Admissions through Emergency
Patients are typically admitted to inpatient settings via an Emergency Room or Department (ER or ED) in an admitting facility. Additionally, transfers from outlying hospitals and RAAPID admissions typically route via the ER. Patients assessed by emergency room prescribers may be admitted by the same clinicians. Or ER prescribers may consult inpatient services that then assess the patient and, if indicated, proceed with admission.
In general, the Admission Navigator should be used to progress sequentially through steps that must be taken to facilitate safe admission to an inpatient ward. This reminds the clinician to estimate an expected discharge date, do problem and medication reconciliation, and set up admission orders.
Admission Order Sets
In general, admissions to hospital should be initiated with an admission order set. AHS order sets are designed to ensure that all important instructions are considered, including vitals, oxygen, monitoring, isolation and other considerations. The requisite orders are already assembled and the user choses between relevant options. Those choices can be saved as personalized order sets, speeding the next similar admission.
Admission order sets can be supplemented with individual order items. Alternately, users may build a personal order panel that includes all order elements needed for specialized admissions. The panel can be added after a base order set is entered. Some supplemental orders are used only in facilities that support the requested action.
Observation Bed Request Order
This order (search for "obs") should be used to communicate to bed planning and nursing that a patient requires a dedicated "observation bed" on an inpatient unit. When the observation requirement no longer pertains, the order should be discontinued. This order does not replace specific patient monitoring orders (e.g., telemetry, psychiatric observation, etc.), and should only be used at facilities that support some kind of observation bed designation.
Admission Orders
"Admit to Inpatient" orders are part of all admission order sets and must be completed for an admission to proceed. The order initiates bed search and allocation. Accordingly, admission orders should be entered as soon as a decision to admit is made and an admitting hospital service selected. For this reason, it may be practical to enter and sign an admission order before the rest of an admission order set is completed.
Parts of the Admit order composer are particularly important:
Service
Select from among the available hospital services.
A "hospital service" is a general or specialty clinical service with assigned inpatient beds on the facility bed map. It is possible that a desired specialty (e.g., "Infectious Diseases") will not be listed in the Service field of an admission order. In this case, a hospital service (e.g., "General Internal Medicine") will admit patients for the non-admitting service (which is typically consulted). Appropriate choices will be known to the desired service for a particular facility.
Level of Care
Unless a patient is admitted directly from emergency to critical care, use "Acute" as the level of care. This can be adjusted later.
Admitting provider
This will normally be the prescriber entering the admission order. When trainees enter admission orders, they should select the attending or attending on on-call to whom they report when the admission order is entered (e.g., emergency room consult attending).
Most Responsible Physician
Select the provider who is the responsible attending at the moment of admission. This is easily changed later. This is especially important when admitting patients after hours when the attending for the admitting service may not be the attending on-call.
Provider Team
Select from the provider teams available for the admitting facility. A provider team is not a hospital location. Those admitting to a particular hospital service should know the provider team(s) associated with that service and so select the team appropriate at the time of admission. Entering the provider team doing ED assessments and admissions is okay. Bed coordinators or clinicians can later change the provider team when a bed is found and the best provider team determined.
Diagnosis
The admitting diagnosis will default to become the principal hospital problem, something easily edited later.
Expected Discharge Date
It is a minimum use requirement that an Expected Discharge Date (EDD) be entered within 24 hours of admission. It is easiest to enter this information at admission. Of course, clinicians may have little idea how long a hospital encounter is likely to be for patients with multiple problems. However, a general estimate can be made and entered. This will be revised every 1-2 days while the patient is hospitalized.
Enter the following shortcuts to represent approximate intervals to expected discharge:
"T+1" in the EDD field to indicate that a very short stay (day or less) is expected.
"T+3" in the EDD field to indicate a short term admission (3 days or less), as is typical for many surgical procedures or modest infections
"T+5" in the EDD field to indicate a typical admission (5 days or less) with no comorbidities or disposition issues likely to prolong the encounter.
"T+10" in the EDD field to indicate a complex admission (10 days or less) with little basis for estimation. This date will be revised as the encounter progresses.
Unit
Busy facilities will have high bed occupancy rates, making it impossible to anticipate exactly where a bed will be found. Patients can remain in "emergency inpatient" status for hours to days.
If a bed manager has not specifically indicated that a patient can be admitted to a particular ward, leave this field blank. The ward assignment can happen later.
Bed Request Comments
Use this field to record specific hospital service requirements. What is understood and acceptable will vary from facility to facility. Check local norms. For example, some facilities have "iCare" beds and this requirement can be entered to this field.
Other facilities may have "observation beds", with an expectation that such need be identified with an observation bed order (see above).
Admission Care Requirement
This optional field should typically be left blank. It is rarely possible for prescribers to correctly select facility-appropriate nurse-patient ratios. The bed management team, together with nursing, will make an appropriate choice later.