Routine Hospitalist Admit Orders

May 18, 2011 in Misc by RangelMD

Just as many outpatient medical practices have become little more than “patient mills” where Medicare patients with multiple complex medical problems are hustled in and out every 15-20  minutes (total actual face to face time with the doctor often being as little as 10 minutes),  so too has inpatient medical practice started to resemble an assembly line.  Ideally, a hospitalist is supposed to act as the patient’s primary care provider while they are hospitalized which means not only coordinating care among one or more specialist consults but also managing the care of the patient as a whole.

In reality, many hospitalist services are overwhelmed with patients  who would never be considered for a hospital admission 90% of the time in the rest of the world (a 90 year old with 15 mins of mild chest pain? really? Seriously?). Having to manage dozens of complex patients with multiple medical problems is itself not a manageable situation so certain . . um . . shortcuts are needed.

Behold! The standardized, modern, hospitalist admission order set (with helpful comments added);

____________________________________

BY AND LARGE GENERAL HOSPITAL (B&LGH)

Date:

Admit to Medicine Dr. ______________ (The actual name does not matter as there is only a 40% chance that the patient  will be seen by this doctor and not 3 or 4 different covering docs while in the hospital).

Diagnosis ________________________(Not important since this often comes from the ER doc and should be considered for novelty purposes only).

Condition ________________________(Only important if this case gets presented as part of a TV medical show).

Diet ____________________________(Other then pain meds, the only order most patients care about).

Activity__________________________(Usually much more than the patient will ever regularly get at home).

Home Medications to continue _____________________   (Only a few patients have a complete and accurate list. Besides, the nursing staff will make these determinations for you).

Protonix 40 mg IV q 24 hours (regardless of admission diagnosis)

Demerol 25 to 50 mg IV every 6 hours as needed for pain  (Morphine is far superior for pain control  but patients keep asking for it and the name sounds so “cool”).

Laxatives: None until day 4+ in the hospital without a BM (hospitalists are too important to order laxatives from the get-go).

Antibiotic: __ Zosyn 3.375 gms IV q 6 hours. __ Levoquin 500 mg IV q 24 hours. ___ Rocephin 1 gm IV q 24 hours (pick one regardless of admission diagnosis).

  • Is the patient on antibiotics? Consult an infectious disease specialist.
  • Is serum  creatinine more than 1.4? Consult nephrology (points awarded if the patient never needs any treatment other than IV fluids).
  • Is the patient nauseated? Consult gastoenterology (extra points are awarded if the patient undergoes an endoscopic exam that could have otherwise been done as an outpatient).
  • Is the patient depressed about being sick and in the hospital? Consult psychiatry (extra points if patient to be given supportive psycotherapy while in the hospital).
  • Is the patient confused about being in the hospital? Consult neurology (extra points if patient gets a complete stroke work up + an EEG).
  • Does the patient have a history of cancer that went into remission 15 years ago and was admitted for an acute MI? Consult oncology.
  • Does the patient have anemia after loosing several pints of blood from a bleeding ulcer? Consult hematology.
  • Is the patient morbidly obese? Consult pulmonology because they MIGHT have obstructive sleep apnea.

If  you have consulted less than 3 specialists then return to above orders and reconsider or randomly pick an organ system to undergo intense scrutiny.

Is the D-dimer level more than 0.4? Order CAT scan angiogram of the chest.

Discharge the patient when seen and cleared by all specialists (i.e do not call me as I will have left the hospital hours ago).

Please share.