguish the two settings: general wards accommodate stable, low-risk individuals recovering from routine procedures or managing chronic conditions with minimal oversight, focusing on activities of daily living and basic nursing.^[36] HDUs, however, serve patients at elevated risk of deterioration—such as those post-major surgery or with single-organ threats—who require heightened vigilance to avert full intensive care unit admission, thereby optimizing resource use across the hospital.^[38] This targeted placement in HDUs prevents unnecessary escalations while ensuring timely support for those beyond ward capacity.^[1]

International Variations

In the United Kingdom, high-dependency units (HDUs) are typically integrated into National Health Service (NHS) trusts as part of broader critical care services, with dedicated funding streams supporting their operation within hospital pathways for acutely ill patients requiring intermediate monitoring.^[39] In the United States, equivalent units known as progressive care units (PCUs) or step-down units operate under hospital-specific protocols guided by national standards from the American Association of Critical-Care Nurses (AACN), which emphasize nurse-to-patient ratios of 1:3 or 1:4 and integration with intensive care units (ICUs) to manage moderately stable patients at risk of deterioration.^[25] Australia maintains structured standards for HDUs through the College of Intensive Care Medicine (CICM), requiring them to be co-located with Level II or III ICUs in major facilities, with a minimum of four beds per unit and a nurse-to-patient ratio of 1:2 to ensure 24-hour specialist oversight.^[14] Surveys of hospitals in Australia indicate a median critical care bed ratio of 3.7 per 100 hospital beds, encompassing both ICUs and HDUs, reflecting a policy-driven emphasis on intermediate care availability in public and tertiary settings.^[40] In contrast, developing countries often implement HDUs on an ad-hoc basis due to resource constraints, such as limited equipment and staffing; for instance, in Malawi, a nine-bed HDU was established at a major referral hospital in 2020 with a 1:4 nurse ratio and basic oxygen support, addressing gaps where ICU capacity is only 0.1 ventilator beds per 100,000 population.^[41] European policies promote HDUs, or intermediate care units (IMCUs), as essential for post-ICU discharge to optimize patient flow and reduce mortality, with formal guidelines in countries like the UK, Germany, and Spain supporting their role in managing recovering critically ill patients through structured transitional care.^[42] In Italy, national decrees such as Decree-Law 34/2020 have allocated resources for over 4,000 sub-intensive beds to facilitate this step-down process, resulting in up to a 37% reduction in hospital mortality odds in facilities with IMCUs.^[42] Across Asia, HDUs vary by income level, with higher-capacity systems in Japan utilizing them for mechanically ventilated patients outside full ICUs to conserve resources, while in India, national guidelines from the National Health Systems Resource Centre advocate for HDUs in public facilities to bridge care gaps amid lower overall critical care bed densities compared to high-income regions.^[4] Emerging integrations with telemedicine in rural Asian contexts, such as in Southeast Asia, aim to extend HDU-like monitoring to remote areas, though implementation remains uneven due to infrastructural challenges.^[43]

History and Evolution

Origins

The concept of high-dependency care originated in the early 20th century with postoperative recovery areas established in hospitals during the 1920s, alongside advances in surgical techniques.^[5] Formal high-dependency units (HDUs) for medical patients emerged in the 1970s in Europe, particularly in the UK, as an extension of intensive care units (ICUs) to address intermediate-level care needs arising from ICU overload and increasing surgical volumes. Influenced by post-polio epidemic advancements in respiratory management from the 1950s, such as ventilation techniques developed during the 1952 Copenhagen outbreak, early HDUs focused on postoperative recovery and single-organ support for patients not requiring full ICU intervention. For instance, the Brompton Hospital's Blunt ward, established around 1972–1973, served as a pioneering medical HDU for severe acute asthma cases, utilizing repurposed equipment like Engström ventilators to manage respiratory failure amid rising cardiothoracic surgery demands.^[44] During the 1980s, HDUs gained formal recognition in the UK through Department of Health and Social Security (DHSS) guidelines, which supported their development to alleviate ICU bed pressures caused by surgical booms and resource constraints. These guidelines emphasized HDUs' role in providing multidisciplinary care for high-risk postoperative patients, marking a shift toward structured intermediate care models. The Intensive Care Society, founded in 1970, further promoted standardization, culminating in the 1980s expansion of HDU beds as essential components of critical care infrastructure.^[44] In the United States, the concept of stepdown or high-dependency units originated in 1968 for cardiac patients transitioning from ICUs, as proposed by Gotsman and Schrire, but widespread adoption occurred in the 1990s amid escalating healthcare costs and ICU shortages. The 1983 National Institutes of Health Consensus Development Conference on Critical Care Medicine addressed major issues in critical care practice, including resource allocation to contain costs.^[38]^[45] By 1995, 63% of surveyed U.S. hospitals included at least one stepdown unit, driven by efforts from the American Association of Critical-Care Nurses (AACN) to promote cost-effective progressive care models for intermediate-acuity patients.^[38]^[45]

Modern Developments

In the 2010s, high-dependency units (HDUs) began integrating artificial intelligence (AI)-driven early warning systems to enhance patient acuity prediction and timely interventions. These systems analyze real-time vital signs and electronic health records to forecast clinical deterioration, outperforming traditional scoring tools like the Modified Early Warning Score in sensitivity. For instance, machine learning-based early warning systems implemented in surgical HDUs have increased the completion rate of assessments and reduced unanticipated adverse events by enabling proactive care adjustments.^[46]^[47] The Rothman Index, a predictive analytics tool developed in the early 2010s, exemplifies this trend by providing a continuous, diagnosis-independent measure of patient condition across acuity levels, including HDUs. It aggregates data from up to 26 physiological parameters to generate scores that predict risks such as ICU readmissions or mortality, aiding in safe patient transfers from intensive care to HDU settings. Studies validate its utility in identifying deterioration trends, with scores below 20 indicating a 25.9% mortality risk compared to 0.3% for higher scores, thus supporting evidence-based staffing and resource allocation.^[48]^[49]^[50] Parallel to AI advancements, telemedicine adoption in HDUs—often termed tele-HDU—has expanded remote monitoring capabilities since the mid-2010s, allowing off-site specialists to oversee patients via video and data feeds. In progressive care units akin to HDUs, telemedicine interventions have reduced mortality by up to 30% and shortened length of stay through continuous virtual surveillance, particularly for high-risk postoperative cases. This integration minimizes transfer delays and optimizes nurse workflows by alerting teams to anomalies in real time.^[51]^[52] The COVID-19 pandemic from 2020 to 2022 catalyzed a rapid expansion of respiratory-focused HDUs to manage surges in acute hypoxemic respiratory failure without overwhelming intensive care units. In regions like Europe and North America, HDUs were reconfigured as intermediate respiratory care hubs, admitting patients requiring non-invasive support and preventing up to 50% of potential ICU escalations through dedicated cohorts. The Milan model, for example, established multidisciplinary HDUs that served as catchment areas for emergency and ward transfers, with integrated pulmonology and infectious disease expertise.^[53]^[54] Guidelines emphasized surge capacity strategies, including cohorting patients in expanded HDUs and prioritizing non-invasive ventilation (NIV) protocols to conserve mechanical ventilators. The World Health Organization recommended high-flow nasal oxygen and NIV as first-line therapies in HDUs for COVID-19 patients with moderate respiratory distress. Rapid reorganization of respiratory HDUs, such as increasing bed capacity by 20-50% through modular setups, aligned with international standards to sustain care during peak waves, reducing overall hospital mortality by facilitating timely de-escalation from full ventilation.^[55]^[56]^[57] Looking to future trends in the 2020s, HDUs are shifting toward hybrid models that blend in-unit care with wearable technologies for seamless transitions to outpatient monitoring, emphasizing personalized care pathways. Wearables, such as continuous vital sign patches, enable non-invasive tracking of parameters like heart rate and oxygen saturation in HDUs, reducing alarm fatigue by 25-40% and streamlining nurse responses through AI-filtered alerts. Studies in high-acuity settings demonstrate these devices improve workflow efficiency, with implementations yielding up to 20% reductions in monitoring time while enhancing early detection of decompensation. Recent developments as of 2025 include expanded integration of HDUs in specialized areas like obstetric and rural care to support maternal health and resource-limited settings.^[58]^[59]^[60] Personalized care pathways, powered by digital platforms integrating electronic health records and patient-specific data, further support this evolution by tailoring interventions based on individual risk profiles and comorbidities. For example, AI-driven pathways in HDUs have increased patient engagement and adherence, leading to 15-25% efficiency gains in resource use and recovery times through predictive modeling of discharge readiness. These trends, backed by 2020s research, position HDUs as pivotal in value-based care, bridging acute and chronic management to lower readmission rates by 10-15%.^[61]^[62]

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Online Courses - AACN
Explore industry-leading clinical education and training for acute, progressive and critical care nurses, from new and experienced direct care nurses to nurse ...ECCO · Essentials of ECG... · Sepsis Online Courses · Order NowMissing: high dependency
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Simulation Training in the ICU - PMC - PubMed Central - NIH
In this article, the effectiveness of simulation for areas important to the practice of critical care is reviewed.
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[PDF] Health Building Note 04-02 Critical care units - NHS England
This Health Building Note provides guidance on critical care units that admit patients whose dependency levels are classified as level 2 or 3 (see ' ...
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[PDF] GUIDELINES FOR THE PROVISION OF INTENSIVE CARE SERVICES
... standards for equipment monitoring and staffing are the same as those used for patients being managed on a critical care unit and in line with GPICS standards.
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[PDF] Enhanced Care: Guidance on service development in the hospital ...
May 2, 2020 · Despite not meeting the current criteria for admission to HDU, patients do need a level of observation and monitoring that cannot be provided ...
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COVID-19 Guidelines Dashboard - Open Critical Care
(This includes those those admitted to the HDU/ICU experiencing breathlessness, a respiratory rate of >30/ min, and/or SpO < 90% on room air.).
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[PDF] 220502S Adult Critical Care Service Specifications | NHS England
• NHS Estate Guidance 2013 HBN 04/02. Department of Health/NHS England ... HDU: High Dependency Unit. ICNARC: Intensive Care National Audit and Research ...
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Role of Obstetric High Dependency and Intensive Care Unit in ...
Nov 19, 2018 · High dependency unit care on the other hand is appropriate for patients requiring support for a single organ system (excluding advanced ...
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Improvement in clinical outcomes following institution of dedicated ...
Mar 13, 2009 · The mean length of stay (level 3) reduced from 7.0 days to 6.0 days, which in combination with the reduction in ICU admissions saved 250 level 3 ...
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Things We Do For No Reason™: Routine Overnight Vital Sign Checks
General medicine floors commonly default frequency for measuring vital signs to every 4 hours (Q4), a practice that dates back more than a century to the time ...
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Surveillance Monitoring to Improve Patient Safety in Acute Hospital ...
Apr 26, 2023 · In contrast, patients on a general care unit are considered lower acuity. Fewer severe episodes of deterioration are expected; consequently, ...
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Intermediate Care Units in Internal Medicine
ImCU (Intermediate Care Unit); HDU (High-dependency Unit); SICU (Subintensive Care Unit); PCU (Progressive Care Unit); ICU (Intensive Care Unit); LoS ...
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Integrated care in action – Health inequalities - NHS England
Integrated care systems provide stronger foundations for working with local government and voluntary sector partners on the broader agenda of prevention and ...
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Apr 29, 2025 · AACN has published "AACN Standards for Appropriate Staffing in Adult Progressive Care," the first staffing standards for this growing specialty.
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Postoperative critical care and high-acuity care provision in the ...
Feb 8, 2019 · We aimed to quantify adult ICU/high-dependency unit (ICU/HDU) capacity in hospitals from the UK, Australia, and New Zealand (NZ), and to identify and describe ...
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Establishment of a high-dependency unit in Malawi
Nov 19, 2020 · These extreme resource constraints prompted the creation of a dedicated and sustainable HDU to improve care for this vulnerable and ...
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Intermediate Care Units in Europe and Italy: A Review of Structure ...
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https://jamanetwork.com/journals/jama/fullarticle/400138
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[PDF] History of British Intensive Care, c. 1950–c. 2000 - CORE
high dependency goes back far, far longer than that. The Brompton's medical high dependency unit (HDU), the Blunt ward, opened, I think, in about 1972 or ...
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Major Issues in Critical Care Medicine - JAMA Network
In March 1983, a consensus development conference was held at the National Institutes of Health to address issues related to the practice of critical care.
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The implementation of a real time early warning system using ...
Oct 4, 2025 · Conclusion Implementation of an automated EWS system on a surgical high dependency unit improves the number of complete MEWS assessments ...
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AI-Powered early warning systems for clinical deterioration ... - NIH
Jun 2, 2025 · The findings suggest that AI-based early warning models positively impact patient outcomes in real-world clinical settings.
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The Rothman Index predicts unplanned readmissions to intensive ...
Mar 7, 2024 · The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.
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Development and validation of a continuous measure of patient ...
Rothman Index, a measure of patient condition, is independent of diagnosis and spans all acuity levels. •. May help clinicians to improve continuity of care and ...Missing: HDUs | Show results with:HDUs
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PulmCrit- The Rothman Index: Artificial intelligence or merely a ...
Jan 25, 2020 · The Rothman Index is an illness-severity index embedded in the electronic medical record, tracking 26 variables to predict how sick a patient ...
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Impact of Telemedicine on Mortality, Length of Stay, and Cost
Our study showed that TPCU intervention significantly decreased mortality in progressive care unit and hospital and progressive care unit length of stay despite ...
[54]
Improving Care in Progressive Care Units Through Telehealth
for patients and hospitals alike ...
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COVID-19 multidisciplinary high dependency unit: the Milan model
Oct 9, 2020 · Cardiologists, infectious diseases specialists, rheumatologists, intensivists and respiratory physiotherapists are fundamental components of the ...Missing: composition | Show results with:composition
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Innovations and Challenges in Intermediate Respiratory Care Units
Dec 31, 2024 · ICRUs have been essential in managing patients with COVID-19 and severe respiratory failure, preventing ICU admission for nearly 50% of severe ...
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high-flow nasal oxygen and non-invasive ventilation- Part 1
Aug 5, 2022 · Management of critical COVID-19 Advanced non-invasive respiratory support: high-flow nasal oxygen and non-invasive ventilation- Part 1 ...Missing: surge capacity HDUs
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Managing ICU surge during the COVID-19 crisis: rapid guidelines
The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19.
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Reorganizing the respiratory high dependency unit for pandemics
RHDUs are a transition between ICU and wards. Reorganization is needed to minimize ICU admissions, and noninvasive therapies can prevent intubation.
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A retrospective cross-sectional study showing wearable ... - Nature
Aug 8, 2025 · Wearable technology has the potential to simplify ICU operations, reduce alarm fatigue, and ultimately improve patient care and reduce adverse ...
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Wearable devices for patient monitoring in the intensive care unit
Feb 27, 2025 · These devices allow for continuous, non-invasive monitoring of physiological parameters such as heart rate, respiratory rate, blood pressure, glucose levels, ...
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Personalized Digital Care Pathways Enable Enhanced Patient ...
May 15, 2025 · The software creates personalized care pathways by capturing patient health and demographic data from hospital EHRs, manual inputs by HCPs, or ...
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Economic Perspective of the Use of Wearables in Health Care
The studies indicate that wearable technologies can increase quality-adjusted life years and be cost-effective and potentially cost-saving.