Initial Evaluation and Admission Orders for the General Medicine Patient

Patients are admitted to the hospital when (1) they present the physician with a complex diagnostic challenge that cannot be safely or efficiently performed in the outpatient setting; or (2) they are acutely ill and require inpatient diagnostic tests, interventions, and treatments.The decision to admit a patient includes identifying the optimal clinical service (i.e., medicine, urology, neurology), the level of care (observation, general floor, telemetry, ICU), and necessary consultants. Admission should always be accompanied by clear communication with the patient, family, and other caregivers, both to procure relevant information and to outline the anticipated events in the hospital.

The scope of illnesses cared for by internists is enormous.During a single day on a typical general medical service, it is not unusual for physicians, especially residents in training, to admit ten patients with ten different diagnoses affecting ten different organ systems.Given this diversity of disease, it is important to be systematic and consistent in the approach to any new admission.

Physicians are often concerned about making errors of commission.Examples would include prescribing an improper antibiotic for a patient with pneumonia or miscalculating the dose of heparin for a patient with new deep venous thrombosis.However, errors of omission are also common and can result in patients being denied life-saving interventions.Simple examples include: not checking a lipid panel for a patient with coronary heart disease, not prescribing an angiotensin-converting enzyme (ACE) inhibitor to a diabetic with documented albuminuria, or forgetting to give a patient with an osteoporotic hip fracture calcium, vitamin D, and an oral bisphosphonate.

Inpatient medicine typically focuses on the diagnosis and treatment of acute medical problems.However, most patients have multiple medical problems, and it is equally important to prevent nosocomial complications.Prevention of common hospital complications, such as deep venous thromboses (DVT), peptic ulcers, line infections, and pressure ulcers, are important aspects of the care of all general medicine patients.

A consistent approach to the admission process helps to ensure comprehensive and clear orders that can be written and implemented in a timely manner. Several mnemonics serve as useful reminders when writing admission orders. A suggested checklist for admission orders is shown below and it includes several interventions targeted to prevent common nosocomial complications. Computerized order entry systems are also useful when designed to prompt structured sets of admission orders.

Checklist mnemonic: ADMIT VITALS AND PHYSICAL EXAM

• Admit to: service (Medicine, Oncology, ICU); provide status (acute or observation).

• Diagnosis: state the working diagnosis prompting this particular hospitalization. • MD: name the attending, resident, intern, student, primary care MD, and consultants.

• Isolation requirements: state respiratory or contact isolation and reason for order. Telemetry: state indications for telemetry and specify monitor parameters.

• Vital signs (VS): frequency of VS; also specify need for pulse oximetry and orthostatic VS.

• IV access and IV fluid or TPN orders (see Chap.3). • Therapists: respiratory, speech, physical, and/or occupational therapy needs. • Allergies: also specify type of adverse reaction.

• Labs: blood count, chemistries, coagulation tests, type & screen, UA, special tests.

• Studies: CT scans (also order contrast), ultrasounds, angiograms, endoscopies, etc.

• Activity: weight bear/ambulating instructions, fall/seizure precautions and restraints.

• Nursing Orders: call intern if (x/y/z), also order I/Os, daily weights, and blood glucose.

• Diet: include NPO orders and tube feeding.State whether to resume diet after tests.

• Peptic ulcer prevention: proton-pump inhibitor or misoprostil for high-risk patients.

• Heparin or other modality (warfarin, compression boots, support hose) for DVT prophylaxis.

• Yank all Foley catheters and nonessential central lines to prevent iatrogenic infections.

• Skin care: prevent pressure sores with heel guards, air mattresses, and RN wound care.

• Incentive spirometry: prevent atelectasis and hospital-acquired pneumonia. • Calcium, vitamin D, and bisphosphonates if steroid use, bone fracture, or osteoporosis.

• ACE inhibitor and aspirin: use for nearly all patients with coronary disease or diabetes.

• Lipid panel: assess and treat all cardiac and vascular patients for hyperlipidemia.

• ECG: for nearly every patient _50 years at the time of admission.

• X-rays: chest x-ray, abdominal series; evaluate central lines and endotracheal tubes.

• Advanced directives: Full code or DNR; specify whether to rescind for any procedures.

• Medications: be specific with your medication orders.

It may be helpful to remember the medication mnemonic “Stat DRIP” for different routes of administration (stat, daily, round-the-clock, IV, and prn medications). For the sake of cross-covering colleagues, provide relevant prn orders for acetaminophen, diphenhydramine, calcium carbonate, and sleeping pills. Specify any stat medications since routine medication orders entered as “once daily” may not be dispensed until the following day unless ordered as stat or “first dose now.”