Admission, Transfer, and Discharge
Objectives
Identify guidelines for admission, transfer, and discharge of a patient.
Discuss the concepts of the Health Insurance Portability and Accountability Act (HIPAA).
Describe common patient reactions to hospitalization.
Identify nursing interventions for common patient reactions to hospitalization.
Discuss the nursing process and how it pertains to admitting, discharging, and transferring the patient.
Discuss the nurse's responsibilities in performing an admission.
Describe how the nurse prepares a patient for transfer to another unit or facility.
Discuss discharge planning.
Explain how the nurse prepares a patient for discharge.
Identify the nurse's role when a patient chooses to leave the hospital against medical advice.
Key Terms
admission (p. 262)
against medical advice (AMA) (p. 277)
continuity of care (p. 271)
discharge (p. 272)
discharge planning (p. 272)
disorientation (p. 262)
empathy (p. 263)
health care facility (p. 262)
home health agency (p. 275)
separation anxiety (p. 262)
third-party payers (p. 271)
transfer (p. 271)
Common Patient Reactions to Admission to a Health Care Facility
Admission, defined as the entry of a patient into a health care facility, such as a hospital, is often an anxious time for patients and their families. Patients are typically concerned about health problems or potential health problems and the potential outcome of treatment. They may also be experiencing pain or discomfort.
The initial contact with nurses and health care workers is crucial, offering an opportunity to alleviate anxiety and fears and to foster a positive attitude toward the care to be received.
Conveying concern for the patient while implementing efficient admission routines can significantly ease the patient's anxiety and promote cooperation and positive response to treatment. Admission routines perceived as careless or excessively impersonal can heighten anxiety, reduce cooperation, impair response to treatment, and potentially aggravate symptoms.
The nurse's role is to assist the patient in maintaining dignity and a sense of control and in becoming comfortable in the new environment of the health care facility, which differs significantly from the patient's home and may have new sights, sounds, and smells that can interfere with their comfort.
Each person's reaction to admission is unique. Common reactions include:
Fear of the unknown, which causes insecurity.
Loss of identity, which reflects a need for esteem, love, and belonging.
Disorientation, which is mental confusion characterized by inadequate or incorrect perception of place, time, and identity.
Separation anxiety, which is fears and apprehension caused by separation from familiar surroundings and significant people.
Loneliness.
These reactions are related to some of the needs described by Maslow.
Fear of the unknown is often the most common reaction and relates to Maslow's need for safety. Providing explanations about facility policies, information about medical orders and procedures, and simple, direct answers to common questions can help the person feel more comfortable and in control. Examples of patient questions include:
"How do I work the bed?"
"How do I call the nurse?"
"How or when do I get some food?"
"When can my family visit?"
"What are they going to do to me next?"
Orienting the patient to the new environment and answering these simple questions can alleviate much of the fear and anxiety felt by the patient on admission.
Loss of Identity
Many patients experience a loss of identity during the admission process, reflecting a need for esteem, love, and belonging, as described by Maslow. The act of placing an identification (ID) band on the patient's wrist can sometimes make them feel reduced to a number and name rather than a person. Explaining that the ID is a necessary procedure for positive identification and patient safety is important.
Learn new patient names quickly and address them with Mr., Mrs., Ms., or Miss followed by their last name. Use first names only at the patient's request. Avoid using terms such as "honey," "dear," "Gramps," and "Grandma."
Lifespan Considerations for Older Adults
Older adults admitted to health care facilities today are likely to be seriously ill.
Medical conditions that necessitate admission often result in some level of disorientation in normally alert and oriented older adults.
Older adults, who often have vision or hearing limitations, are more likely to become agitated or fearful on admission and may experience relocation stress.
Transfers, even within the facility, can be confusing and upsetting.
Hospitalized older adults are frequently concerned about being unable to return home and needing institutional placement.
Appropriate referrals for home nursing, therapy, homemaking, home nutrition programs, or other services are essential.
Health care professionals should converse slowly and clearly with older patients, allowing them time to process information and answer questions.
Changes in environment and daily routine can cause disorientation, loss of appetite, or reversal of sleeping-waking patterns.
The stress of being in a health care facility can be serious due to a reduction in adaptive capacity, leading to feelings of helplessness, lack of control, and dependency.
When an older adult patient is transferred to a new facility, ensure support people are accessible, the patient is oriented to new surroundings, they can bring memorabilia, and they have an opportunity to make decisions about their care.
Separation Anxiety and Loneliness
Separation anxiety and loneliness reflect Maslow's needs for belongingness and love. Separation anxiety is common in young children, but adults and older adults often experience it as well. In children, it is generally expressed by crying; in adults, behaviors may include withdrawal or excessive talkativeness; and in older adults, it may manifest as disorientation or depression.
The company of friends and loved ones is the best remedy for separation anxiety. Liberal visiting hours are encouraged. Many facilities allow small children to visit relatives, considering facility policy and the patient's condition. Parents are encouraged to stay with their hospitalized child to prevent anxiety. Some facilities allow pet visits, and many long-term facilities have pet therapy programs or resident pets.
The licensed practical/vocational nurse (LPN/LVN) can help reduce the severity of these reactions with a warm, caring attitude and with courtesy and empathy, which is the ability to recognize and share the emotions and state of mind of another and to understand the meaning and significance of their behavior. To help patients adapt, treat them with respect, maintain their dignity, involve them in the plan of care, and adjust facility routines to meet their desires whenever possible.
Cultural Considerations for the Hospitalized Patient or Long-Term Care Resident
If a patient does not speak English and is not accompanied by a bilingual family member, contact the appropriate resource (usually social services) to secure an interpreter. Culture plays a vital role in the patient's ability to cope with stress and illness. Assist the patient with maintaining cultural practices as much as possible.
*It should be noted that any reference to cultural practices among a specific culture are commonalities. Individuals within a culture may or may not possess the same practices, beliefs, or values.
Consider the decision-making process of the family. Some patients may need extra time for decisions regarding care and procedures if the family unit is important in this process. Other patients may refer to whomever is the authority figure for decision making.
Some cultures often intertwine religion and culture; therefore, in the interests of cultural sensitivity, include the assessment of the patient's religious beliefs on admission to the health care system.
Some cultures often value personal relationships over rules and procedures. Be sure to consider the importance of the patient's loved ones when planning care.
Some cultures believe that leaves have a special significance in healing. The nurse may sometimes find leaves in the clothes and on various parts of the body. Leaves are thought to have mystical power related to regaining or keeping health.
Some cultures are more likely to feel they are receiving effective treatment when a nurse is seen. In these cultures, a nurse is given more authority and status than a physician, and the patient may be more cooperative with directions given by a nurse. When nursing measures are implemented (e.g., taking the patient's blood pressure), tell the patient what you are doing and that it is for the patient's benefit. Nursing actions are seen as caring and helpful.
Some cultures associate wheelchairs with sickness. Therefore the patient who is allowed to walk out of the hospital at discharge is more likely to feel that care has been effective.
A belief with some cultures is that contact with blood, skin disease, and corpses causes illness. These cultures may also believe improper care of the body, including poor diet and lack of sleep, causes illness.
Some religions observe sundown Friday to sundown Saturday as the Sabbath, which is a time of rest. These patients may avoid the use of any electronic equipment during that time, so the nurse should find alternatives to the use of this equipment if possible.
Admitting a Patient
The admission procedure generally begins in the admitting department, where a representative obtains vital information from the patient, such as:
Demographic information
Insurance information
Identifying information (social security number)
Emergency contacts
Privacy and confidentiality must be maintained, and an interpreter should be used if the patient does not speak English. This information collection may become the nurse's responsibility depending on the facility and the time of admission.
Once collected, an ID band containing the patient's full name and date of birth is placed on the patient's wrist. Some facilities include a facility number on the ID band. Patient allergies are typically identified on a separate red wrist band. This information should be checked and verified before procedures and medication administration by looking at the ID band and asking the patient to state their information (if capable). Identification of an unconscious patient is delayed until a family member or legal guardian is present.
Consent Forms and Patient Rights
On admission, the patient signs a consent form for general treatment. The Joint Commission (TJC) and Medicare and Medicaid Services require hospitals and other health care facilities to present a Patient's Bill of Rights to the patient or their legal guardian. Facilities may also present other written forms containing policies and procedures that further inform patients of their rights and the nurse's responsibilities in ensuring these rights are honored.
The Patient Self-Determination Act of 1991 and the Health Insurance Portability and Accountability Act (HIPAA) are also presented on admission. Facilities that accept Medicare and Medicaid reimbursement must present information on the Patient Self-Determination Act, addressing the patient's right to refuse or accept medical treatment and information regarding advance directives. The facility must refer patients requesting information about advance directives to appropriate resources. All patients must be given and sign a document verifying receipt of information regarding HIPAA.
Telephone Admitting
Some hospitals or surgery centers use telephone admitting. The day before a planned admission, a representative calls the patient at home to gather information, give instructions regarding arrival time and items to bring/leave at home (e.g., jewelry, large sums of money). Upon arrival, the records and ID band must be verified with the patient for accuracy.
People brought to the emergency department are sometimes admitted directly to a patient care room, special care unit (SCU), intensive care unit (ICU), coronary care unit (CCU), or burn unit. In these situations, a family member provides the admitting office with the necessary information.
Room Preparation
When unit staff are notified of a new patient's arrival, they prepare the room. A neat, clean room with appropriate temperature, lighting, and personal care items makes the patient feel expected and welcome, facilitating a therapeutic nurse-patient relationship.
If special equipment is needed, such as oxygen, have it in place and ready. A patient arriving on a stretcher needs the bed in the high position, while the low bed position is best for a patient arriving by wheelchair or walking.
Greeting the patient by name and making them feel welcome is crucial. Introduce yourself with your first name and title. A warmly welcomed person is more at ease.
Remember that patient admissions can occur at any time. Regardless of the time or unit activity, the staff must be courteous, interested, and receptive. The new patient needs an orientation to the unit and the room.
The facility's routine must be explained, including meal times, visiting hours, laboratory/diagnostic imaging schedules, health care provider rounds, and the policy on side rails. Many facilities provide booklets for this information, including details about social services, religious services, cafeteria, library, and gift shop. Patient teaching may also occur during admission.
The electronic health record (EHR) can expedite the admission process by transferring information into admission forms. The admission department and admitting nurse must verify this information with the patient to ensure accuracy. This practice benefits both staff and the patient.
Admission Procedure on the Patient Care Unit
The admitting procedure on the patient care unit is more extensive than in the admitting department. Check the ID band and verify the information with the patient. Assess immediate needs such as pain, shortness of breath, or severe anxiety, and report the results. If another patient is in the room, introduce the two patients.
Encourage the patient to give jewelry, money, and medications to family members to take home if the patient feels comfortable. If no family member is present, valuables are placed in the facility safe, following facility policy. Loss of valuables has serious legal implications for the nurse and facility. Documentation of the disposition of valuables must be in the medical record. In an Alzheimer's unit or mental health unit, the facility assumes responsibility for patient belongings, making careful listing and description even more important.
Patient Room Orientation
Orientation should include the following:
Explanation of policies applicable to the patient
How to adjust the bed and the lights
How to call the nurse from the bed and the bathroom
How to operate the telephone and the radio
How to operate the television
How to use the intercom system if one is present
The location of lounge areas
The location of shower and bathroom facilities
The relationship of the room to the nurses' station
Patient Teaching During Admission
Some teaching occurs during the admission process, with the nurse providing information regarding physical assessment findings, planned diagnostic procedures, and facility routines. A formal teaching plan does not begin until assessment is completed and a care plan is developed.
In an emergency situation, instruct family members on the rationale for any procedures and routines to expect in the patient's care.
Teaching begins early in a patient's admission. Introduce instruction when the patient is able to be attentive and learn from the information. This is sometimes difficult in an acute care setting. Keep information specific, and focus on topics such as the nature of the patient's illness, medications needed for treatment, and use of equipment in self-care (e.g., dressing, ambulatory devices).
Explain shift times and shift changes to the patient.
Consider how hospitalization influences an adult patient's occupational status. Will the illness seriously delay work that the patient is assigned to complete? Will there be a considerable delay before the patient can return to work?
Confirm the patient's understanding of transfer and procedures through discussion and questions. Explain the reason for the transfer, the time it is to occur, and what procedures are planned.
Be prepared to repeat information and instructions to the patient and significant others during the transfer of a patient because transfers often elicit feelings of anxiety.
Before the patient leaves the facility, provide for return demonstration of any skills taught.
Patients who have short stays in health care facilities often do not receive teaching until the day of discharge.
Anticipation of some prescriptions is not always possible. The day of discharge is sometimes the only opportunity to teach patient about medications. Some facilities have standardized information material that provides specific information about individual medications.
Obtain the help of social services or discharge planners to ensure the transfer of a patient to a long-term care facility or home care agency is appropriate in meeting the patient's physical and mental needs.
Skill 11.1: Admitting a Patient
Perform hand hygiene. (Reduces spread of microorganisms.)
Prepare the room before the patient arrives: care items in place; bed at proper height and open; light on. (This makes patient feel expected and welcome.)
Courteously greet the patient and family. Introduce yourself. Project interest and concern. Introduce roommate. (The patient and family are more at ease when they know the people around them.)
Check the identification (ID) band, and verify its accuracy. (Ensures identification before tests or surgery is performed or medication is given. In long-term care facilities, the residents may not wear ID bands. A picture of the resident is used for identification purposes.)
Assess immediate needs. (Establishes trust when needs are recognized and met.)
Orient the patient to the unit, the lounge, and the nurses' station. (Promotes safety.)
Orient the patient to the room. Explain the use of equipment, call system, bed, telephone, and television. (Allows the patient some control over the environment and promotes safety.)
Explain facility routines, such as visiting hours and meal times. (Decreases fear of unknown and gives a feeling of security.)
Provide privacy if the patient desires or if abuse is suspected. Family members are sometimes asked to leave the room. (This allows the patient to answer questions openly and honestly without fear of the family member hearing the answers.)
Admission of an infant or small child requires emotional support for child and parents. Parents generally are encouraged to stay with their child to prevent separation anxiety. The most reliable source of admission information is the parent.
Assist the patient to undress if necessary. (Helps maintain dignity and shows respect for the patient. Helping the patient undress prevents fatigue and falls. Provides opportunity to assess range of motion and the skin.)
Follow facility policy for care of valuables, clothing, and medications. (Helps prevent loss of valuables, clothing, or medications, which is disturbing to the patient and family and potentially results in legal problems.)
Obtain the patient's health history and perform the initial nursing assessment. (Provides a basis for individualized care.) When a patient is admitted in critical condition, only the most pertinent information must be collected immediately. The remaining information can be obtained later. Young children are very curious about what is happening to them and the environment around them. Encourage the child to use equipment on dolls to help reduce anxieties. Encourage children to express how they feel. Invasive procedures (e.g., obtaining blood specimens, starting intravenous lines) generally are performed best in a treatment room. (Enables children to perceive their room as a safe area.)
Provide for safety: bed in low position, side rails up (unless admission is to a long-term care facility), and call light within easy reach. (Promotes patient safety.)
Begin care as ordered by the health care provider. (The patient and family develop a positive attitude about the institution when care is started immediately.)
Invite family back into the room if they left earlier. (Decreases family anxiety when they observe the patient is settled.)
Perform hand hygiene. (Reduces spread of microorganisms.)
Record the information on the patient's health care record according to agency policy. (Provides information that also can be used by other health professionals. It is the beginning of the permanent record.)
Allow patient and family time alone together, if desired. (Admission procedure is often stressful and fatiguing. Allows time for decision making.)
Perform patient teaching (see the Patient Teaching box).