| Physical and material resources. What level of support will actually be provided for oxygen and monitoring related consumables? Will use of these need to be ‘rationed’ and only permitted on the high-dependency unit (HDU)? What new costs will the hospital incur to sustain procurement of an expanded set of oxygen consumables used at higher volumes? Will a larger generator be needed for periods when mains electricity is interrupted to power machines? If an area of the surgical ward is refurbished and repurposed as a 4-bed HDU, what impact will this have on surgical care? Will other wards also have new areas designated for those needing oxygen and better monitoring or should all those needing oxygen go to the HDU? | Workforce capacity and capability. Capability (training) seems to be addressed but hospitals will get no new nurses, Tto ensure one of the six trained nurses is on the HDU 24/7 will they have to work 12-hour shifts and increase working hours? Will they tolerate this? What happens in case of absence? Policy on HDU indicates 1 nurse to 3 patients, previously when offering only low-flow oxygen policy allowed for 1 nurse to 6 patients. Is it reasonable to have only one nurse working alone for 4 HDU beds? general wards will lose nurses, increasing their workloads adversely affecting staff and patients. If only one physician is fully trained is it safe to operate the HDU if this physician is unavailable? Or will new physicians need to be recruited and paid for? | Organisational relationships. When the trained physician is not available will the ‘specialist nurses’ trust the medical advice of less well-trained physicians? Might this result in junior clinicians avoiding the HDU as they become fearful of making mistakes? Could this lead to emergence of a ‘them and us’ situation especially at vulnerable times such as nights and weekends? Will relationships between the HDU nurses and wider hospital nursing body sour if they feel those on HDU are getting special treatment such as paid overtime? There have been great difficulties in negotiating referrals with the referral level hospital with local staff feeling their efforts are not respected and even feeling patronised, how will productive relationships be developed beyond respiratory care? |
| Goal alignment. Improving oxygen supplies is a local priority but not confined to respiratory illnesses, post-operative, maternity and neonatal care are also priorities. Support for equipment, resources, staff training and maintenance should extend to all these areas. | Action team There is one local physician, s/he and a senior nurse could be key focal points. They will have to work with senior staff to reallocate nurses and liaise with the biomedical engineering department. They will need to negotiate with surgical team leaders to redesign the allocated space, will they become a separate organisational unit (eg, for resource and personnel management) or be part of the surgical or medical unit? The physician already runs the medical ward. | Organisational support How will the new HDU team leaders engage with senior facility managers, will they need to join hospital management committees? How many? Who will order and manage the equipment and consumables provided, will they be given training to do this and who will be involved in long-term resource planning to support the HDU? Under what circumstances can the senior team allocate resources to other priority areas? Who will develop local guidelines for admission to the HDU and manage disagreements? | Responsiveness As provision of HDU care is not currently part of national/regional policy and planning how will this expansion of service delivery be allocated budgets to enable sustained HDU support? Current health information systems are not designed to capture HDU workloads and outcomes, how will this be addressed to support planning and management? What possibilities are there for employing additional staff to support the HDU? | Learning What form will support from the regional referral centre take? Will it only involve the expert visiting the facility? Or will HDU staff visit the tertiary centre or other units to share practice ideas? Is advice available 24/7 in emergencies, through what mechanism? Is someone responsible for capturing learning on implementing HDU care and sharing this with policy makers and planners? |