Direct Admits

Genista, BSN, RN · Jan 2, 2003

Most of our direct admits go through admitting first. That's kind of nice, b/c it gives us a few minutes heads up as to when our patient is arriving. Most are pretty stable diagnoses, and ambulatory.

But ONE time, a few years ago, when I was a new grad on med/surg...

I got a direct admit 50 yr old male w/ unstable angina with active chest pain straight from the MD office. Boy was I PO'd about that! Yep, he arrived with NO ORDERS, active chest pain & SOB, no IV, no EKG, no labwork, NO ORDERS.

Gee, do ya think the MD could have written a few orders & maybe sent him through ER 1st to get some enzymes drawn & worked him up a bit!? This patient arrived in the middle of my shift & took up a good 1.5 hours right off the bat. I had 6 other patients to take care of, too (you know how that goes). I don't mind pt arriving w/o orders, if stable, but that was a definite QA on that pt that time.

On the lighter side, I have had a few direct admits whom admitting told me were "on the way," but didn't show up for hours (the patient was shopping, or going out to lunch first, etc.) LOL! I figure the patient must be pretty stable & not in acute distress, if they have time to go shopping & out to lunch first!?

:roll

BBFRN, BSN, PhD · Jan 2, 2003

Originally posted by defib queen
As an er nurse, I would have to ask, why would you want all direct admits to be worked up in er first? In our er, if we worked up all the direct admits before they were admitted, we would not have time or space to take care of the emegency patients. We have a real problem with our patient ratio being at least 50% or greater being non-urgent problems i.e. cold symptoms for 4 days, etc. things that could have waited for the doctors office to open or be taked care of with otc meds. This takes precious time away from urgent and emergent patients and a toll on the staff at our facility.
I really don't have a problem with a patient being a direct admit if they have seen their pcp. I worked on a busy med-surg floor for 3 years, when I got a direct admit report came from patient assessment, just as in the er with walk-in patients we don't get a report from someone, we get report from patient history and assessment.

I agree with you, Defib. Most of our direct admits are not people who need to be seen in the E.R. first. A good number of them have already been seen in another facility or in our clinic. We have to assess them once they come up on the floor anyway. Of course, I work in a teaching hospital, and we have Doc's in-house 24/7.

hapeewendy · Jan 2, 2003

I think that if it was serious enough that they be sent to be directly admitted to the hospital then they need to get some orders written on them before they show up on the unit....

I understand the ER problems of being overwhelmed

but I'm still so bothered by my own personal experience with a "direct transfer" that I cant see it any other way ....

if that woman had gone thru the ER A dr would have written orders on her, talked to the family and gone from there, instead she's rolled through our doors with no assessment, no chart, no orders no nothing and were just supposed to "figure it out"

floors are also very overwhlemed and that situation took up a ton of everyones time , that of course , should have been spent otherwise..

MissdonditaBsn · Jan 2, 2003

Originally posted by defib queen
As an er nurse, I would have to ask, why would you want all direct admits to be worked up in er first? In our er, if we worked up all the direct admits before they were admitted, we would not have time or space to take care of the emegency patients. We have a real problem with our patient ratio being at least 50% or greater being non-urgent problems i.e. cold symptoms for 4 days, etc. things that could have waited for the doctors office to open or be taked care of with otc meds. This takes precious time away from urgent and emergent patients and a toll on the staff at our facility."
____________________________________________________

I really didn't mean to imply that I think that all admits should go through the ER. With that I do agree. I was just curious. We officially do not have a policy at our facitlity that outlines the type of patients that we would allow to admit as a direct admit. Essentially we will allow anyone to come in as a direct admit. wouldn't want to upset the docs and all. The only problem is that the docs will often send in patients who are not necessarily stable as a direct admit and really we have no recourse for action when this happens. Normally, the doctors are smart about it but occassionally one will slip by.

I also have concerns with a patient who is ill sitting in Admitting being registered. They are not seen by a nurse there, it is merely a process of getting insurance information and making sure that the patient is entered into the computer properly. The patient usually does not come with orders and while we are a teaching hospital, we are still often waiting for the patient to be seen by a resident, who then has to page the attending and so on. We can often wait for a long time before we can do anything with the patient.

We are currently in the planning stages of a pilot program at our hospital. We will call the area the Admission Center. When a patient is admitted, they will report directly to this area. This area will be staffed by a RN, PCT, and Registration Clerk. The patient will be seen immediately by an RN, be registered at the bed side and hopefully will be seen within a reasonable amount of time by a resident. It is our hope that we will be able to convince the attendings to send the patient with an intial set of orders so that we can begin treating the patient immediately. I would be happy if these orders consisted of nothing more than a diagnosis, iv order, pain medication and diet order. These are the things that we need the most to make a patient feel as if we are doing something for them. We are taking a lot of criticisim over the development of this area. Many people feel that it is a waste of resources. I think that it might be a good idea.

Scavenger'sWife, RN · Jan 2, 2003

I work on a very busy med-surg unit and we do get direct admits. (Probably 10% of our admits.) They are always stable and non-emerg pts. If the situation is serious, they must go thro ER 1st for emergent care and stabilization before hitting the floor.

I agree with the problem already stated with the D.A. pt who comes from the MD office and has NO ORDERS! Sheesh, the doc coulda written out at least a DIET and an IV order for heaven's sake. The biggest complaint from the pt is they can't eat or even get water until I make sure they aren't going for tests or labs. We carry cell phones when we are working the floor, so I make sure to call the MD right from the pt's room in front of the pt so they can hear me request orders. Helps settle the pt down when they see I really DID call.

LadyZad · Jan 2, 2003

We also received direct admits at the hospital I work at. They are about 60% of our admissions. If the patient is in admitting and the clerks there can see the pt requires immediate attention, they will just send the pt to the ER first to be seen there prior to admission - they are very consistant at this. We also have some Docs who will send pt's without orders, which is very frustrating and a waste of time.

As for receiving admissions that are not stable, I have had more problems with getting unstable patients to a med/surg floor coming from our ER. I have often coded patients while still in the ER stretcher when in report I was told "the patient is fine"......... but that's a nothing subject.

Nurse Ratched, RN · Jan 2, 2003

The idea of getting a pt in with no orders is completely unfathomable to me. We legally cannot allow a pt in the door without orders either written by a doc or verbally given/telephoned by a doc to a nurse. Isn't that a huge liability issue without it? - there's no one to take accountability for the pt if there is no admitting doctor to give orders and be responsible for calling for followup. I'm amazed (well, not really I suppose) that mgt allows these potential lawsuits to go unchecked.

renerian, BSN, RN · Jan 2, 2003

We did alot of directs.....................skip go and come on home.......right to the floor without any special policies. We called the doc with an assessment got orders. We had standing orders for sickle cell anemia clients for immediate pain meds, blood draws and such.

renerian

montroyal · Jan 3, 2003

EMTLA( what was cobra) covers the law regarding direct admissions and transfers. If a patient is transfered from a in patient facility, they cannot be brought to the ER of the receiving hospital unless they have had a life threatening status change while enroute. Nurses to Nurse report must be called prior to the patient leaving the original facility. If this is not done, the sending facility is liable for $ penalties, and the sending nurse can be disciplined by their BON for patient abandoment. The transfer form must have the name of the RN that received report and the room which is available for the patient. No inpatient can be transfered from a facility to another without an avialable bed. This does not prohibit ER to ER transfer., but nursing report must be completed prior to the pt leaving the original facility.

A patient sent from a MD's office or clinic is different. If the patient has an order to be admited to a hospital, the admiting MD must write any orders he/she wants done in the ER and the patient must be evaluated by the admiting MD prior to being moved to the floor, not the ER MD. The admiting MD must also have privilages in the ER. Most ER MD's do not have admiting privilages and therefore they can not write orders for an admited patient. ER MD's also can only be consulted for life threatening emergency on inpatients when the facility has written protocols inplace. As always, there are some facilities that have special procedures which contradict these rules.

Any patient who is a direct admit that is inapproriate for the unit they are to be admited to should have several things done. First, the admiting MD should be contacted and the situation explain to him/her. Orders to DC the admission and have the patient sent to the ER for re-evaluation and proper disposition should be obtained. An incident report with all the details should be completed. This will ensure the patient is properly cared for. But keep in mind, the ER is not a place to have IV's placed, labs drawn, xrays done, or admission paperwork completed. ER's are for the treatment and care of patients who have life threatening or life altering processes which require immediate treatment. I realize this is not always( almost never) your typical ER patient, but that is the way ER's are supposed to be.

wsu.rn · Jan 3, 2003

i work on a telemetry unit and my hospital allows direct admits. it has been my experience that da are a setup fir disaster. with no workup in the er. 90% of out da end up in ccu. icu where they should have been in the first place.

deespoohbear · Jan 3, 2003

We get direct admits all the time, especially from 2 certain family doctors....Usually the person is stable, cellulitis, dehydration, pain management. Every once in awhile, one of the boneheads will send someone to us directly that ought to have been brought in on EMS and evaluated in the ER, then admitted. I had a direct admit one evening from a family doc. Supposedly, acute exacerbation of COPD, but stable. The guy was brought of the elevator in a wheelchair, and I almost called a code right then and there. The man looked like crap. Severe resp distress....after I got the man stabilized, I placed a call to the admitting physician....

The other bonehead doctor will call us with a direct admit and then not fax or call orders ahead of time. One time I called the office after the patient had been there for 2 hours to complain about no orders. The office nurse replied "Dr. Bonehead is busy, he will send orders when he can." Well, excuse me. I haven't just been sitting around all day with my fingers shoved up my butt whistling dixie....I am kind of busy too. I told the nurse, "Well Dr. Bonehead thought this person was sick enough to be admitted, then this person should take priority over whoever maybe in the office...." Incident report got made out over that little deal.....What the heck do these docs think we are going to do with these patients with no orders? They might as well stayed home....would be a lot whole cheaper to lay in their own beds and be miserable than in a $600 dollar a night semi-private room.... :rolleyes:

Usually a patient has to be seen either by the ER doc or their attending MD before admission. I did get our family doc to admit my husband last year with dehydration and intractable vomiting without being seen. The ER doc working that particular day is a real jerk and I just didn't feel like dealing with him. So, I paged our family doc, and he called in orders for admission.....any other time I will take my family through the ER if it is outside of normal office hours and I feel like they need seen. Just when one particular doc is working, I will page my personal physician first...

I don't have a real problem with direct admits, as long as they are STABLE and come with appropriate orders...

Tweety, BSN, RN · Jan 3, 2003

Originally posted by Nurse Ratched
The idea of getting a pt in with no orders is completely unfathomable to me. We legally cannot allow a pt in the door without orders either written by a doc or verbally given/telephoned by a doc to a nurse. Isn't that a huge liability issue without it? - there's no one to take accountability for the pt if there is no admitting doctor to give orders and be responsible for calling for followup. I'm amazed (well, not really I suppose) that mgt allows these potential lawsuits to go unchecked.

Usually on the direct admits we get without orders, it's understood we call for orders when the patient arrives. Or there they come with the orders "Admit to Dr. So & So, call upon arrival", what's so hard about giving the orders prior to arrival is you know the patient is coming?