A Patient Guide to the High Dependency Unit

The High Dependency Unit (or HDU) is a specialist ward where patients are looked after when they require closer monitoring or a higher level of care than can be provided on the general orthopaedic wards.

At Stanmore the HDU is also known as the Alan Bray Unit. Dr Alan Bray was a much-loved and well respected anaesthetist at Stanmore, and was the first director of our High Dependency Unit.

Whilst you remain primarily under the care of your Consultant Surgeon, on the HDU your care will be lead by a Consultant Anaesthetist, with the support of an Anaesthetic Registrar. These doctors specialise in looking after people during their operation, as well as afterwards, or when they are critically ill. The nursing team consist of a Lead Nurse, Clinical Nurse Managers, Sisters & Charge Nurses, and Staff Nurses, who are all trained in in both routine post-operative care of patients as well as specialist High Dependency care.

On the HDU we have a higher ratio of nurses per patient as well as the units’ dedicated anaesthetists. These doctors and nurses will work together with your Consultant Surgeon to get you the best care during your time on HDU

The most common reason for being a patient on the HDU at Stanmore is because you have just had major or complex surgery. By looking after you on a specialist ward with greater numbers of specially trained nurses and doctors we aim to:

• Closely monitor you to reduce the risk of post-operative complications occurring
• Recognise complications early, and rapidly begin investigating and treating any complications if they do occur
• Provide expert help with the management of post-operative pain
• Provide rapid access to specialist services such as cardiology, radiology, physiotherapy and dietetics

Also, we know that some patients, such as those with underlying medical conditions, may be at greater risk of developing problems after an operation so we may admit them to the HDU, even after less major surgery, due to this risk. Occasionally we admit patients to the HDU before the operation to ‘optimise’ them – that is to make sure everything is in the best possible condition we can achieve before patients undergo surgery. Patients may become seriously unwell on the general orthopaedics wards and may need to have close monitoring that cannot be provided there. On these occasions, patients may have to be transferred down to HDU.When required, we can also provide Intensive Care (more specialist 1-1 nursing). This can occur immediately after your operation or if you become unwell on the ward.

HDU can be a daunting environment for both you and your family. Our staff understand this and are there to help at all times. So if you have any worries or questions, please ask us.

Upon arrival at the HDU, either from the Recovery area or the Ward, you will be admitted by the nurse allocated to you, and the anaesthetic registrar. The admission process may involve:

• Placement of routine monitoring equipment such as blood pressure cuff, ECG dots and a Sats Probe which measures your oxygen levels.
• Taking of blood samples for analysis in the laboratory
• Placement of venous or arterial cannulas (‘lines’) Application of compression stockings (also known as TEDs) and a sequential compression device (SCDs) on your calves
• Placement of a urinary catheter

Many, if not all of these things, may already be in place, particularly if you are coming from the operating theatre. Your allocated nurse and the HDU anaesthetist will also assess your pain and check for any other problems. If you need any specific therapies these will also be started.

The whole admission process may take up to an hour. Our aim is to make you as comfortable as possible whilst providing you with excellent medical care.

During this time it can be frustrating for your family or carers, who may have to wait until the admission process is complete before seeing you, and of course we understand they will be anxious to hear how you are doing. We ask for you and them to be patient with us during the admission process. A member of staff will keep your family informed of what is happening while they wait in the relative’s room.

HDU can be noisier than the wards and have unfamiliar sounds such as alarms and bleeps from monitors and equipment, which can be disconcerting. These alarms serve to alert staff to any changes.

Part of the care that we provide on the HDU is close observation and monitoring. This means the regular checking of things such as blood pressure, temperature and breathing. There may also be specific observations depending on your operation, such as monitoring the strength and feeling in your arms or legs. Some patients can find this an annoyance, particularly over the first post-operative night on the HDU. However this close observation is necessary to spot and to prevent complications, and will be one of the reasons you have been referred to the HDU, so we would ask you to bear these small disturbances with good grace and patience. You will be turned or repositioned in your bed every two to four hours to allow us to monitor your wounds as well as to prevent pressure sores.

Overnight, you will be assisted with a wash or bed-bath and linen change. Our staff will try to liaise with you to time your wash appropriately over the night, whether it be late into the evening or early in the morning, before the shift change over. In our HDU, as on most critical care wards in the UK, it is often difficult to provide single sex accommodation care. This is in part because the layout of the ward is designed to allow us to provide high nursing ratios and maximize patient safety, as well as the fact that access to a critical care bed is governed primarily by the patient’s medical requirements. Of course we will always do our best to see that the highest standards of privacy and dignity are maintained at all times.

We recognise how important having visitors is to you and your recovery and we will always try to be as accommodating as possible.

• Visiting hours are from 14:00 till 19:00 If you arrive from
• Recovery late into the night after the set visiting hours, time permitting, we may allow your visitor to see you for 30mins.
• Your next of kin can be kept up to date by calling the unit. If you have a mobile phone, your relatives may contact you on there.
• We allow a maximum of two visitors at the bedside. Of course others can wait in the relatives room
• If you wish to bring children less than 5 years old to the HDU please discuss this with the Sister in charge first. Children should be well behaved and supervised by an adult at all times
• Please always wash your hands or use the hand sanitising foam or alcohol gel as you enter the unit, to help reduce the risk of infection
• If you are a carer for a patient on the unit and need to visit/stay outside of these times please make a member of staff aware and provision can be made.

The visitor’s waiting room is located by the entrance to the HDU, as you come in the door. Sometimes we may ask visitors to wait in the relatives room before seeing you. This is usually because you may be receiving personal care and are therefore not appropriate for visitors, are being assessed by one of the team, or the doctors and nurses are busy attending an emergency, so please be patient.

In order to respect the privacy and confidentiality of all our patients, we will ask visitors to wait in the relatives room during emergency situations, patient care and procedures, and during the nursing handover.

Most commonly patients are admitted for overnight observation following their surgery. The following morning, if the HDU team are happy with your progress, plans will be made to discharge you back to the appropriate Orthopaedic Ward to care for your post-op needs.

Of course, if you have more complicated surgery or other medical problems you may need to stay longer than one night, and the most critically unwell patients may stay for much longer.

Every morning you will be assessed by the High Dependency Team, who will decide whether it is appropriate to discharge you from the HDU back to the ward. They will explain this decision to you.

We will only discharge you to the ward when we are happy that you are ready and that you no longer require High Dependency care.

If you expect to stay on the HDU for one night, following your operation, you will find you do not need all your personal belongings. Some of them will be left safely on the ward. We have limited space on the HDU, therefore please limit the amount of personal belongings. For your overnight stay you will only need the following:

• Mobile phone – this may be used to keep you friends and family up to date with your progress in HDU.
• Toiletries including shower gel or soap, shampoo, toothbrush and toothpaste etc.
• Hairbrush or comb
• Something to occupy you such as books, magazines or puzzle books. You may also bring a tablet or laptop computer. You will need headphones so as not to disturb other patients.
• A notebook and pen is a good idea so that you can write down questions you have when the doctor is not available
• If you use a BIPAP or CPAP machine please bring it with you, including all the tubes and connections.

Limit clutter and gifts. Keeping your bed area free from clutter makes cleaning easier. Where possible, it is advisable to mark all items of personal property with your name. To make this easy for you, we advise you to have these already set out before you head down to surgery. Therefore when we ask your Ward Nurse to collect them for us, they are easy to find.

If you are unhappy with any of the care you are receiving or have received whilst on the HDU we really want you to tell us. We want every one of our staff to deliver excellent care. There should be no exceptions to this. Some patients do not like to complain, but unless you tell us we cannot improve, so please do let us know.

The easiest way is to let someone on the HDU know about the problem. You could speak to the nurse looking after you or, if you feel too uncomfortable to, you can speak to one of the other nurses on the unit, one of the doctors, the nurse in charge or our Lead Nurse.

Before you are discharged from the HDU you will be asked to complete a patient satisfaction survey. If you prefer you could use this to record any problems or complaints. This survey is recorded anonymously.

The Hospital has a Customer Care & Patient Advice and Liaison Service (PALS). They offer confidential advice and support to patients and their relatives or carers. If you are unhappy with the response you receive from the staff on the ward you should contact the Customer Care & PALS Coordinators at the Stanmore site on 020 8909 5383 or 5439. The Customer Care & PALS Coordinators will be able to offer advice and co-ordinate an investigation into the complaint. Our staff will contact them for you if you ask.

We would be grateful if you and your visitors would adhere to the following rules, which are imposed to reduce infection rates, improve patient safety and preserve the dignity and privacy of our patients.

• There are to be only 2 visitors to a bed space at a time. If you have more than 2 visitors, then they will have to rotate from the bed space and the visitors room.
• Taking photographs on the unit is strictly forbidden
• Flowers and animals are not allowed due to the risk of spreading infection
• Visitors are not allowed to eat or drink on the unit
• The only person permitted to sit on a patient’s bed is the patient. If you require a chair please ask and we will provide one
• Latex balloons are not permitted, as we may have patients with a serious latex allergy
• If any of your visitors are unwell with colds, flu or tummy bugs we request and strongly advise that they refrain from visiting you until they are well

When you are discharged to the ward it means the team are happy with your progress and that you no longer need the same level of monitoring and intervention. It is a step towards recovery and rehabilitation, and ultimately discharge from hospital.

There will be fewer nurses, less interventions and less equipment on the ward compared with the HDU. If you have been on the HDU for a long time this may seem unsettling at first. Of course the ward nurses are there to make your hospital stay as comfortable as possible so please ask them if you have any concerns.

If we feel that the ward staff may need support when you first move back to the ward we will ask our Acute Intervention Team to come and visit you. The Acute Intervention Team are senior highly skilled nurses who visit patients on the hospital wards after they have been discharged from HDU. They will check on your general condition, assess your pain control and review any tests we may have asked for. The frequency of their visits will depend on your condition but is at least once a day. If they are concerned they can easily communicate with the HDU doctors for advice. The Acute Intervention Team work closely with the doctors and nurses on the wards to assist your recovery

• ECG Electrocardiogram. A test that records the electrical activity of the heart. It is used to diagnose many different heart conditions such as abnormal rhythms or heart attacks.
• Pre-operative Before your operation.
• Post-operative After your operation.
• PCA or Patient Controlled Analgesia A machine (or ‘pump’) which contains a strong pain killer such as Morphine or Oxycodone which you control to administer your own pain relief. Pressing a button will give you a small dose of the drug via your drip.
• Oxygen Sats Oxygen saturation-It refers to the concentration of oxygen in the blood.
• Pulse Oximeter (Sats Probe) A small probe, a bit like a clothes peg, that clips gently onto a finger or toe and measures the amount of oxygen the blood is carrying. Works using an infra-red light and sensor
• Monitor A machine that displays parameters such as heart rate, respiratory rate, blood pressure and blood oxygen saturation. An alarm may sound if one or a number of these fall outside a pre-set range. False alarms may occur as abrupt movements can cause the monitor to register inaccurate readings
• Nasal cannula A light flexible tube used to give supplemental oxygen to a patient. Oxygen flows through the prongs extending into the nostrils. Intravenous (IV) A drug, nutrient solution or fluid that is administered into a vein.
• Intravenous cannula (IV line) A small tube place directly through the skin into the vein.
• Blood Gas A blood test to check the levels of oxygen and carbon dioxide in the blood, as well as other useful metabolic parameters. A commonly performed test on the HDU.
• Urinary catheter A thin flexible tube that is inserted into the bladder and allows urine to flow through it into a drainage bag.
• NBM Nil By Mouth. Ordered when a patient is allowed nothing to eat or drink. Essential before a general anaesthetic to prevent regurgitation of stomach contents into the lungs when going to sleep.
• Nasogastric Tube (NG Tube) A soft narrow plastic tube that is passed through the nose and down past the back of the throat, through the oesophagus and into the stomach. This can be used for feeding when there are swallowing problems.
• Ventilator (‘Vent’) Also known as a breathing machine. A ventilator is used to provide complete or partial assistance to a patient’s breathing. It does this by blowing air, usually with added oxygen, into the lungs. This is usually done via a breathing tube which goes through the mouth into the windpipe (trachea). Patients are kept comfortable with sedative and pain-killing drugs, similar to a mild general anaesthetic, if this is required.
• Non-invasive Ventilation Another way of providing assistance to a patient’s breathing , but via a special face-mask, so that sedation is not required. Comes in two forms CPAP ‘cee-pap’ and BIPAP