Chapter 24 ADMISSION, TRANSFER AND DISCHARGE PROCESS
Admission to a health care facility such as a hospital is a major event for clients and for their significant others, as they are often anxious about the admission, the illness and its implications. It is therefore most important that the nurse is familiar with the admission protocol so they can carry out the necessary activities in a manner which will help to reduce anxiety. This chapter outlines the admission process, transferring and discharge of children, adolescents and adults.
My great-aunt had been developing memory loss over a year. She developed a urinary tract infection and became very confused, and was admitted into hospital for treatment. It was decided that she was too confused to ever go back home to her unit. She was transferred directly from hospital into an aged-care facility, never to return home to her own space and possessions. I remember feeling sad for my great-aunt who had been a single independent woman all her life. I never thought that for some people being admitted into hospital could mean that they may never resume their lifestyle again and how stressful and depressing this can be for the individual and their family.
Admissions are classified as either elective or non-elective. An elective admission is a planned admission, when individuals know in advance that they will be entering a health care facility. In many instances a person’s name will have been placed on a waiting list until a bed becomes available. A non-elective or emergency admission is one in which admission to a health care facility has suddenly become necessary. The person may be acutely ill or severely injured. Admission may be arranged by a medical officer (local general practitioner) or may be via the emergency department of a hospital, without the person having been seen by a medical officer.
Health care facilities adopt admissions and discharge policy whereby people for elective admission report to the admitting department on a specified date at a specified time. Implementing this policy promotes efficient admission procedures and subsequent care of the individual. Before an elective admission the person visits the admitting department to arrange the date and time. At this visit the individual is given a printed information leaflet providing details about the admission. Information on the leaflet includes a list of items the person should bring with them; details about visiting hours; the facilities available (such as the kiosk and telephone service); and any instructions regarding pre-admission investigations or procedures that have been prescribed. Alternatively, this may be conducted over the phone or by mail.
Most people face admission to a health care facility with reluctance, while others may experience relief that something is being done to deal with their illness. Whether a person is to be admitted for a brief or an extended period, any admission is associated with various potential stressors. Previous admissions can affect a person’s reactions and expectations, while an individual being admitted for the first time faces the unknown. Elective admission for a relatively minor condition generally causes less stress than does an emergency admission. The nurse must remember that although many anxieties about, and reactions to, admission are common to most people, each person is an individual.
Stress is a phenomenon in which the individual perceives environmental stimuli as taxing their physiological, psychological or sociological systems. Stressors, which may be classified as either physical or psychological, are factors that require a response or change. Apart from the implications of the reason for admission, admission to hospital is a major stressor for most people. Features of admission that produce stress and pose a threat to self-concept, self-esteem and body image include:
The nurse should therefore attempt to reduce the stressors related to admission to a health care facility. The nurse should approach the client in a warm and empathetic manner and provide information about the admission procedures and subsequent activities. The nurse should implement ways of maintaining the client’s independence, self-esteem and dignity. One of the most important ways in which this can be achieved is to involve the individual in planning and evaluating care.
The process of admission prepares the individual for their stay in the health care facility. Admission procedures that are efficient and demonstrate appropriate concern for the individual will help to ease anxiety. Effective admission procedures are directed towards:
Before the client is admitted to the unit, the nursing team will determine the location of their bed. Depending on need and availability, the client may be admitted into a single or shared room. Before the client arrives the nurse should check to see that the room is in order and that all the necessary items are available. The room should contain a bed, bedside locker, over-bed table, chair and wardrobe. The bed may need to be adapted to meet specific needs; for example, by providing extra pillows, a bed-cradle, a sheepskin blanket, or a fracture board under the mattress.
Although the items placed in the room may vary slightly in different health care facilities, the basic items provided for each individual are two bath towels, two face washers and an information booklet. Extra items, such as oxygen equipment, suction apparatus, side rails for the bed or an intravenous pole are placed in the room if required. The top of the bedclothes may be turned back or they may be folded down to receive a client who arrives on a trolley.
Chapter 23 provides details of the admission assessment. Before arrival in the unit (unless it is an emergency admission) the client reports to the admitting department. Here a member of the clerical staff obtains and records information including the person’s full name; age; sex; marital status; religion; address; the name, address and telephone number of next of kin; and details about any hospital insurance. An identification band (Figure 24.1) is placed on the client’s wrist as a basic safety precaution against mistaken identity and treatment. Some facilities require clients to wear two identification bands, one on the wrist and one on the ankle. The person is advised whether to attend the X-ray or pathology department before admission to the unit. The individual is then escorted to the unit, where a nurse receives them.
The nurse who is responsible for admission to the unit should greet the client, and any accompanying relative or friend, in a warm and friendly manner. The nurse should address the person by name and introduce themselves, then escort the person to the room and begin the process of admission. Depending on the circumstances, a relative or friend may be present and may be offered a seat in a waiting area.
The admission procedure is basically the same in most health care facilities but will vary in detail in different settings, and in sequence, according to circumstances. The client is taken to the room and introduced to any other person in the room. If sharing a room, privacy must be ensured. The client is shown the general layout of the room and where to put personal belongings. It is important that the client is shown how to use the signal device, any fitted television or radio controls, and lights. The client’s identification band should be checked and compared with the card on the bed to see that they are correct. The client is shown the location of the bathroom, toilet, sitting room and telephones. Depending on circumstances, the client may remain in day clothes and be able to walk about the ward, or may be required to change into night clothes and get into bed.
Although the client will have been advised not to bring valuable items, documentation is made of any personal effects. It is not generally necessary to itemise clothing, but a list is compiled of any items of value, such as a wristwatch, jewellery, television set, radio and money. Some health care facilities also require that documentation is made of any prosthesis, such as dentures, a hearing aid or artificial limb. If the client has a large sum of money they are advised to either send it home or to place it in the health care facility’s safe. A ‘valuables’ envelope is provided for the safe-keeping of money or valuable items. It is very important to inform the client that the health care facility does not accept responsibility for valuable items unless they are deposited in the safe. The nurse should refer to the facility’s policy regarding the procedure to be followed when the person’s valuables are to be stored.
Many health care facilities have a booklet that contains information about various aspects of the organisation. The booklet contains details such as visiting times; meal times; how to identify the various personnel; kiosk, telephone, television and laundry facilities available; regulations regarding smoking, and the time the individual is expected to vacate the room on discharge.
As soon as practicable, assessment is made of vital signs and weight, and the information documented. A sample of urine is obtained and urinalysis performed. (Information on vital signs and urinalysis are provided in Chapters 21 and 22.) The client’s height may also be measured and documented.
Throughout the admission procedure, the nurse should discreetly observe the client to gain information that will assist in planning care. Assessment is made, and documented (Figure 24.2), of the client’s:
At the time of admission or as soon as possible afterwards, a nursing history is compiled and a nursing care plan developed. (Information on these and other aspects of the nursing process are provided in Chapters 19 and 20.)
The client should be provided with a flask of fluid and offered a cup of tea or coffee, unless oral fluids are contraindicated. Anybody accompanying the client may also be offered a drink or shown where to find the kiosk. This is of particular importance if it is an emergency admission. The client’s significant others may be very distressed, and may appreciate being shown to an area where they can sit and rest for a while. The health care facility may also provide accommodation for the relatives if the client is very ill.
Before leaving the room the nurse should ensure that the client and significant others have been given all the information they require. The nurse should answer any questions or, if not able to, refer them to the nurse in charge. The nurse should also bear in mind that a person who is stressed tends not to hear or remember all the information given; therefore, ensure that the information is repeated whenever necessary.
When a child has a condition that requires hospitalisation the nurse should understand the effects of admission on the child and parents. Admission to hospital may be planned or unexpected and the nurse should realise that an emergency admission is a time of crisis for the child and family, as there is no time to prepare them for the event. Children must never be threatened with hospitalisation as a form of punishment, nor should they be told they will be going on a holiday rather than telling them they are to be admitted to hospital.