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.

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.

ICU Downgrades can only occur between 07:00 AM and 10:00 PM.

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.

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.

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 or write notes for this admission.

If this occurs, you can either:

Call Admissions (7am-4pm, x54180) or AOD (4am-7am, x58236) and ask them to make a "Virtual Bed." Once this is done, you can place orders and write notes related to this patient in CPRS.

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.

*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.

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.

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.

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.

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."

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."

OPT means Outpatient
INP means Inpatient Mediation

Click to see the Bounce Back Policy

Click to see the PCU Policy

Intern Responsibilities

Resident Responsibilities

Wards Policies

How to Get Things Done