Admissions
Admissions can be received multiple ways: through the ED, CLC, direct from clinic, as overflow in the morning, or as transfers from other services or other hospitals.
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The medical center has wards hospital beds that are medical-surgical floor beds, medical-telemetry beds, and PCU beds (progressive care unit aka an intermediate care bed). The ED will decide what type of bed the patient needs and will place the admit order (aka the ADT order), however you may disagree and discuss with your attending and the ED attending to decide for a higher or lower level of care.
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ICU Downgrades can only occur between 07:00 AM and 10:00 PM.
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***Please note: Admissions are an ED-Driven Process. We should not delay admissions and all patients should be seen promptly; if you are concerned about the appropriateness of an admission/level of care, please promptly see the patient and close the loop with the ED/your attending to discuss further. FURTHERMORE, no admissions should be delayed past 6PM unless an attending-attending discussion has occurred with the swing shift attending. If you have any questions, please talk to the chiefs.***
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Admitting Team (starting 7/29/2024)
The admitting team has started on service. Their role is to assist on-service teams with admissions between 2-10PM. For those residents on the service, further details will be provided via email the week before your rotation.
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Please Note:
1. Receiving handoff from the ED is the primary team's responsibility. Once you receive hand-off and the ADT order is placed, the senior resident can discuss with the attending whether or not a patient is suitable for the admission team. However, the admitting team is not a primary service; the primary team is still responsible for the patient. Once the admitting team completes the admission, they will staff the patient with the primary team attending. The residents on the primary team are expected to be present as this will serve as the admitting team's handoff of the patient to the primary team.
2. Any patient given to the admitting team should still be seen by primary team. A full evaluation is not expected but the patient should at minimum be seen to see if they are appropriate for floor admission.
3. For late, call day admissions (between 5:15-6) that are given to the admitting team, it is expected that the primary team provides a brief signout to the appropriate night-float intern, as the patient being admitted is still part of their service. They should also tell the night-float intern that the admitting team will come sign out the patient by 10PM. Senior residents should also expect a call from the admitting team with their attending for handoff. These patients should not be included in overflow sent to the chiefs the following morning as they already have team assignments (aka the call team).
4. Any patient admitted after 6PM by the admitting team will be signed out to the night team senior residents by 10PM. They should be included in the overflow email sent to the chiefs the following morning.
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Direct Admissions
There can be direct admissions from the CLC, Cards, GI/IR suites, or clinics and they will typically go to a medical-surgical bed. Patients can also be direct admits from surgical teams who do not have a primary service (ie. Urology). Referring physicians need to place a "Admission Referral Consult Inpt" consult on CPRS. Please ensure all sections of the "Admission Referral Consult Inpt" consult are filled out by the referring physicians (including the not required parts), especially the contact information. After fully completing the consult, referring physicians first call the Flow Center (x57887) to get a bed assigned and then Admissions or AOD (x54180,x57152,x58236) to find who the admitting team will be. The referring physician should call the admitting team once there is a bed for patient signout.
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If you think these patients are potentially unstable, they should be referred to the ED for evaluation and treatment instead of a direct admission. You would talk with the referring physician about this change in status should it arise.
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Regarding COVID tests, the patient will either receive one prior to admission (generally if it is a planned admission) or can be swabbed by the unit nurse once on the floor.
ORDER SETS
There are admission order sets including for Heart Failure, CAP, COPD, stroke, alcohol use disorder, and COVID. You should use them because they prompt important orders and best practices for those diagnoses. The order sets are located in the upper left hand corner of the "Add New Orders" tab.
Telemetry order set
You need to order the telemetry order set on admission, and it needs to be reviewed daily, ideally during rounds, and discontinued if no longer indicated or appropriate. You can customize the alarm and call provider parameters. If you want to discontinue the order set, change the ADT order level of care from “telemetry” to “medicine” and notify the patient’s nurse or place a nursing text order. If you renew, please remember to renew all the parts of the order set (or just reorder it). More information is available here.
Admission note
Admission H&P notes must be written by a physician. They cannot be written by a medical student, although the medical students can help and should practice writing their own H&Ps. ​
Although a patient may have a bed assigned per the ED and Admissions, sometimes the patient chart is not updated with the assigned bed on CPRS. When this occurs, you cannot put in active orders:
If this occurs, you can:
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Write "Delayed Orders." You can write delayed orders for anyone who is moving from one location to another (ie. PCU to Med/Tele). This also applies for new ED admissions. Click the Order tab>>find "Write Delayed Orders" in a gray box on the left menu bar above where it says "Write Orders">>Click the level of care the patient is planning to receive (ie. Med/Tele)>>fill in the "Delayed" ADT order and then add any other orders. All these orders will automatically move from delayed to active once the patient has a bed in CPRS.
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You can also start an admission note:
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Notes tab -> New Note -> Encounter Location -> DC/MEDICAL SERVICE​
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*Orders are tied to the floor section the patient is on. If the patient moves from one location to another, you must change the orders to ensure they will continue on the new floor. To do, you can right click and Renew Order which will change the Location column to where they currently are.
Life sustaining treatment
Life-sustaining treatment notes (LST) are notes that document code status among other patient wishes. They provide an overall perspective of how the patient wants to be cared for and their priorities. They are often written by a patient's primary care doctor or geriatrician in the outpatient setting. They are on the Face Sheet in the top right-hand corner.
When admitting a patient, please look at the previous LST so that when you confirm their code status on admission (a practice you should do with every admission), you have the context of that conversation. If the patient desires a code status that is different from what was previously documented, you should write a new LST. This can be done through the Notes tab >> Add new note >> Life-sustaining treatment note. If the patient now desires to be DNR the note will generate a DNR order.
Medication reconciliation
One of the most important parts of an admission is the patient's medication reconciliation. Here you are confirming and documenting what medications they are taking outpatient, and considering which ones to continue while they are inpatient. There are a few ways to view a patient's outpatient medications in CPRS; however, please note, many veterans seek care outside the VA as well as inside and so the medication list may be incomplete. The best source of what medications a patient is taking is the patient themselves. Always confirm a medication list with a patient with every admission.
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Outpatient medications can be viewed by going to the "Meds" tab of the patient's chart and looking at the bottom-most section labeled "Outpatient Meds." Here medications are listed as "Active," "Active/Susp" (indicating they have been sent but not yet filled by the patient), "Expired" (meaning the refills on this medication have run out - either purposefully or not purposefully), and "Discontinued." Always review with the patient any medications that are "Active," "Active/Susp," or "Expired" to see if they are taking them currently or should be taking them.
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The section above "Outpatient Meds," labeled "Non-VA Meds" are medications filled by non-VA providers that have been entered into the system by the patient's VA provider. These may or may not be accurate and need to be reviewed with the patient.
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Once confirming with the patient, you can copy forward the outpatient medications to inpatient medications by highlighting the ones you'd like to continue on the "Meds" tab and going to "Tools" >> "Copy to Inpatient." This will prompt you medication by medication to confirm the timing of when you'd like the medications to be administered but is a quicker and easier way to continue medications accurately.
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The patient's active inpatient medication list can then be viewed in the "Orders" tab or by navigating to the "Reports" tab >> "Medication Admin History."
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To double check at any time during hospitalization that patient is on all their home medications, here is a trick:
Go to "Reports" tab at the bottom >> Open "Health Summary" >> "Medication Reconciliation."
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OPT means Outpatient
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INP means Inpatient Mediation
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