Harbor:Direct Admission after Hours

  • Direct admissions during daytime business hours should be done OUTSIDE of the ED whenever possible
    • In general, a clinic can only direct admit to their own service (unlikely a patient in optho clinic can be directly admitted to neuro, but if the admitting service is aware of the patient, we can page them directly from triage for admission orders)
    • Clinic calls for stable patients requiring admission should be directed to an ED attending
      • Ask: “Is the patient unstable? What immediate workup does the patient need in the ED that cannot be done once admitted?”
        • Exceptions: emergent/urgent work up and stabilization, need immediate cardiac monitoring
    • If it seems like the patients does not need the ED and should be a direct admission, escalate:
      • ED Attending to Clinic Attending
        • Clinic Attending to Clinic Medical Director and Clinic Nursing Director
          • ED AOD
    • Do not spend time trying to walk them through the process outlined below (it is only for reference). The Clinic Medical Directors should be able to walk their teams through the direct admission process.


  • Business hours process: Any direct admissions before 8pm on Weekdays:
    • If patients are coming from a clinic within the hospital building, they should send the rapid COVID test to the lab and hold stable patients in clinic until a bed is available
      • Patient flow will attempt to place in isolation room in 5E until swab is resulted
    • Admitting physician directly contacts Bed Control (x64010) for Ward Beds or Patient Flow (x65620) for Tele/PCU beds, clinic admissions get priority over ED admissions.
    • Scheduled Admission Office (x64412, x64416) open from 8:00 until 4:30pm to create FIN, stable patients go there while awaiting a bed.
    • Call UR (X65093/4/5) to get InterQual to meet
    • If no bed by 6:30pm, then the admitting physician will be contacted and their service should take the patient to the ED to wait until a bed is obtained.
    • Hold in the WR and place on the tracking board as a pre-arrival
    • Do not register in ED as they (already have orders)
    • If the hospital capacity is limited, it is important that orders are placed as PLANNED, NOT ACTIVE, so they can be activated in any hospital location (this will allow a pre-admission that is boarded in the ED to have orders such as antibiotics completed while waiting for a bed)


  • Afterhours process: If after 8pm on weekdays, or weekends and holidays:
    • If patient presents to the ED and is stable send to ED registration
      • ED registration confirms appropriate paperwork with bed control/patient flow
      • If ED registered inadvertently make a "registration in error"
    • If no paperwork
      • ED registration contacts admitting physician to complete
      • If unable to contact admitting physician, the patient is directed back to the router for ED visit
    • Admitting physician completes "Clinic/Emergency/Urgent Admission Request Form" (can be obtained from ED registration window x2075/2076/2078 or Bed Control)
    • Admitting physician provides to ER Registration -> create a pre-admit FIN
    • Admitting physician provides to Bed Control/informs location of patient to release bed (ER)
    • UR financially clears patient or calls to obtain authorization (if OOP) and informs Bed Control of approval or denial
      • If the patient is denied, UR informs the admitting physician and Bed Control of denial
    • Admitting physician then must decide whether this is urgent and needs to be seen in ED and transferred to in-network hospital or stable for outpatient treatment
    • If patient is DHS (approved), admitting physician inputs the admitting order on the pre-admit FIN
    • ER Physician will document the patient's presence in AWR/ED as a Pre-arrival with name and patient location (AWR or room *) with brief note with admitting service and physician to contact for questions (pager *)
    • Stable patients should be placed in one of the internal waiting rooms and until the upstairs bed is available; reassessment should occur per nursing protocol (q2 hours for ESI 2-3)
    • If a patient is in any way unstable or requires immediate intervention or cardiac monitoring, they should be registered and seen as an ED patient and the admitting team should be notified of the change in patient status as soon as possible


Chappell 7/2017, updated 3/2025


See Also

References

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