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Critical Care Patient Flow

Patients typically flow between levels of critical care, within and between hospitals.

  • Step-up: escalation from emergency department or general wards, to HDU (L2) or ICU (L3).


  • Step-down: discharge from a higher level of care to a lower one, e.g. ICU to HDU, or ICU to ward. This is a period of risk for the patient, and should be carefully planned. Late-night step down to wards, may be associated with worse outcome, and can arise due to discharge delays caused by ward bed capacity. This element of the pathway is a current area of concern and is addressed in the Network quality measures.


  • Inter site transfer: patients may need to be stepped up across sites for specialist tertiary care (cardiac, neuro, spinal, burns, intestinal failure), and subsequently stepped down to closer to home ('repatriation').
    In addition, as reconfiguration progresses, some acute sites may not have full level 3 general units, and inter site transfer may become necessary as part of non-tertiary care. This is contentious and requires detailed risk assessment and planning.