1
When does a patient get admitted to the hospital?
The decision to admit a patient for management and treatment within the hospital is based on clinical judgment, treatment protocols, and, most importantly, the patient’s medical condition. Most of these decisions are made within the emergency department. Emergency medicine physicians are trained to resuscitate, diagnose, and plan disposition. The patient’s disposition includes discharge, observation, or admission to the hospital. When the physician’s clinical judgment determines that the patient requires care in an inpatient setting rather than an outpatient setting, the physician will choose to admit the patient.
Certain patient presentations are identified by hospital protocol for admission. For example, almost all hospitals will admit a patient with active chest pain and electrocardiogram (ECG) changes, if not for treatment, then at least for monitoring of ECG rhythm, vital signs, and laboratory results.
2
What if the patient does not want to be admitted?
In most situations, patients will agree to be admitted to the hospital. If the patient insists on leaving, the physician will typically clarify that medical advice warrants admission and document that the patient was informed of the medical recommendation but left against medical advice.
There are several situations in which patients may be admitted against their will. When the patient expresses a plan to hurt himself or herself or others, he or she can be forced to be admitted to the hospital. When it has been determined that the patient does not have the mental capacity to make his or her own medical decisions, he or she can also be admitted without consent. When a patient arrives at the hospital in distress, needs emergency resuscitation or surgery, and is unable to give consent because of the presenting medical condition, the patient may be admitted without consent.
3
From where are patients admitted?
Patients can be admitted to the hospital from several different settings as displayed in Fig. 3-1 . The majority of patients are admitted from the emergency department. Once in the hospital, patients often move from one location to another (intra-/interservice transfer) based on the severity of their medical condition. An inpatient service may receive an admission from the operating room after surgery, from the intensive care unit (ICU) when the patient’s condition improves, or from another inpatient service when one of several medical issues has resolved.
For example, a patient in a motor vehicle accident might be taken straight to the operating room and then be admitted to the orthopedic surgery service for follow-up of a fracture repair (Surgery → Admit). This patient may then develop a pulmonary embolus and be transferred to the ICU for respiratory distress (Inpatient service → ICU). When the patient’s status improves and breathing is done independently, he or she could be admitted to the general medicine service for continued care (ICU → Inpatient service). If the patient suddenly develops atrial fibrillation with an accelerated ventricular rate, he or she may need admission to the cardiology service (Inpatient service → Inpatient service). Although this situation is rare, it does occur and is an excellent example of the variability of patient admissions.
Other possible sources for patient admissions include transfers from outside hospitals that do not have adequate resources or capabilities, direct admissions from outpatient clinics, and patients who called their physician for medical advice and were arranged for admission from home.
4
To where are patients admitted?
Most hospitals have two or more levels of inpatient care based on the severity of the patient’s illness. Each level differs in the number of staff members per patient, frequency of care, and accessibility to extensive monitoring and treatment. Most hospitals have an observation unit (which may not be considered a hospital admission), an inpatient service with or without extensive monitoring, and an ICU. Some larger hospitals have levels of care between the ICU and inpatient service, commonly referred to as the stepdown unit.
5
Who decides to what service a patient gets admitted?
The majority of decisions as to which service to admit a patient to are controlled within the emergency department. In addition, a consulting service may choose to recommend admitting a patient to its service for further treatment. Some hospitals may have protocols for admitting procedures for “typical” patient presentations. For example, patients with chest pain may be sent to the cardiology service, whereas patients with seizures are sent to the neurology service.
When a patient is to be admitted to a general medicine service, there is often a resident within the emergency department who is assigned the role of allocating patients throughout the hospital. The allocation is dependent on severity of the patient’s condition, distribution of patients within the hospital, and likely length of hospital stay. Each service may have a cap or quota—a maximum number of patients the service can accept each night. There are rules under which a service may have to accept additional patients above the cap or quota. ICU patients commonly account for this. For example, the cardiology service may allow each of its interns to carry eight patients. Once this number is reached, the patients are admitted to the general medicine service. However, if a patient requires a stay in the coronary care unit, the service is required to take on that additional patient. There may also be services within various hospitals that do not have a cap or quota.
6
What are the important portions of a history and physical examination that should be included during a patient admission?
Every patient who is admitted to a service requires a complete history and physical examination, commonly known as the Admit H&P. Although the focus of this H&P will depend on the patient’s presentation and the admitting service, the general outline in Table 3-1 can be followed to avoid leaving out important portions.
| Medical History | ||
|---|---|---|
| Abbreviation | Name | Description |
| CC | Chief complaint | The patient’s main problem requiring medical care. |
| HPI | History of present illness | A thorough description of the chief complaint and associated symptoms that have led up to the patient’s current status. Include pertinent positives and negatives. |
| PMH/PSH | Past medical/surgical history | Any past medical conditions or surgeries related or not related to the chief complaint. |
| MEDS/ALL | Medications and allergies | All medications the patient is currently taking including dosages, as well as past or recent medications that are relevant to the HPI. Any over-the-counter (OTC) medications, herbal supplements, or vitamins. Any allergies the patient may have to medications or medical treatments. |
| FH | Family history | Any illnesses that may run in the family such as cancer, diabetes, or heart disease. Focus on illnesses that may be related to the chief complaint. Age and medical conditions of any siblings or children. |
| SH | Social history | Current location, living situation, marital status, and number of children; employment and education; tobacco, alcohol, or recreational drug use. |
| ROS | Review of systems/symptoms | Complete review of all patient symptoms within each of the organ systems. |
| CODE | Code status | Because the patient is in the hospital, it is important to determine whether he or she would like emergency resuscitation including intubation if necessary. |
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