Admission and discharge practices; High Dependency Unit audit outcome

Abstract

This paper presents the findings of retrospective audit of admission and discharge practices of a nurse led High Dependency Unit (Nurse Specials Unit) in Perth, Western Australia. The aim of the study was:* to review the effectiveness of the inclusion and exclusion guidelines for patients admitted to the Nurse Special Unit (NSU);* to identify characteristics of admitted patients; and* to determine the level of adherence to admission protocols for documentation of patient condition, plan for care, medical and Clinical Nurse Consultant review.The sample comprised all patients admitted to the NSU from September 2004 - March 2005, excluding those (50) in the pilot study (n = 154). Thos audit revealed patients were primarily elderly and admitted for close nursing supervision. Inclusion and exclusion criterion were adhered to, however documentation of patient data, in relation to current status and plan for care, was poorly completed and frequently absent during intra hospital transfer. This lack of clear documentation poses a significant risk to the patient. Further research is required to determine strategies that result in appropriate and useful transfer documentation. In addition, the content of transfer data that permits continuity of care needs to be determined.