High dependency and special nursing care

    • Note: This guideline is currently under review.  


      In 2011 the philosophy of nursing RCH inpatients was agreed to be;
      “Patient Allocation within a team based model of nursing care”.

      The philosophy promotes two concepts – ratios and team work. Within the Victorian context nursing ratios 1:4 am/pm 1:6nights are used as the tool for nursing resource allocation in acute public hospital inpatient settings. However often within the tertiary paediatric setting patient acuity demands a higher level of nurse resourcing. Within RCH nursing judgement is used to identify the patients who have higher nursing resource needs and HDU/Special Criteria clinical codes are assigned to identify the patient numbers in the RCH Bed tool.


      To provide RCH nursing staff with:

      • clinical guidance in the identification, assessment and accurate documentation of high dependency and special patients
      • to ensure the efficient and effective use of nursing resources by stepping up and down the care requirements at the clinically appropriate time. 

      Definition of terms

      • High Dependency (HDU): .A patient who requires a higher nurse to patient ratio. Generally this is one nurse to two high dependency patients.
      • Special: Patients who require one on one nursing care. This may be for a variety of reasons, including Mental Health specials.
      • Bed Meeting: Twice daily meeting with RCH Access team, NUMs, AUMs, Director of Clinical Operations and Executive Director Nursing Services to forward plan nursing staff to match predicted patient demands.
      • Handover report: Enter the ward patient view in EPIC to alter HDU allocation (previously known as the Bed Tool)

      Key stakeholders

      Director of Clinical Operations, RCH Access Team, NUM, AUM, Nursing Hospital Manager; Executive, Medical staff

      Identification process

      • HDU or Special patients are identified by the Unit Manager and/or the Associate Nurse Unit Manager, often in conjunction with the treating medical or surgical team.
      • A clinical code is allocated to the patient from the RCH High Dependency Criteria this recorded on the in the ward patient view handover report to alter HDU allocation.
      • HDU or Special patients are assessed, prior to the commencement of each shift.
      • HDU or Special patients can be graded up or down during a shift. 

      Assessment Criteria

      • The following table sets out agreed categories of children who may require HDU or Specialing.
      • The criteria are a guide. They will not cover all HDU or Special patients.
      • If a patient does not fall within these categories, they can be categorised as ‘Other’, upon consultation and agreement with the Nurse Unit Manager or equivalent.
      • Allocation of HDU or Special criteria will always be open to critical review by the Director of Clinical Operations, Nursing Hospital Manager or Executive.

      Click to view the High Dependency Admission and Discharge Criteria table.

      Discharge criteria

      • The discharge or step down of patient’s HDU or Special is usually determined by the clinical judgement of the NUM and/or AUM.
      • Generally this occurs once the underlying condition that prompted the elevation in nursing care requirement reduces or is resolved. 


      • HDU or Special patients need to be recorded in the ward patient view handover report in EPIC.
      • All codes must be recorded for each patient, prior to the bed meeting each day. This is the responsibility of the Associate Unit Manager, who is in charge of the shift.
        http://rch-edboard/ (RCH internal access only)


      • The NUM is responsible for monthly auditing of the use of HDU and Special patients.
      • Audit results will be included in monthly reporting
      • Surveillance and auditing of resource allocation occurs twice daily at the bed meeting.
      • Nursing Executive is responsible for 3 monthly auditing of the use of HDU/Special with ward NUM/ANUM


      Please remember to read the disclaimer.

      The review of this clinical guideline was coordinated by Ashley Doherty (NUM, Koala Ward), Danielle Smith (NUM, Sugar glider Ward), Catherine Lobb (ANUM, Sugar glider Ward), Simone Danaher (NUM, Platypus Ward). Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published December 2013, revised April 2015.