Hospital Admission and Discharge

Admission Definition

“Admission of a client means, allowing a client to stay in the hospital for observation, investigations and treatment of the disease he/she is suffering from.”
“Admission is the entry of a patient into a hospital /ward for therapeutic /diagnostic purposes.”

Purpose of Admission

To receive the patient in ward/ unit for admission according to his/her condition
To welcome the patient and provide care to the patient.
To provide comfort and safety to the patient
To provide immediate care.
To be ready for any emergency.
To assist the patient in adjusting to the hospital environment
To obtain information about patient such as address, guardian, any information that serves as a basis of care e.g. Allergy, diabetes.
To establish Nurse-patient relationship

Types of Admission

A. Based on the condition

Emergency
Routine /Elective

B. Based on the Purpose of the Admission

Therapeutic Admission
Diagnostic Admission

C. Based on the Length of the Hospital stay

Short-term Duration
Long term duration

A. Based on the condition

1. Emergency Admission

Clients are admitted in acute conditions requiring immediate treatment.
E.g.: patient with heart attack, poisoning, breathing difficulty, RTA( Road traffic accident) etc
Patient should be admitted in casualty or emergency department to save the life of the patient.

2. Routine / Elective Admission

Clients are admitted for investigations and planned treatment and surgeries.
E.g.: patient with diabetes, hypertension, appendicitis, jaundice etc

B. Based on the Purpose of the Admission

Therapeutic Admission-Therapeutic admission means patient has already diagnosed with medical condition and now require medical care for the improvement.
Diagnostic Admission-Admission called is diagnostic admission when the patient has to undergo some procedure and require investigation like biopsy.

C. Based on the Length of the Hospital stay

Short-term Duration-Admission is called short- term if the patient is admitted for a 24-48 hours in the hospital. eg. Jaundice.
Long term duration-Long-terms admission is required when the patient suffers from a disease condition and needs more than 48 hours to recover from the disease condition. eg. Spinal cord injury.

Client's Emotiom Reaction

Anxiety
Fear
Denial
Emotionally upset
Anger
Sad

Admission Procedure

Steps	Rational	Scientific principal	Nursing Principle
Prepare room, arrange all items in place & adjust height of bed	To feel safe & secure and easy transfer from stretcher to bed	To relieve fear & anxiety and encourage adjustment	Comfort & safety
Check patient’s identification and greet him/her & relatives. Introduce yourself	To help them to feel at ease	To encourage adjustment	Comfort & individuality
Observe client’s vital signs & symptoms for laboratory tests, if required	To know condition of patient on admission, to assist physician in line of treatment	To detect any variations from normal	Therapeutic effectiveness
Provide privacy. Give admission bath, if needed. Change to hospital clothes	To relax & make patient comfortable. To make important observations	To help in relaxation of patient	Comfort & therapeutic effectiveness
Explain use of bathroom & other equipment in the room or ward Place call bell & locker in easy reach of patient Explain meal timing and visiting hours to client & relatives	To help the patient be at ease & knowing how to use equipment to prevent accidents	Help in adjusting to new environment, reduces anxiety, helps in preventing accidents	Comfort & safety
Return patient’s valuable and clothing	To provide client with his/her own valuables		safety
Answer queries of client & relatives	Decrease anxiety & fear	Helps to avoid stress	comfort
Complete necessary records according to agency policy which includes nursing history & assessment	Important part of client’s permanent record	Record of patient's data	Individuality & therapeutic effectiveness

Medico Legal Cases-

A medico-legal case is one where besides the medical treatment; investigations by law enforcing agencies, are essential to fix the responsibility regarding the present state / condition of the patient.

Medico Legal Cases Include -

Accidents like Road Traffic Accidents (RTA), Industrial accidents
Cases of trauma with suspicion of foul play
Electrical injuries
Poisoning
Chemical injuries
Burns
Sexual Offences
Attempted suicide
Domestic violence and child abuse
Cases of asphyxia as a result of hanging, drowning, suffocation etc
Death in the operation theatre
Death due to Snake Bite or Animal Bite
Drug overdose
Drug abuse
Dead brought to the Emergency Dept (Found dead) and deaths occurring within 24 hours of hospitalization without establishment of a diagnosis.

Medicolegal Issue during Admission of the Patient

Medicolegal cases forms a major part of the emergencies brought to the casualty department of the hospital. Reporting of medicolegal cases is an integral aspect for the prevention of medicolegal issues in future. There are various medicolegal issues-

Assault- Assault is defined as the intentional act that cause another person to fear that he/she is about to suffer physical harm.
Injuries- Injuries means any damage to any part of the body caused by violence. Injuries can cause harm to the mind, reputation and property of the person.
Disclosure of the information- This is the one of the major elements in both medical and ethical aspects of informed consent. It seems to be very simple to disclose information about patient's condition, the methods of treatment and alternative for the treatment. However, this does not always happen. There is obligation to present sufficient information so that the patient would be able to make the informed decision.
Medical negligence- Medical negligence means the improper or unskilled treatment of a patient by a medical practitioner. This includes negligence in taking care from a nurse, physician, surgeon, pharmacist or any other medical practitioner. Medical negligence leads to 'medical malpractices' where the victims suffer some sort of injury from the treatment given by a doctor or any other medical practitioner or healthcare professional.

Some examples of medical negligence are as follows-

Administration of medicines in improper manner.
Not giving medical advice properly.
Leaving any foreign object in the body of the patient such as a sponge or bandage, etc. after the surgery.

Role of Nurse in Admission of Medicolegal

Cases Inform immediately to the medical officer. The medical officer will inform to the police regarding the patient.
Nurse has to make sure patient's death within 24 hours of admission must be reported to the police by the medical officer.
All the communication should be in the written form.
Detailed history, physical examination findings, general examination findings, level of consciousness and vital parameters record should be there.
In case any reports, X-ray films or images given to the patient, a written proof should be taken for that.
When it is decided that the case is MLC, record it on the patient's file with red ink on the right-hand side top corner.
Do not give any statement about patient's condition to police,magistrate or media.
Only a doctor is authorized to give information.

ROLE OF NURSE IN ADMISSION OF THE PATIENT

Nurse has the following role in the admission of the patient. It includes-

1. Preparation of Unit or Room

The first role of the nurse is to prepare the unit or to the room which includes-

Keep the bed ready. Linens and blanket should be clean. Prepare admission bed.
Position the bed. For ambulatory patient the position of bed should be normal. For patient on stretcher, bed should be in the lowest position.
Inform the housekeeping staff to make the room and washroom ready for use.

2. Entry of the Patient

When received the patient, enter the patient's information in the admission register as well in the computer system which includes identification data, date of admission, diagnosis and medical record number.

3. Availability of the Equipment

Make sure that all the articles and equipment are available needed by the patient
Assemble all the necessary articles and supplies, e.g., hospital gown, bed bath articles, etc.
Assemble special equipment and supplies like oxygen cylinder, cardiac monitor, etc.
Make sure that equipment are functioning properly.

4. Orientation of the Patient

Orient the patient to the surrounding environment.
Educate the patient regarding use of the call bell in the hospital.
Make every effort to be friendly and courteous with the patient.
Orient patient and relatives to the hospital policies and protocols.
Educate the patient about the fire safety measures and emergency exit plans in the hospital.
Inform the patient about the attending physicians' as well as to the other healthcare team members involves in the care.

5. Meeting Needs of the Patient

Recognize the various needs of the patient and meet them without delay.
Nurse should find out likes and dislikes of the patient and include patient in the plan of care.

6. Care of Patient's Valuables and Clothes

Handover the patient's valuables to the family members at the time of admission.
The aids which are needed by the patient like hearing aids, eye glasses and dentures need to be checked and informed to the family members as well as to the patient.

7. Treatment

Record patient's medicines in inpatient medication record.
Carry out the instructions as prescribed by the physician.

DISCHARGE

Definition

“Discharge of patient from the hospital means, relieving a person from hospital setting, who admitted as an inpatient in that hospital”
“Discharge or dismissal from the hospital means the departure of patient from the hospital”
“Discharge from the hospital is the point at which the patient leaves the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home.”

PURPOSE OF DISCHARGE

To be certain that the patient has the information on his/her condition.
To inform about the follow-up visits or referral to other health agencies.
To teach the Nursing procedure or care he/she needs at home & to take re-demonstration
To provide for a safe, efficient return of all patient’s clothing, valuables & to check that all hospital equipment & clothing in the hospital
To help make the safest arrangements possible for the patient at the time of discharge
Provide continuity of care at home
To assist the patient to manage successfully the change from hospital environment to home environment
To prevent any misunderstanding or difficulties for the patient or hospital in relation to patient’s discharge, medicines, bills.

Types of Discharge

Planned Dischareg
Abscond
Parole
LAMA/DAMA
Transfer/Referral
Death
Discharge on Request

1. Planned Dischareg -Patient’s treatment is over and the attending physician has discharged the patient. (Planned discharge means patient has completed the initial and actual management of disease in the hospital.)

2. Abscond- Patient leaves the hospital without prior information. (If the patient runs away from the unit/hospital)The record of the absconding patient must be kept under lock and key. To avoid this situation. the nurse must ensure that all the patients are present in ward. Special carer should be taken while handling and taking over in each shift.

3. Parole-Parole is used in psychiatric hospitals. The patient can be sent to home for 2-3 or 4 days by the approval of psychiatrist in charge. If patient does not return after the parole, the discharge process should be done according to the hospital protocol and policy.

4. LAMA/DAMA (left against medical advise/ discharge against medical advise)-In LAMA/DAMA, patient chooses to leave the hospital before the treating physician recommends discharge.

In case of LAMA, doctor clearly explained the patient and family members that taking the patient from the hospital may impose risk to the life of the patient, but still patient or patient's family want to take the patient to some other hospital or to the home.
In case of LAMA patient or patient's relative will sign a declaration form saying that the risks and consequences of taking the patient from the hospital were informed to the patient or family.

5. Transfer/Referral- Patient is transferred to another health care facility or within the same hospital from one ward to another.(Sometimes when the patient cannot be treated at the admitted hospital due to lack of facilities or any other reasons, then the patient is referred or transferred to an extended care facility. This is known as referral or transfer)

6. Death- after death of patient, the dead body is handed over to the relatives after completing the discharge procedure.

7. Discharge on Request-In this type of discharge, treatment is not complete, but by taking the patient out of hospital, there is no immediate danger to the life of the patient.

Discharge Planning

The patient, the patient's family members, medical staff, nursing staff, social worker, dietician all work together to coordinate the discharge. The doctor plans the discharge with the patient and leaves a written order on the patient's chart.

The IDEAL discharge planning approach focus on the key points of involving the patient and the family members in discharge process.

IDEAL

I-Include
D-Discuss
E-Educate
A-Assess
L-Listen

1. Include- Include the patient and family members in the process of discharge planning.

Always include the patient and the family members in group meetings about the discharge.
Recognize the family members who will provide care to the patient at home.

2. Discuss- Five main areas to avoid problems at home need to discuss with patient and the family members.

Explain what life at home will be like home environment, support needed, what the patient can or cannot eat, and the activities to do or not to do.
Discuss the medications, purposes of each medication, how much to take, how to take and the side effects of each medication.
Discuss the warning signs. Discuss with patient and the family members, how to identify the warning signs or potential problems. Instruct to write down the name and contact information of someone to call if there is a problem.
Explain test results to the patient and family. If the test results are not available at time of discharge, let the patient and his/her family members must know when it will be available.
Discuss regarding the follow-up visit. Offer to make follow-up appointments for the patient.

3. Educate- Educate the patient and the family members in simple language about the condition of the patient. Education regarding the diet, exercise and medications should be given. Also educate regarding the changes that may be needed at home like side rails for elderly patients or anti skid mat in washroom to prevent the accidents.

4. Assess- Assess how well doctors and nurses has explained the diagnosis, condition, and the steps in the patient's care to the patient and the family members and use teach back method to confirm.

5. Listen- Listen to the patient and his/her families goals, preferences, observations, and concerns.

Procedure of the discharge involves-

Review doctor's order for discharge. It should be in the written form. The treating consultant will confirm the discharge.
Preparation of the cumulative hospital charges for the patient.
The nurse will return the extra medications to the pharmacy.
Final cumulative billing sheet of the patient sent to the cashier.
Preparation and processing of the final bill.
Patient settles the bill and receive payment slip.
Patient or family members goes to the respective wards and collect the discharge summary or physician prescription.
Patient comes to the nurse's unit where physician or staff nurse explains the medication and follow-up date.
In follow-up, advice the patient, for regular follow-up as advised by the physician.
Remove the lines and tubings if patient have.
Cut off the identity bracelet.
Ask the patient to change the hospital dress and wear his/her own dress.
Transfer the patient to hospital lobby in a wheelchair.
Document the return process of the patient in progress notes.
Inform the housekeeping to clean the room.
Check all the documents of the patient and send to the medical record department.
Change the status of the inpatient room.
After inpatient room is cleaned, the nurse will change the room status and the room to be ready for the next patient arrival.
In the situation, when there is delay in the discharge process, due to unavoidable circumstances such as patient waiting for the family members, to pick up or arranging insurance, etc., the patient will be transferred to the transit room that is holding area.

CARE OF UNIT AFTER DISCHARGE

After a client is discharged & before admitting another patient, the room is cleaned & aired.
All articles used by client should be taken to utility room, washed, cleaned, sterilized if necessary or disinfected by chemicals. The articles are re-arranged and kept ready for next client.
Used linen should be sent to laundry.
Mattress, pillows, blankets etc should be exposed to sunlight and then the bed is made with fresh linen.
If the room was used for a client with communicable disease, it should be fumigated.

Role of the nurse in an MLC during discharge-

When a patient has to be discharged, inform the police on duty in the hospital and to the Chief Medical Officer (CMO).
Discharge only after the clearance.
If the MLC patient absconds, inform the nursing supervisor on shift and CMO immediately and the treating doctor.
No MLC patient can leave the hospital with LAMA.
The care given to the patient should be documented timely, accurate and duly sign the nurses' notes.
Records related to the treatment of the patient has to be stored safely and should be handed over to the authorized person as designated by the hospital authority.
In case of death of an MLC, the body is not to be handed over to the relatives. Label the body properly and sent to the mortuary.
CMO and/or police officer should be informed simultaneously.