Document Number # QH-GDL-365-2:2012

Guideline for the operation of High Dependency Units (HDUs)

in Mental Health Services
Custodian/Review Officer: Executive
Officer, Mental Health Alcohol and Other
1. Purpose
Drugs Branch
This Guideline provides recommendations regarding best
Version no: 2
practice around the management and operation of High
Applicable To: all authorised mental Dependency Units (HDUs) in mental health services.
health services in Queensland
Approval Date: 14 August 2012
Effective Date: 14 August 2012
2. Scope
Next Review Date: 31 July 2014
Authority: Executive Director, Mental
This Guideline applies to all Hospital and Health staff and
Health Alcohol and Other Drugs Branch employees (permanent, temporary and casual), including
Approving Officer: contractors and volunteers working in treatment settings
……………………………………… where specialist mental health services are delivered.
Name: Associate Professor Jagmohan
Gilhotra
Supersedes: Guidelines for Operation of 3. Related documents
Mental Health High Dependency Units
(HDU) in Queensland. Policy and Standard/s:
Key Words: mental health, high
dependency unit, safety.
 Mental Health Services Policy: National
Standards for Mental Health Services 2010
Accreditation References:
National Standards for Mental Health Procedures, Guidelines, Protocols
Services (NSMHS):
 Mental Health Act 2000 Resource Guide
Standard 1 – Rights and Responsibilities
Standard 4 – Diversity Responsiveness  Implementation Standards for Safety
Standard 5 – Promotion and Prevention  Implementation Standards for Delivery of Care
Standard 6 – Consumers
 National Standards for Mental Health Services
Standard 7 – Carers
2010
Standard 8 – Governance, leadership
and management  Queensland Plan for Mental Health 2007-2012
Standard 9 – Integration
 Mental Health Visual Observation Guideline
Standard 10 – Delivery of Care
Forms and templates
EQuIP5: 1.1.1; 1.1.2; 1.1.3; 1.1.4; 1.1.5;
1.1.6; 1.2.1; 1.2.2; 1.3.1; 1.4.1; 1.6.3; 
2.1.1; 2.1.2; 2.2.1; 2.2.4; 2.4.1; 3.1.1;
3.2.1.

National Safety and Quality Health
Service Standards: 1.1.1; 1.4.1; 1.7.1;
1.8.1; 1.9.1; 1.17.1; 1.18.1; 6.2.1; 6.4.1;
9.5.1; 9.8.1.

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Queensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental
Health Services

4. High Dependency Units in Mental Health Services

The provision of more intensive clinical care is on occasion necessary within mental health
inpatient units for the effective management of acutely unwell consumers. This provision of
care may take a number of forms including but not limited to increased mental health
visual observations, access to a low stimulus environment and the scope for delivery of
intensive care should it be clinically indicated.

An intensive care area is a separate potentially lockable area within a mental health
inpatient facility, designed to provide for the safe management of consumers requiring a
higher level of individual care. Internationally the term Psychiatric Intensive Care Unit
(PICU) has been adopted, but in Australia this has led to confusion with Paediatric
Intensive Care Units. Consequently the preferred nomenclature may need to avoid
reference to PICU. Individual services should agree locally on their preferred name but
some may prefer to continue to use the term High Dependency Unit.

The following guidelines are intended to provide mental health services (MHS) with a
framework for the operation of these units. They do not replace professional judgement on
a case-by-case basis. MHS are to consider best practice for their service and develop
local protocols that reflect this. In order to facilitate adaptation of the guidelines to meet
local service needs and the needs of the individual, specific definitions of level of care and
time frames have not been included.

4.1 Guiding Principles

 Consumers are managed in the least restrictive environment, based on clinical
need that considers their safety and the safety of others.
 An individual’s basic human rights (privacy, dignity and confidentiality) are
recognised and met.
 MHS have clearly defined processes for the provision of safe HDUs.
 Services have a designated lead clinician with authority to make decisions
regarding all aspects of the HDU operation.
 The delivery of care and treatment must be consumer-centred, multi-disciplinary,
comprehensive, collaborative and timely. Length of stay should be
commensurate for clinical need and identified risks.

4.2 General Issues

HDUs are considered part of an acute inpatient mental health facility. Secure Mental
Health Rehabilitation Units (SMHRU) and High Secure Inpatient Services (HSIS) may also
include a capacity for an HDU in their design. In such cases these guidelines will equally
apply.

HDUs provide safe management for consumers requiring intensive mental health care.
When these needs cannot be met due to the severity or the duration of the consumer’s
condition, access to a SMHRU or HSIS may be required. This should only occur after all

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Queensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental
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appropriate management options within the MHS have been tried and following discussion
at a senior level. To facilitate this, individual units are encouraged to develop protocols
with their receiving SMHRU and HSIS.

HDUs, when locked, are not considered seclusion (providing the consumer is not confined
alone), however must be staffed at all times.

4.3 Environment
All acute inpatient mental health facilities will have a designated intensive care area. This
area may have the potential to be locked and ideally be separated from the open ward.

There are no set requirements on the number of intensive care beds, but it is
recommended that a minimum of 10–15% of acute inpatient beds be allocated for this
purpose.

The HDU environment is important and efforts should be made to ensure the milieu is
conducive to desired clinical outcomes. Ideally there will be adequate communal space,
access to personal space with appropriate maintenance of privacy and access to an
outdoor area. There should be ease of access to the seclusion rooms as clinically
indicated.

Mental health facilities are to have a policy on smoking that includes and considers
consumers confined to the HDU. This Policy is to respect consumers’ and staffs’ right to a
smoke free environment, if it is to permit consumers in HDU to smoke.

4.4 Safety
Personal duress alarms will be available to staff working in the area. These must alert
other clinical staff to an emergency and its location.

The duress alarm system should be clearly understood by all staff, including agency and
non-HDU staff. There should be clear procedures for staff to follow with regards to alarms.
Testing of the system is to occur regularly.

4.5 Admission Criteria

Admission to an HDU is based on current clinical need and made in the context of a
treatment plan which identifies the consumer’s diagnosis, clinical needs, treatment goals
and expected outcomes. Explanation of the decision to admit a consumer to an HDU
should be given to both the consumer and their carer/next of kin if the consumer has
consented as clinically indicated. Voluntary consumers will not be routinely managed in an
HDU care setting; should this be clinically required, informed consent must be obtained
and clearly documented.

4.6 Management in HDU

While a staff member will always be present in the HDU it should not be assumed that the

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Queensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental
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consumer is always being observed e.g. consumers in bed or in the bathroom. The
minimum requirement for visual observation in an HDU is at 15 minute intervals. Visual
observations may be undertaken more frequently depending on the clinical needs of the
consumer (refer to the Visual Observation Guidelines for further information). Surveillance
cameras in HDUs should not be used for the purpose of mental health visual observations.

In keeping with the philosophy of least restrictive environment, consumers are to have
access to outdoor areas, structured activities and ward based activities as soon as clinical
needs allow.

The consumer’s mental state, risk screen and treatment plan is to be reviewed daily, this
review is to be clearly documented. Consultant psychiatrist review should occur at a
minimum twice weekly and include review of the consumer’s current treatment plan.

Planning for reintegration into the open ward should commence on admission to the HDU.
The timing of transfer from the HDU to the open ward is a clinical decision, based on a
comprehensive review of all available clinical information and considering a graduated
approach where necessary.

The consumers’ right to maintain familial and interpersonal relationships is supported,

however processes will be in place that safely balance and consider the rights of all
consumers with the rights of visitors and staff.

The Mental Health Act 2000 allows for searches of consumers and their environment in an
Authorised Mental Health Service if a doctor or senior registered nurse reasonably
believes that the consumer is in possession of something harmful. Please refer to the
Guideline: Searches in Authorised Mental Health Services.

4.7 Staffing
The selection of staff who work with acutely unwell consumers is important. In staffing
these areas, consideration must be given to the skill mix, gender mix, level of staff
experience and the staff/consumer ratio required. The staff/consumer ratio should remain
dynamic depending on the clinical needs of the consumers.

4.8 Quality Activities

MHSs are encouraged to establish local processes, collect data and identify clinical
indicators that can be used to monitor the practices in HDUs. This data should be
reviewed on a regular basis to ensure ongoing best practice. In addition, there should be
processes for:

 responding to (and reporting of) critical incidents; and

 debriefing and counselling of both consumers and staff following critical
incidents.

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Queensland Health: Guideline for the operation of High Dependency Units (HDUs) in Mental
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5. Definition of Terms
Definitions of key terms are provided below.

Term Definition / Explanation / Details Source

High Dependency Unit A separate potentially lockable area within a mental Guidelines for the
health inpatient facility, designed to provide for the safe Operation of Mental
management of involuntary patients requiring a higher Health High
level of individual care. Dependency Units in
Queensland

Authorised Mental Health A mental health service declared under section 495, Mental Health Act
Service (AMHS) Mental Health Act 2000. To be an authorised mental 2000
service or a public hospital if there is no authorised
mental health service readily accessible for a persons
examination or assessment.

8. Guideline Revision and Approval History

Version Modified by Amendments authorised by Approved by
No.
2 Penny Dale and Catherine Robert Troy Dr Bill Kingswell,
Scott-Richardson
Acting Executive Director
Mental Health Alcohol and
Other Drugs Branch

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