When to Admit

Knowing when to admit can be tricky, let’s improve your admission acumen! In this episode, we discuss 6 specific categories that can be used to help admit patients you are on the fence about. Gaining insight into how admission is determined. Intended for medical providers in all specialties.

no handout

For this episode, we are not covering obvious admission criteria, such as those who need to be admitted to the ICU and we also do not cover those obvious patients who can be managed outpatient. Rather we are focusing on the “grey zone” of patient admissions, those who could go either way. I have whittled this down to 6 different admissible criteria.

You should know that it is the Insurance companies, specifically Medicare and Medicaid who determine admission criteria because they tell hospitals what they will and won’t pay for. It ultimately all comes down to money. Which is why I recommend medical providers pay some attention to what is politically happening with Medicare and Medicaid- since that will trickle down and affect you on a daily basis.  

Alright, so lets talk about the 6 reasons for admission already. Notice that there is a theme in all of these reasons — there is action or intervention for the inpatient team to DO – some therapy, procedure or medication. On top of this, the reason for admission has to be a new-ish problem that the inpatient team could reasonably resolve or improve in a few days.

#1- Requiring Oxygen.

You could deem this hypoxia. So Medicare came up with a magic number of 88%, to which patients at this number or lower qualify for home oxygen, so most use this number as admission criteria for adults because who is to say if 93% is hypoxic or not.

Also worth mentioning if patient is already on home oxygen they can require more oxygen than usual, this would meet this criteria. Other examples that meet this are: 

• COPD/asthma exacerbation
• PNA
• Flail chest (3+ rib broken)
• Pulm edema
• Pneumothorax (small)
• COVID

#2 – Requiring pharmacologic IV therapies.

This is probably the biggest category by far and while most medications come as IV therapies, there has be a very solid reason why oral medications cannot be given. Lets break this section into 3 subcategories.

One subcategory is resuscitation, like requiring IV fluids or IV blood products. Like: 

• AKI severe dehydration 1 point of Cr change
• Dehydrated Chemo pt 
• Dehydrated child with lots vomiting/diarrhea
• Rhabdomyolysis patient 

Another category is IV medications, this would include antibiotics, diuretics, insulin, antihypertensives and more. so a few examples:

• CHF exacerbation requiring diuresis for first time
• HTN emergency
• DKA/HHS pt requiring insulin

• Failed outpatient antibiotics
• Immunocompromised Infection/neutropenic fever (think cancer, AIDS, transplant pts)
• Sepsis

Remember to ensure that a different or new oral antibiotic couldn’t be used. There is a big movement toward antibiotic stewardship and away from strong antibiotics if at all possible. Plus many IV antibiotics has similar efficacy and bioavailablity as oral and IV. Best example I can think of is Clindamycin. Therefore, IV clinda is only ordered if absolutely required.

The last category isn’t exactly IV but those requiring complex/new medication regimens. Like:

• New onset DM
• New onset afib (for anticoag)

#3- Requiring procedural intervention.

Most of these will be obvious, like stroke or STEMI patient. But a few that may not be obvious:

• Arterial ischemia
• Ingest fb
• Certain fractures
• Medical device malfunction
• Surgery complications requiring more surgery
• Deep organ abscess
• GI bleed
• Need for pacemaker
• Childbirth

#4- Acute inability to tolerate ADLs (actions of daily living)

To clarify, this can’t be a slow chronic decline since patients cannot be admitted to nursing homes direct from an emergency department. These things are also required to not be easily fixed by a simple prescription, foley catheter, or other procedure. Instead think of things like

• Inability to tolerate oral (intractable vomiting, severe dehydration)
• Inability to walk (femur fracture, CVA, Guillain Barre)
• Inability to swallow (food bolus, achalasia, tumor growth)
• Inability to urinate (infected stone, cauda equina)
• Altered mental status or extreme change in behavior, like the way old people get confused because of a urinary tract infection to the point where person can’t be discharged home alone safely.

#5- Sudden or severe worsening of organ failure

Think acute problem of a chronic diagnosis. You can also place concern for threat to an organ into this category as well. Notice also that noncompliance doesn’t qualify for admission. Same goes for slowly progressive ascites in cirrhosis patients, yes it hurts, but its expected and can be managed outpatient with scheduled paracentesis most of the time. So good examples would be:

• Jaundice (typically needs intervention)
• Pulm Edema in CHF patient (this one kinda goes in hypoxia)
• Kidney AKI (esp if infection or Cr elevation in only 1- goes in need for fluids)
• New onset or emergent need for dialysis
• Transplanted organ failure or rejection
• Threat or new failure of a single organ (like if only have 1 kidney or they have a large splenic or liver infarct or blood clot)

#6- Observation to prevent acute worsening.

The hardest category because it is more strict. Just “making sure” the patient is okay doesn’t qualify here because there is nothing for inpatient team to DO. Only a few specifics fit in this category:

• Small bowel obstruction (needs NG and could require surgery if perf acutely)
• High risk chest pain (can get trop trending & stress test in the morning)
• Alcohol withdrawal (once get through initial fear for death and seizure, can go home)
• Abuse (social admit, this person needs safety or placement in nursing home or foster home and should not be sent home to abusers)
• Harm to self or others (psych)
• Intractable pain (this one requires at least 3 different medications be given with no result)
• Failure to Thrive (this one is also sticky but usually caregiver can’t get pt to eat or take their meds or the chemo patient is dehydrated and on their last legs- this one is picky but it covers such a wide base from elderly, to kids to mentally or physically delayed, you could also include folks with some psychiatric diagnoses like extreme anorexia here)

And that concludes my admission list. Can you think of something I didn’t include? I hope so! It means you can apply this to your practice.

Notice what is NOT on this list.

Like New diagnosis of most cancers are not an admittable diagnosis, same with most rashes or even fevers. Same with DVTs (you can write an anticoagulant script and be discharged). 

Most patient frustration happens because someone has promised them treatment or admission or because they simply think they ought to be admitted due to pain or lack of diagnoses/answers. Unfortunately, this is not something insurance companies value and will not result in an admission regardless of how upset the patient becomes or what their other doctors would have liked.  

The final simple truth to know about admissions: How you portray your patient in your chart and documentation is the ultimate factor for getting a patient admission paid for.

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