Hospital Patient Admission

Complete workflow for admitting a patient to the hospital, from admission order through bed assignment and inpatient encounter creation

Flow

Hospital Patient Admission Workflow

Complete workflow for admitting a patient to the hospital from admission decision through bed assignment, encounter creation, and initiation of inpatient care.

Workflow Overview

Hospital admission is a complex, multi-step process involving clinical decisions, bed management, comprehensive assessments, and coordination across multiple departments.

Admission Sources

Emergency Department (ED)

  • Most common: ~50-60% of admissions
  • Acuity: Often higher acuity
  • Time pressure: ED boarding issues if beds unavailable
  • Examples: Chest pain → MI, respiratory distress, trauma

Scheduled/Elective

  • Planned: Days to weeks in advance
  • Pre-admission testing: Labs, EKG done outpatient
  • Examples: Elective surgery, chemotherapy, scheduled delivery
  • Insurance: Pre-authorization obtained

Direct Admission

  • From clinic: Provider sends patient directly
  • Examples: Decompensated CHF, cellulitis needing IV antibiotics
  • Coordination: Provider calls hospital to arrange

Levels of Care

Medical-Surgical (Med-Surg)

  • Standard care: Most common
  • Nurse ratio: 1:4-6 patients
  • Monitoring: Standard vital signs

Telemetry (Step-Down)

  • Cardiac monitoring: Continuous ECG
  • Nurse ratio: 1:3-4 patients
  • Between: ICU and Med-Surg acuity

Intensive Care Unit (ICU)

  • Critical illness: Life support, organ failure
  • Nurse ratio: 1:1 or 1:2 patients
  • 24/7: Intensivist coverage
  • Subspecialties: Medical ICU, Surgical ICU, Cardiac ICU, Neuro ICU

Bed Management Challenges

Hospital at Capacity

  • ED boarding: Patients wait in ED for beds
  • Safety concern: Overcrowding
  • Mitigation:
    • Discharge acceleration (discharge by noon)
    • Transfer to other facilities
    • Flex staffing
    • Diversion (close to new ED arrivals)

Bed Turnaround

  • Environmental services: Clean room after discharge
  • Target: < 60 minutes
  • Tracking: Real-time bed board

Nursing Admission Assessment

Comprehensive Evaluation

  • Vital Signs: BP, HR, temp, RR, O2 sat, pain
  • Physical Assessment: Head-to-toe
  • Fall Risk: Morse Fall Scale, Hendrich II
  • Pressure Injury Risk: Braden Scale
  • Pain: 0-10 scale, location, character
  • Psychosocial: Mental status, safety, support system
  • Education: Patient/family learning needs

Risk Screening

  • Fall Prevention: Yellow socks, bed alarm, frequent rounding
  • Pressure Injury: Turn q2h, specialty mattress
  • VTE Prevention: Sequential compression devices, pharmacologic
  • Delirium: High-risk (elderly, dementia, ICU)

Medication Reconciliation

Critical Safety Step

  • Goal: Accurate and complete medication list
  • Sources:
    • Patient/family interview
    • Medication bottles (if brought)
    • Community pharmacy records
    • Prior hospital records
    • Health Information Exchange (HIE)

Reconciliation Decisions

  • Continue: Home med continued in hospital
  • Hold: Temporarily stopped
  • Modify: Dose/frequency adjusted
  • Discontinue: No longer appropriate
  • New: Hospital-initiated medication

High-Risk Medications

  • Anticoagulants: Warfarin, DOACs
  • Insulin: Exact dose and timing critical
  • Opioids: Risk of oversedation
  • Immunosuppressants: Transplant patients

Admission Order Sets

Standardized, Evidence-Based

  • Condition-Specific: CHF, pneumonia, COPD, post-op
  • Completeness: Ensure no missed orders
  • Quality: Built-in best practices
  • Efficiency: Faster order entry

Common Components

  • Admission: Admitting diagnosis, service, attending
  • Allergies: Documented and verified
  • Vital Signs: Frequency based on acuity
  • Activity: Bed rest, ambulate, PT/OT
  • Diet: NPO, regular, restrictions
  • IV Fluids: Type and rate
  • Medications: Continue/new
  • Labs: Admission labs, monitoring
  • Nursing Protocols: Fall prevention, DVT prophylaxis
  • Consults: Specialists as needed

Department Coordination

Pharmacy

  • Order review: Clinical pharmacist
  • First dose: Priority delivery
  • Pyxis: Stock automated cabinets
  • IV preparation: Compounding

Laboratory

  • Admission labs: CBC, CMP, coags
  • Monitoring: Per orders
  • STAT capability: Critical results

Imaging

  • Portable X-ray: If patient unstable
  • Scheduled: Transport to radiology
  • STAT CT/MRI: For emergencies

Case Management

  • Social work: Discharge planning begins on admission
  • Insurance: Continued stay review
  • DME: Durable medical equipment needs
  • Placement: SNF, LTAC, home health

Technology Systems

Bed Management System

  • Real-time: Current bed status
  • Assignment: Optimize placement
  • Tracking: Patient flow metrics
  • Predictive: Anticipated discharges

EHR Integration

  • Encounter: Inpatient visit record
  • Orders: CPOE (Computerized Provider Order Entry)
  • Documentation: Notes, flowsheets
  • Medication: eMAR, barcode scanning

ADT (Admission, Discharge, Transfer)

  • HL7 ADT Messages: System notifications
  • Census: Current patient list
  • Billing: Triggers claim processes

Quality & Safety

Admission Metrics

  • ED to Floor Time: Target < 2 hours after bed assignment
  • Med Rec Completion: 100% within 24 hours
  • Fall-Free: Zero harm goal
  • Pressure Injury: Prevention bundle compliance

Patient Experience

  • Communication: Care team introductions
  • Explanation: Why admitted, what to expect
  • Family: Visiting hours, phone updates
  • Comfort: Noise, lights, temperature
  • Appointment Scheduling (for elective admissions)
  • Lab Order Workflow
  • Prescription Fulfillment (discharge prescriptions)
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