Admissions Guidelines

Foreword

These guidelines have been produced in response to specific commitments in the

National Health Strategy: Quality and Fairness – A Health System for You; they
aim to develop a health service approach to Admissions. The guidelines have been
developed using international best practice which focuses on a “whole systems
approach”.

The specific commitments፡ admission protocols will ensure that emergency

patients will be the only group of patients admitted to the hospital through

the A & E Department” are at the heart of the principle of “people-cent

redness” approach set out in the National Health Strategy.

The guidelines are not intended to be prescriptive rather they should act as

a reference or guide to people working within the system, supporting the

overall commitment to delivering better quality health services.

Executive Summary

Introduction

Admission to an acute hospital may be planned (elective) or may be

required as a matter of urgency (emergency). Elective admissions are those

which occur as a consequence of referral to hospital by a general

practitioner, medical consultant, a visit to the hospital outpatient

department or a planned transfer from another hospital. Some patients

may confound these definitions e.g. patients requiring chemotherapy who

may be both urgent and planned.

“Admission protocols will ensure that emergency patients will be the only

group of patients admitted to the hospital through the A & E Department”.

This document is based on international best practice, focusing on a “whole

systems approach” to effectively address elective and emergency

admissions. Grounded in the principle of “people-centeredness” which,

increasingly, influences the planning and delivery of services, the guidelines

aim to support health care professionals in the development of local

policies and protocols.

The purpose of the guidelines is to direct the provision of an effective and

efficient level of appropriate patient centered care, through the

development of appropriate links between PHCU.

What is required for a system wide approach?

The National Health Strategy and the proposed reforms of health care

organization provide the context for the provision of a system wide

approach in addressing and managing patient’s needs based on the

principles set out below.

The key elements to such an approach include:

 Strategic and timely service planning (e.g. Regular annual review).

 Uniformity of structures and processes (i.e. following national

guidelines where they exist).

 Linked protocols and pathways (e.g. shared between primary and

secondary care and based on international best practice, so that

objective measures of performance are readily available).

Strategic planning for all service areas should provide demonstrable

evidence of coherent assessment, evaluation and planning, taking account

of the health care needs of the population.

Aim
: The aim of managing a patient in the hospital is to ensure their safety in a

supportive and therapeutic environment.

The proposed structural reforms should be developed in the context of the

links required between service areas to ensure smooth and timely

movement of patients from one care setting to the next. This will require

connectivity at national, regional, and local levels; and between all

stakeholders.

It is recognized that regardless of policies and procedures adopted, there

are constraints that apply, including capacity and funding issues, both

current and future. The guidelines seek to recommend best practice within

these constraints. Service evaluation and measurement of outcomes that

are comparable with other similar services nationally and internationally

should form part of routine performance review and ongoing quality

improvement.

Admission to an inpatient facility provides the opportunity for a safe and

secure environment where direct observation, regular monitoring and

continuous therapeutic support are provided.

Parameters of the protocol:

Target population: staff handling patients who are admitted to the

psychiatric in patient facility.

Types of Admission

a. Voluntary :
Comes on his/her own with/without family

Patient signs himself or herself voluntarily

A voluntary patient can make a written request to the Medical Superintendent

requesting his/her discharge from Hospital.

Patient to be discharged within 72 hours of receiving the request unless not

deemed well enough and is admitted involuntarily or under the Medical

Superintendent’s urgency order.

B. Involuntary
Brought by relatives / guardian / primary care giver.

Reception order to be signed by the relative/guardian/caregiver [18 years and

over]

C. Court

Reception order from the Magistrate

Criminal Procedure Code- Warrant of committal will be valid until the next

court date as indicated on the warrant.

At the request of spouse or relative or police officer of the rank of inspector

or above

Objectives:

The key strategic objectives underpinning an effective and coherent

admissions policy for emergency and elective patients are:

  The provision of an integrated personal health and social services

system resulting in seamless patient centered care at all times.

 The utilization of resources to maximize clinical and organizational

effectiveness and outcomes.

 The establishment of fully integrated networks of acute care which

are accessible to each person.

 The provision of levels of local access to acute care whilst at the same

time ensuring high quality clinical care.

 The acquisition of clinical admissions data to assist service planning

and monitoring.

ADMISSION PROCEDURES

1. OUTPATIENT DEPARTMENT/SUPERVISOR’S OFFICE

Triage nurse will alert the doctors of any emergency according to her/his assessment

i. All admissions to be authorized by the doctors

ii. All patients will be admitted according to the admission criteria.

iii. Ensure all the necessary papers are filled and signed by relatives/patients,

admitting nurse and doctor.

iv. Doctors to document where patient is supposed to be nursed

v. Medication card to accompany patient to the ward

vi. High Risk patients [suicide, forensic, escapee] (Refer to decision tree for

management of high risk patients.

1. Risk Assessment for suicide, aggression and absconding to be done (i.e. level of

risk for each to be determined

2. High risk forms to be completed and to accompany patient to the ward, verbal

order is also considered for agitated patients

Vii. Brief summary of the patient’s history to be given to the ward staff

before patient comes

ix. Forensic patients to come with proper documents for admission – i.e. The prison

removal order, magistrate reception order/committal order, or warrant. The

admitting doctor should check the admission order before the patient is taken to the

ward. Other documents such as the charge sheet, summary of facts and contacts for

relatives should also be available at the time of admission, if not, the forensic nurse

should follow up and obtain these documents.

x. Patient to be accompanied to the ward by at least one staff member but may need

more depending on the situation and request of the outpatient staff and/or

admitting doctor.

xi. All patients escorted by police/prison officers need to be handcuffed and to stay

with the patient until seen by the doctor or admitted.

xii. Inpatient checklist to be given to relative.

xiii. Patients belongings – refer to belonging protocol

B. IN THE WARD

i. Patients to be thoroughly checked/searched by two members of the staff as

soon he/she enters the ward, if possible depending on their mental state. If a

search/check cannot be conducted as soon as the patient enters the ward, it

must be done within the first 24 hours of admission while sedated if

 necessary. If not done within this period, reasons for not doing so must be

clearly documented in the patient’s folder.

ii. Aggressive/violent patients to be searched with the presence of police

officers. If police are not present, please follow procedure in 5bi

iii. Patients belonging to be checked, documented and kept in the safe place

[refer to belonging protocol]

iv. Patients to be nursed in the ward according to the doctors and nurses

assessments

v. Explanation of the ward procedures and protocols to be explained to the

patient dependent on the patient’s mental status.

What are the Principles Practice in Hospital Admissions?

A number of principles should under pin the development of an effective emergency and elective
admissions planning function. These include:

 The provision of patient centered services, which are accessible to the population without
compromising safety, quality and clinical standards, to the right people in the right
location and at the right time.
 Patients should be consulted and included in all decisions about their care.
 Clinical practice and care should be based on the most up to date evidence.
 Co-operation and clinical networking between hospitals and between care groups are
essential to optimize outcomes, particularly where complex care issues are involved.
 A service based on good clinical governance (i.e. founded on continuous quality
improvement, staff development, risk management and audit).
 Acute hospital services should be organized into three parallel streams of care
interdependent of each other. This involves a division of acute hospital services into
emergency, elective and out patients department/day care.
 The pivotal role of the Primary Care Teams should be emphasized.
 Early induction training of healthcare professionals in relation to the principles set out
above.
Effective management of hospital beds and associated resources

The effective management of hospital beds and associated resources is vital if the growing
demand placed on hospital resources is to be met.Recognized impediments to patient “flow” in
hospitals include:

 Difficulties in gaining access to inpatient beds (i.e. insufficient bed capacity).

 The resulting congestion within Emergency Departments.
 Inappropriate retention of patients in hospital beds.
 Beds are available for emergency admissions.
 Beds are available for elective patients; this assists in keeping waiting lists down.
 The quality and appropriateness of patient care is high.
 Patients get the care they require when they are discharged from hospital.
 Scarce financial resources are not wasted and value for money is achieved.

Quality and safety

To ensure that all patients admitted to hospital receive the high quality and safe service to which
they are entitled, resources must be efficiently and effectively utilized. Services are organized so
that patients, depending on their needs, can move smoothly between emergency care and the best
and most appropriate inpatient care, primary care and continuing care.

Effective quality assurance and safe care are essential rights of all users of the health services.
Achieving the standards set by the Irish Health Services Accreditation Board will ensure that all
hospitals are providing such care.

Emergency admissions

An emergency hospital admission is defined as one that is not planned and which results from
trauma (injury) or acute illness which cannot be treated on an outpatient basis.
In order to manage the balance between elective and emergency admissions, the factors below
have been identified as effective in improving the management of admissions and general patient
flow in the Emergency Department (ED):

 Where there is a mix of elective and emergency admission in hospitals, occupancy levels
should allow for flexibility in dealing with the natural ebb and flow of illness and injury
in the community. Thus, a level of about 85% hospital bed occupancy is desirable.
 Having a senior medical presence in the emergency department at all times. Only
appropriately assessed patients should be placed in a hospital bed options for outpatient,
day care and primary care (including home care and ambulatory practice) should be
maximized.
 Investment to support adequate provision of primary and community care so as to:
- reduce avoidable attendances at the ED; and
- Support early discharge from hospitals where appropriate.

Elective admissions፡

Achieving the correct balance between the competing demands for hospital beds by elective and
emergency cases of varying complexity is likely to remain a considerable challenge for the
future.

 Local clinical consensus on the ratio of emergency admissions to planned elective

procedures.
 Measures to review and monitor criteria for hospital admission and for lengths of stay.
 Greater emphasis on ensuring that in admitting elective patients, consideration is given to
the length of time they have been waiting since the decision to admit was taken - taking
account of their clinical needs.
 Greater standardization of waiting list administration with consistent monitoring of
cancellations, suspensions and removal from lists without treatment.
 Emphasis on planning discharge from day of admission.
 The adoption of a whole systems approach to bed management.
  The appointment of a manager or clinician with sufficient authority and support to
balance and monitor the competing demands of emergency and elective pressures
ensuring all bed and theatre resources are fully utilized.

The process of hospital admission

A range of service processes have been identified as effective in managing the flow of patients
through acute hospital services which will be outlined later. In addition, regular communication,
good relations and ad hoc liaison, between all those involved are essential to effective bed
management.

Opportunities to provide an integrated service delivery system arise at two important service
points, before hospital admission and after hospital admission.

Before the patient is admitted to hospital

 There should be a clearly defined pre-admission process, which applies to both emergency
and elective admissions.
 The decision to access a hospital service should be shared between the patient and a member
of the primary care team (PCT) where possible.
 Pre-admission services are integrated into secondary care service delivery.
 Pre-admission assessment is conducted on an outpatient basis wherever possible; some
aspects of pre-admission assessment may be undertaken by the Primary Care Team if
appropriate.
 Pre-admission assessment aims to optimize a patient’s health status before planned
admission to hospital.
 At the pre-admission visit, the patient and his/her cares are properly informed about their
medical condition, proposed treatment and likely hospital procedures.
 The patient’s General Practitioner and/or the Primary Care Team with which the patient is
enrolled should be involved in the pre-admission process, as appropriate.
 The planning for the patient’s discharge from hospital should begin at the preadmission visit
and co-ordination of the patient’s care for both admission and discharge is commenced at the
pre-admission visit.
 Patient information is co-ordinated and made available to all relevant providers in an
efficient and timely manner.
 Pre-admission planning to facilitate ‘day of surgery admission’ where appropriate.
 Pre-admission services may require a dedicated individual e.g. Admissions Manager.
 Referral pathways for primary care should enhance service delivery and complement the
streaming of patients into appropriate diagnostic and therapeutic services within the acute
setting.
 Integrated service delivery using a range of tools to support the process, for example:
o shared care protocols for chronic disease and other healthcare management;
o integrated care pathways with or without care/case management; and
o Key worker concept for co-coordinating patient care.
 After the patient has been admitted to hospital
The Acute Hospital Service should co-operate with other service providers in primary, community and
continuing care. To achieve this, the following factors have been identified as important in the effective
integration of patient care:

 A description of the range and detail of the services provided in each care setting should
be available to all users and providers.
 The route of access to each service is made explicit in appropriate formats to providers
and users.
 A range of tools to support effective service delivery, including:
- Referral guidelines and protocols for consultant care and diagnostic services.
- Discharge plans agreed between the hospital and a key worker in primary care.
- Discharge planning that commences on day of admission.
- Efficient communication from acute care service providers e.g. discharge letter
accompany patient or/and e-mailed to GPs and key worker on or before the day of
discharge.
- Integrated care pathways facilitated by key workers.
- Individual care plans appropriate to the needs of the patient and their careers are
developed by the multidisciplinary team and in collaboration with them e.g. chronic
disease management.
- Shared care arrangements between patient/GP/consultant for specific health
conditions.
- The development of care/case management in the health services should be further
developed.
 Effective communication systems to be developed between service providers to support efficient
continuity of care. This to be supported by an appropriate Information Technology interface.
 The provision of medical prescriptions, aids and appliances along with transport issues to be
identified and addressed to meet the needs of patients/clients, families and communities.

Formalized arrangements for liaison between hospitals and GP and /or primary careers is initiated,
supported and enhanced, on issues of policy development as well as individual care plans.

What are the important factors in admitting patients from

1. Emergency Department (ED)?

2. Elective admissions
1. Emergency Department (ED)?

 Extended access to rapid assessment clinics and outpatient radiology and pathology
services.
 Rapid assessment and extended access to diagnostics (unnecessary delays in admitting
and/or discharging patients from hospital may arise from avoidable delays in patient
assessment by specialists, duplication of tests or the absence of high or low dependency
beds).
 Early Senior Medical decision making available at the point of admission.
 Close multidisciplinary team work.
 National agreed standardized triage processes to ensure clinical prioritization of patients
on their arrival in the Emergency Department and to ensure timely and appropriate care is
delivered.
 Patients should be streamed into the following categories:
- resuscitation;
- Minor illness and injury stream (patients who are unlikely to be admitted);
- Pediatric cases;
- Specialized medical/surgical team assessment for patients who may
require admission; and
- Psychiatric case assessment service.
 Care pathways to minimize delays in the Emergency Department if admission is definite.
These pathways should be developed in consultation with the relevant professionals and
stakeholders.
 Rapid access facilities such as Medical Assessment Units (MAU) requiring robust,
specific and auditable operational policies.
 Protocols for transfer of patients within and between regional areas and tertiary units to
continue to be developed and implemented with pre-hospital emergency care, trauma
teams and other relevant parties.
 Nurse led services i.e. Advanced Nurse Practitioners
 Short Stay observation wards or Clinical Decision Units (CDUs) are advocated in
emergency patient care. Such units should be directly adjacent to the Emergency
 Department and should be supervised by Consultants in Emergency Medicine. The length
of stay should not be greater than 24 hours.
 Chest Pain Clinics, geriatric, respiratory clinics and in-house specialist services should be
used to fast track patient management where possible.
 Information Systems should be used to provide comprehensive comparable and reliable
data on activity waiting times.
 Decision support systems enhance consistency of decision making such as nurse led
telephone triage can be used to enhance consistency of medical and nursing decision
making. (direct telephone advice service).
 There should be regular and influential audit of clinical activity.
 The critical role of Health Care Staff should be acknowledged with appropriate support
for professional development and influence in decision making at all levels.

2. Elective admissions
What are the key principles in planning elective hospital admissions?
A patient’s episode of care should be planned before his/her admission and should take
account of the entire “journey” up to and after discharge from hospital. Patients and their
careers should be partners in this planning. Bed management should be overseen by a
Hospital Bed Manager (HBM) who has the authority to implement the bed management
policy and to co-ordinate the bed management team. The bed management service should
operate on a permanent basis, i.e. for 24 hours on every day of the year. The bed manager
reports to a senior member of management. Part of their role would include continuous
analysis and the provision of reports and forecasts.
The function of allocating beds to patients should be centralized and the Hospital Bed
Manager should have authority over the access to all hospital beds. There should be an
awareness of the bed designation ration as set out by the Department of Health and
Children. The Hospital Bed Manager should work within the notional allocation of beds
to each specialty to ensure that patients are accommodated in the most appropriate bed
available at the time of their admission, and to ensure that patients are cared for by staff
with the appropriate expertise.
 What are the key processes for effective elective admissions?
The following key requirements have been identified to facilitate effective elective
admission practices:
 Centralized waiting list management and agreement on the parameters for scheduling
theatre lists with clinicians.
 Pre-admission assessment should be a standard requirement for all elective admissions to
ensure appropriate planning of the entire patient journey.
 The anticipated length of stay (this should be indicated as early as possible to facilitate
scheduling) for elective admissions should be indicated as early as possible to facilitate
scheduling.
 Increased day surgery can also be supported by before admission assessment to ensure
appropriate scheduling and to minimize transfer to inpatient beds.
 Discharge lounges may be used to facilitate early discharge as well as accommodation for
“day of surgery” arrivals and timely commencement of theatre lists.

Admission Criteria

 You must Have physician Impairment or medial Complication that limits

your mobility, self-Care communication of Perceptional motor Function.
 You must be able to make Functional Progress with in reasonable amount
of time.
 Your functional of impairment must be of recent on set or
progression/exacerbation
 You must be medically stable and require 24 hour rehabilitation nursing
care