Hospital Admission Explained and Why We Aren't The Adult Humane Society.

The hospital admission is a  process a patient must go through to get admitted into a  hospital.  Patients cannot simply show up at the front desk of the hospital's bed control secretary and tell them they need a bed.  That's what you do when you go to a hotel.  Hospitals are not hospitels.  If they were, every homeless person around would be lining up for their free room and board.  If you are wondering how to get admitted into a hospital, there are only two ways that can happen.
  1. You can get directly admitted into a hospital without going to an emergency room  if you have an accepting physician who has agreed  to be the attending physician of record at the hospital you are trying to get into.   We call this a direct admission.  
  2. You can get admitted into the hospital through the emergency room. 
There are no other ways for a hospital admission to occur.  There are, of course, variations to this theme.  In general, however, these are the only two ways you can get yourself a bed in the hospital.  If you feel like no one is listening to your complaints and you're convinced you need a hospital evaluation, you either have to find a physician willing to admit you or you need to convince the emergency room physician you need admitted to the hospital.   If you just show up at the front desk and ask for a bed, most secretaries have been instructed to refer you  to the nearest Motel 8.  

Let's review option number one.  How do patients  become a direct admission to the hospital?  In the old days of medicine, before hospitalists, a family medicine doctor would arrange it.  Usually, the patient would show up in their clinic with weakness or  pneumonia and the doctor  would tell them to go to the hospital admissions desk.  The doctor would call ahead and describe what type of bed they wanted in the hospital.    The patient would show up at the front desk, insurance information would be obtained and the patient would be wheeled five flights up to be greeted by happy and cheerful nurses waiting for them in their hospital room. 

In today's practice environment, rarely will you find a primary care doctor who admits or follows patients in the hospital.  Hospitalists have assumed that role.  In many communities, having a hospitalist program is mandatory to recruit outpatient primary care doctors.  See this image of an internal medicine job advertisement suggesting just that.

If primary care has left the hospital, how do they get their patients directly admitted into the hospital these days?    They call the hospitalist and have the hospitalist arrange for the admission.  The hospitalist takes care of all the specific bed details in direct communication with the bed control center  while the outpatient doctor moves on to the next patient in their rat race of a clinic.  The great  divide between inpatient and outpatient care continues to solidify with every passing year.

Some hospitalist programs will refuse to arrange for a direct admission from a primary care doctor's office.  As I witnessed on a recent list serve discussion at the Society of Hospital Medicine, some hospitalist programs require all direct admission patients to be evaluated in the emergency room first.  What's the reason for this extra layer of excess expense?  Some doctors do not trust that patients will arrive as advertised.   Their main fear is that unstable  patients will arrive in a condition not suitable for direct admission.

I can understand that fear, but I think it's an over reaction.   Sometimes I get calls to admit patients who are unstable and require a higher level of care than I believed. If that is the case, I deal with it like I deal with patients that are crashing in the hospital.  I have to have a certain amount of trust in the triage capabilities of my primary care referral base to have a good working relationship.

Regardless, my experience is often the opposite.    Patients often arrive  less sick than advertised.  Often, they do not require hospital admission  or they only meet  observation status criteria.  In fact, I have, on several occasions, discharged a  patient while the nurses were doing their admission paper work.  Physicians must have faith in the abilities of outpatient doctors to do the right thing.  Sending everyone to the ED is irrational.

How else can a patient be directly admitted to the hospital?  Besides coming from the outpatient doctor's clinic, the second most common transportation mode for direct hospital admission is from an out of town emergency department.  Hospitalists get calls every day from surrounding community emergency departments asking to transfer a patient to their service.   When you're walking the halls of a hospital and you see the EMS crew surrounding an elderly patient in a gurney,  you can be sure they came as a direct admission from another hospital somewhere.  Let's just hope the EMS folks aren't doing CPR on the patient as they role into the room.  That's about as bad as it gets.

Patients can also be transferred for direct hospital admission from other hospital inpatient wards.  This is a very common occurrence.  Patients often decompensate  and require a higher level of care than can be provided in small town America.  The worst patients to decompensate in small town America are post operative surgical patients who need intensive medical therapy by internists and other subspecialists.  Have you ever met a surgeon who likes to take care of another surgeon's post operative surgical care?  I haven't.  Sometimes patients want to be transferred for admission to larger  hospital systems because they don't trust the small town hospital they landed in.  Whatever the reason, inpatient to inpatient transfer for direct hospital admission represents a growth opportunity for hospitalist programs everywhere.

Before hospitalists were ubiquitous, transferring a patient to another hospital was difficult.  Transferring physicians  had to locate a doctor on call and hope they called back quickly.  Sometimes, and my experience confirms this, it can be very difficult to contact the on call physician.  With hospitalists often available 24 hours a day, many doctors can now call one number and speak immediately with an accepting physician.  It's that easy.

These are the only ways to get a directly admitted to a hospital without going to the emergency room first.  Either you come from the clinic, from the out of town emergency department or from the inpatient ward at another hospital.  On rare occasion I've accepted a patient for direct hospital admission from home at the request of the primary care doctor.

We're left with option number two.  Here's how you get admitted to a hospital  through the emergency room.  You arrive at the emergency room by foot, car, ambulance or airplane. Once there,  someone with triage experience will define your status.  The more urgent you are, the quicker you will get seen.  Once the doctor has done their thing, they may decide you can be sent home, decide you can be transferred back to the nursing home or decide you need to be admitted into the hospital.

If you need to be admitted to the hospital, the emergency department doctor will decide who should admit you.  Should the orthopedic surgeon admit the 25 year old healthy wrist fracture?  Should the cardiologist admit the ST elevation MI?  Should the hospitalist admit the elderly man with a COPD exacerbation?

Most patients with acute medical problems that don't require urgent intervention  will get admitted to the hospitalist service. The hospitalist can decide which subspecialists, if any, are needed to provide cost effective quality care.  Sometimes emergency room doctors don't know what to do with a patient, as in the man brought in by his son for admission to the hospital.  Why you ask?  He was too much to care for after his recent surgical intervention on the holiday weekend with multiple family members coming to stay.  That's right.   The man brought his dad to the ER  demanding admission because he didn't have time to  take care of him on the holiday weekend.   That is not a valid reason to admit someone to the hospital.    My partner refused to admit him and  rightfully so.  Medicare has a 1000 page book of criteria that must be met for services to be paid for.

Patients are admitted to the hospital for medical care that requires constant monitoring and an intensity of service for things like intravenous medications, specialized testing and surgical interventions.  The hospital is not a place to drop of your father on a holiday weekend while you prepare your home for your guests.  With the help of social services, a nice assisted living facility was found to help the man's dad get through his recovery.  Of course, this care is not paid for by the Medicare National Bank.  And what was the son's response?  He said, "I'm not paying for that".

To which my partner responded, "This is a hospital.  This is not the Adult Humane Society.   You cannot just drop off your parent like you can your dog."  Good for you partner for saying no.   Sometimes children just need to take care of their parents.   If you don't want to take care of your loved ones, be prepared to pay for right to have someone else do it for you.   Just don't bring them through the emergency department.   Although, if this son could have convinced his father's outpatient doctor  to call the hospitalist, he might have might have been more successful with a direct hospital admission.  Especially at 2 am where the path of least resistance is admission into the hospital.  These original Happy medical ecards help explain.

"I don't always have SOB but when I do doc admits me with PNA vs COPD vs CHF."

I don't always have SOB but when I do doc admits me with PNA vs COPD vs CHF medical humor meme photo.

"I see your son dropped you off at our Adult Humane Society and left.  Don't you worry though.  I am an expert in caring for advanced cases of Too Old To Go Home."

I see your son dropped you off at our Adult Humane Society and left.  Don't you worry though.  I am an expert in caring for advanced cases of Too Old To Go Home ecard humor photo.

"Oh yippee.  Another direct hospitalist admission for a diagnosis of Not Enough Insurance For Me To Deal With The Problem."

Oh yippee.  Another direct hospitalist admission for a diagnosis of Not Enough Insurance For Me To Deal With The Problem doctor ecard humor photo.

Customer service oriented response options when asked to accept a patient transfer:

What to say when another doctor tries to transfer you a patient

Facebook analysis:

Ever wonder who gets admitted to the hospital? Here is a one day analysis of my hospitalist patient list.

17 Patients

Average height 5 '2''
Median height 5' 4''
Shortest height 4' 7''
Tallest height 6'4''

Average weight 222.2 pounds
Median weight 177 pounds
Lightest weight 123 pounds
Heaviest weight 454 pounds

Average BMI 36.6
Median BMI 31.2
Lowest BMI 21.5
Highest BMI 88.9

Percent of patients with low BMI <20 0% (0/17) Percent of patients with normal BMI 20-25 35.3% (6/17) Percent of patients with overweight BMI 26-30 5.8% (1/17) Percent of patients with obesity BMI 31-40 41.2% (7/17) Percent of patients with morbid obesity BMI >40 17.6% ( 3/17)

Percent of patients diabetic 58.8% (10/17)
Percent of normal BMI patients with diabetes 50% (3/6)
Percent of overweight or obese patients with diabetes 63.6% (7/11)

Of the seven folks without diabetes, 4 (57%) were obese. Why were they admitted?

1) Hyponatremia
2) Facial cellulitis
3) Stroke
4) Stroke

Of the seven folks without diabetes 3 (47%) were of normal BMI. Why were they admitted?

1) Bowel obstruction
2) Drug overdose
3) Orthopedic fracture

Of the ten folks with diabetes , 6 (60%) were obese . Why were they admitted?

1) To initiate dialysis (Obese)
2) Sepsis (Obese)
3) Pneumonia (Obese)
4) Bowel obstruction (Obese)
5) Heart failure (Obese)
6) Renal failure (Obese)

Of the ten folks with diabetes, 4 (40%) were not obese. Why were they admitted?

1) Bowel obstruction
2) Fever of unknown origin
3) Persistent diarrhea and dehydration
4) Heart failure

What percent of patients carried a BMI over 30 OR a diagnosis of diabetes? 14/17 or 82%.

82% folks. I'm sure if I was able to do add in current or prior tobacco abuse, that number would push 90-95% or more.

The hospital is basically a short term residential apartment for those with obesity, diabetes and smoking. If you want to tackle the cost of health care in this country you will have to find a way to drastically reduce the prevalence of both. While just a small sample of my daily population, it is compelling to see how the numbers break out. If you have diabetes or a BMI over 30, you will, at some point represent the 80% of the people who visit our hospitals every year. When the Medicare National Bank is bankrupt and nobody can pay your room rent at the hospital, you will not want to be part of that 80%.

Portions of this post are for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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