Your senior will go over how to complete an admission from start to finish, and you will get the hang of it a few months in. JCMC and HVMC electronic health records each have an ‘admission order set’ (only for “Chest pain” and “CHF” at the VA). This order set will open a series of orders that assist in completing an admission.
A brief overview of things that MUST be addressed on each admission is as follows:
- DVT prophylaxis: Most patients will require some form of DVT prophylaxis, unless there is a contraindication. For the most part, all hospitals use lovenox 40mg once a day for DVT prophylaxis.
- If the patients kidney function is poor (Creatinine clearance < 30) we can use heparin 5000 subcutaneous TID OR lovenox 30mg qday
Contraindications include: bleeding, thrombocytopenia, allergy to heparin products and many more.
- Urine drug screen (UDS). Using clinical judgement, make sure to at least consider ordering a standard UDS during admission.
- Diet. General rule of thumb is as follows:
– diabetic patient: carb consistent diet (diabetic diet)
– CHF/heart failure/patient with coronary artery disease: heart healthy diet
– dialysis patient: renal diet
– Resume patients previous diet (for example, if patient has been advised to have a mechanically soft diet due to history of dysphagia)
If the patient is nauseated or vomiting, best to initially keep them NPO and slowly advance their diet as tolerated. This can generally be put in as an order and usually proceeds as follows: clear liquids -> full liquids -> mechanically soft -> diabetic/heart healthy/renal etc
If the patient is sick and will likely require a procedure of some sort soon after admission, it is best to keep them NPO.
*If the patient is likely to go for a procedure in the morning, make sure to put them NPO at midnight*
(Protip: If patient is presenting with stroke/seizure/altered mental status/dysphagia/possible aspiration pneumonia, it is best to keep them NPO and order a speech evaluation. Speech therapists evaluate the patient to assess if they are at risk for aspiration. This usually involves a bedside swallow assessment and, if required, a modified barium swallow. Alternatively, if you feel the patient is likely at low risk for aspiration, you can order the nurse to do a quick bedside swallow assessment and if the patient fails can proceed with speech therapy evaluation.)
- Incentive spirometer. Ordering this on admission for patients will prevent developing atelectasis and nosocomial pneumonia, and increase their respiratory function. Most patients will also require education on incentive spirometer use.
- Get physical therapy/occupational therapy (PT/OT) involved early. Usually just by eyeballing a patient it can often be predicted if they will require rehabilitation and placement after discharge (for example if they appear especially frail/weak). Getting PT/OT involved soon in this process will help establish a disposition for patients early in their hospital course and get them physically active.
- Precaution orders: use these orders as needed for specific patients. Seizure precautions (includes adding padding to the bed), aspiration precautions (raising head of the bed etc), suicide precautions etc.
- Review CSMD. This will make you shine. CSMD is a website where you can check how often the patient has been prescribed controlled substances (narcotics, benzos etc). This often helps when admitting a patient who has multiple prescriptions for pain medications, and can often help with judging if the patient is unfortunately a pain seeker. To make an account on CSMD go to the following website at some point before your first rotation begins: www.tncsmd.com. You will need an NPI number and a DEA number to complete registration (this will be provided to you at some point during or before orientation.
- Admission medication reconciliation (med rec): This is essentially reviewing the patient’s home medications and deciding which ones to continue during the admission. This is too extensive of a talk to go over in full detail, and is highly individual for each patient, but a few pearls are as follows:
- Diabetes medications: Special consideration for metformin: If a patient has an AKI or is about to receive contrast for a study, metformin should be stopped. If poorly controlled on their outpatient oral diabetes medications, we control their blood glucose on insulin. (Metformin and often other oral hypoglycemic medications are almost always stopped)
-Inpatient insulin regimen should consist of a basal (long acting), bolus (short acting) and SSI (sliding scale insulin). Starting doses and titration is beyond the scope of this introductory guide.
- high risk medications: patients on anticoagulants, antiarrhythmics, seizure medications etc should be carefully reviewed for contraindications or dose changes, and if none seen should be continued.
- drug overdose/alcohol intoxication patients: be wary when prescribing opioid pain medications to these patients. Ensure CIWA protocol is initiated for patients at high risk for alcohol withdrawal.