Admissions at VA and VUMC

Dena Kofahi

The steps of an admission are similar whether at VUMC or Vandy, with some differences that will be explained in this section. 

Have a dot phrase (word doc at the VA) with a checklist of what an admission requires, such as: 

  • Callback 
  • Consents (blood products/procedures) 
  • Admit Orders 
  • Diet/NPO 
  • Code Status 
  • Can’t miss further testing 
  • Med Rec 
  • Restrictions/ precautions (fluids, fall, seizure) 
  • DVT prophylaxis 
  • PT/OT 
  • Morning Labs 
  • Contingencies/Handoff (for day team)

Receiving an Admission

Vanderbilt

VA
Admission Page ASAP page to upper level (roll the page up or resend days) and text MAC to confirm. Announced in the Flow Coordinator Teams Chat +/- a page to upper level.
Chart Review Review vitals, labs, EKG, imaging, fluids/meds ordered by the ED before reading ED note to form your own impression. Develop a problem list and write your ED course for the HPI as you do this.
Call-Back to ED for sign-out Callback number in page ED extension with VA phone or Callback number in page

Admission Orders

Admission orders can be placed before or after seeing the patient, but basic admission orders should ideally be placed as soon as possible.

Vanderbilt

VA
Admission Order Set General Admission Order Set: how often you want vitals, vital sign parameters, nausea (check QTCb) and constipation PRN, VTE prophylaxis, PT/OT consult. Similar order set that does not include PRNs. If the patient is in the ED you first need to click the delayed orders option. Choose Na-Medical-Inpatient (or observational) based on admit order. For location choose 2N or 3N, clerk will fix it if needed.
DVT Prophylaxis - Use Padua score
- If on anticoagulation at home, ask last dose!
- Consider carefully holding DVT prophylaxis if a patient will have a procedure or if you are concerned about active bleeding.
- If patient already on a DOAC, should they be switched to shorter-acting agents like lovenox/heparin?
Diet - Consider co-morbidities (renal order for ESRD / CKD, CHO diet for diabetes, etc.)
- Low threshold to place patient on NPO if there is any chance for a procedure.
Home Meds On the orders page click the Home Meds option to populate them and choose which meds you want to order, hold, and not order. If you use the “admission tab” then “admission orders” page and click when each last dose was Epic will automatically adjust to when the next appropriate dose (make sure to review timing!) Under meds tab → highlight outpatient meds you want to prescribe, click the 'Action' tab then 'Transfer to Inpatient.' You can NOT hold meds so keep a list of what you’ve held! If you are writing delayed orders you will not be able to choose the time medications start. Write it as a note in the order’s comment for the pharmacist.
Code Status Obtain from patient if they have capacity or next of kin if they don’t. Similar, write a Life-Sustaining Treatment Note or place code status order.

Med Rec

  • Ask the patient about each medication they take and confirm dosage and timing. Ask when their last dose was for each medication. 
  • Ask if they take any other medications that you did not ask about from their list. 
  • Ask about additional supplements or OTC meds they take. 
  • Corroborate with family members or clinic notes/refill history. You can place a pharmacy consult or ask your team’s pharmacist to help 
  • Typical Considerations 
  • Most oral diabetes medications are HELD while the patient is inpatient, and they are placed on sliding scale insulin instead. 
    • If a patient is already on a home insulin regimen, a typical plan is to prescribe HALF of their home regimen and adjust each day based on amount of SSI used 
    • If a patient is going to be NPO, do not hold their basal insulin. You can hold SSI for NPO patients. 
  • If a patient is hypotensive or you have concern for sepsis, consider holding their home blood pressure medications.
  • If a patient is on tacrolimus, you MUST dose it for 6 AM/6PM and order a daily tacrolimus level at 5 AM. At the VA the tacro level is pulled at 6 AM.

Writing Your Note

  • Once everything is done, it’s time to write your note! Ie a one-liner, the history, and the ED course in the HPI section. Fill in your ROS and the P/E. Write Issessment and plan at the end. 
  • Any notes for patients admitted to a cardiology service should be written in the Cardiology context.

Outside Hospital Transfers 

  • Same as above, but make sure to take the packet of records from their previous hospitalization. If you are admitting overnight, pass it on to the day team. If you are day team give them to the MR to ensure upload into the system.
  • There is often someone to call for hand-off for OSH transfers as well. At VA the admitting attending will typically place a transfer of care note in chart

Direct Admissions 

  • Direct admissions are when a clinician directly admits a patient, bypassing the ED. It is important to see the patient when they arrive on the floor. Sometimes patients will be waiting for a room, so you should try to see them wherever they are located.

Admissions in the CCU/ICU 

  • Same process as any other admission, but if a patient is coming from the ED they are not considered your patient until they arrive to the unit.
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