ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: EMERGENCY ROOM

TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

PURPOSE
To provide a mechanism to facilitate admission of patient in Rafha Central Hospital (RCH).
DEFINITION
1. Emergency Admission
This category of patient includes those who have serious medical problems and who may
be at risk of death or serious injury to their health if not admitted immediately.
2. Urgent Admission
This category includes patients with serious medical problem who may be at risk of
substantial injury to their health if not admitted within 24 hours.
3. Routine Admission
Includes patient with no serious medical problem who are not at risk of substantial injury to
their health if not admitted within 24 hours.
4. ICU
Intensive care facility is a hospital facility for provision of intensive nursing and medical
care of critically ill patients,
5. Hemodynamics
The study of forces involved in circulation of blood.
6. Patient Education
The process of informing a patient about a health matter to secure informed consent,
patient cooperation and a high level of patient compliance.
7. Most Responsible Physician (MRP)
a. A consultant or specialist under whose name the patient is admitted
b. Is responsible for the examination and assessment of the patient (bedside in ER/ in
OPD), making a final decision and starting admission process by writing admission
orders for the patient.
c. He is responsible for detailed plan of care
d. If patient needs ICU admission, then he/she will verbally communicate with ICU
physician. When patient is being transferred to ICU, his team members will escort
the patient and endorse him to ICU physician.
8. Admitting Resident/ Specialist
 Responsible for examination and assessment of patient in ER/OPD and completion of
patient admission file.
9. Head Nurse of ER

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

 Will supervise all the arrangement, supply equipment and communicate with the staff
on floor/ICU/OR, if patient is being admitted via ER.
10. Assigned Nurse in ward
 Is responsible for preparation of the bed, bed side area, equipment and patient’s file.
She/he will receive endorsement of the case from the ER staff nurse and following the
Nursing Admission Assessment/Reassessment Policy.
11. Admission Unit Clerk
a. Obtaining patient’s data and ID copy.
b. Informing the patient and/or relatives regarding floor, patient’s rights and
responsibilities.
c. Prepare admission slip.
RESPONSIBILITIES
It is the responsibility of all clinical department heads, nursing department and admission office.
POLICY
1. Patients shall be admitted to RCH as follows:
A. Emergency Admission
B. Routine Admission
C. Referred Admission
D. Admission to ICU/CCU
2. Patients may be admitted to the Hospital as an inpatient ONLY by a qualified member of
the Medical staff who has been granted the privilege to admit patients to the RCH. All
patients are admitted under a name of MRP.
3. All patients requiring admission will be screened by the admitting doctor to decide the
urgency, the bed category (ICU/Ward), and necessary investigation to establish a
provisional diagnosis or valid need for admission based on the scope of services.
4. In emergency, a screening for patients triage will be carried out. (Refer to Patient Triage
policy).
5. Admissions are accepted 24 hours a day, 7 days a week, irrespective of any holidays via
Emergency Department.
6. The hospital may get patients for admission from other hospitals.
7. The history and physical examination are completed by the admitting doctor in ER/OPD
according to the approved hospital format and any special history or examination
requirements will be determined by the department heads according to the needs.
8. If the patient is being admitted to ICU, then MRP makes the decision to admit the patient.
Only those patient who are likely to get benefit from intensive care will be transferred to
ICU (refer to ICU Admission Criteria)

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

PROCEDURE
A. URGENT AND EMERGENCY ADMISSION:
Urgent and emergency admissions are made via emergency room and occasionally through OPD
When the patient arrives to the ER, the ER physician will evaluate the patient and call the
respective specialist or consultant to evaluate the patient who may need admission.
If the physician decides to admit the patient the procedure of routine admission will be followed
and the following procedures will be ensured.
1. Patient’s relatives/attendants will proceed to admission unit instead of patient himself.
2. The assigned ER nurse will escort the patient to the destined ward and endorse the case to
the ward/ICU/OR nurse.
3. The MRP/designee will call the ward to inform charge nurse regarding admission and to
make the necessary preparation for the patient.
4. Then patient must be assessed by the MRP within 4 hours for urgent cases, and within 30
minutes for emergencies (ref to Patient’s Assessment and Reassessment Policy).

ALL ER procedures will be completed and the patient will be transferred to the proper unit.

If the MRP or team advices for any radiological investigation, shall be performed before
transferring the patient to the ward (exception in case of instability of patient’s status).

If the patient’ is hemodynamically unstable, measures for stabilization shall be started

immediately. Patient MUST NOT be transferred till the hemodynamic stability is achieved.

For all unconscious patients, airway shall be secured before transportation.

All information of the patient including procedures, investigations and results will be endorsed to
the nursing staff of receiving unit and transfer documents are signed ( refer to Internal Transfer
Policy)

All the treatment and care shall be rendered to patient in Emergency Department, as advised by
MRP, till the patient is shifted out to the ward.

Patient will be continuously monitored during transportation and his/her bed shall be equipped
properly with emergency drugs and CPR kit.
B. ROUTINE ADMISSION
Routine admissions are made usually through outpatient department (OPD).
For OPD patients, the physician will take the patient’s history, perform physical assessment and
clinical examination, and complete the patient’s provisional diagnosis in file.

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

If the patient needs admission, the physician shall write the admission order in the medical record.

The patient should be educated/ informed by the physician (and by nurse, where appropriate).
He/she involves the patient in making informed decision about treatment offered, by giving them
accurate and honest information about:
1. An explanation about the medical condition and his illness.
2. Proposed care and treatment, including procedures to be carried out, expected length of stay,
where it can be anticipated, expected results.
3. Likelihood of success of treatment.
4. Potential benefits and risks of complications.
5. Their MRP’s name and other Consultants’ names involved in their care.
6. Change or transfer of the patient care from one Consultant to another (if applicable).
If there’s proposed high risk procedure, the physician ask the patient/relative to sign Informed
Consent (refer to Hospital Consent Policy).

The physician will refer the patient to Admission Unit to complete the admission procedure.

Patient and/or relatives proceed to admission unit with admission request form and medical record
accompanied by the OPD messenger/Nurse.

The Admission unit clerk will do the following:

1. Take patient’s data, ID copy

2. Check eligibility of the patient for admission.
3. If eligible, the clerk will issue the admission slip.
4. Ask patient to nominate/ identify his designee and decision maker on his behalf.
5. Inform patient and/or relatives regarding patient’s rights and responsibilities and ask to
sign Patient Rights and Responsibilities form.
6. Ask to sign General Consent form.

Nurse will take the patient with accompanied relatives to the ward.
The on duty nurse will receive the patient along with patient’s file, and accompany the patient to
his/her room, then the nurse will orient the patient and/or relative regarding the room number,
telephone number, and any necessary information should be known by the patient and/or relatives.
The assigned nurse shall inform the concerned team physician to write admission note, and order
the diet to kitchen after performing primary nutritional assessment (refer to Nursing Admission
Assessment/ Reassessment policy).

The admitting physician (ROD/Specialist) shall write the detailed admission notes in Physician

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

Progress Notes and the instructions on Physician Order Sheet that include the provisional
diagnosis, type of diet, required investigations, treatment, and the plan of care.

C. REFERRAL ADMISSION
Hospital shall accept patients from other hospitals/facilities:

Within the Kingdom of Saudi Arabia:

1. Fax will be received from the concerned facility/hospital and hospital reply will be
forwarded the same way (refer to Patient Acceptance from Other Hospital Policy).
2. Within the city or from the areas in vicinity, patient shall be transported through the
transferring hospital ambulance.
3. From remote areas of the kingdom, patient can be transported through the MEDEVAC (air
ambulance)
4. The patient will be admitted to the ward directly where formalities will be completed.
.
HANDLING OF PATIENTS WHEN BED IS NOT AVAILABLE
When there is no available bed in the proper unit and if the patient needs admission we
have to follow the following steps:
1. The MRP will try to find bed in another unit in the hospital
2. If there is no available bed, in all units of the hospital, all MRPs of the admitted patient
shall make ward round and discharge stable patients to free the bed if possible
3. If still no bed is available, extra bed will be placed in the unit.
4. In case of non-availability of bed, patient can be kept and managed in ER up to 24 hours,
after which patient must be shifted to indoor unit.

D. ADMISSION TO ICU/CCU
1. ICU/CCU provides services that include both intensive monitoring and intensive treatment
for patients with actual or potential vital system failures. During times of high utilization
and scarce beds, patients requiring intensive treatment will have priority over monitoring
(refer to ICU Admission Criteria).
2. All admissions will be arranged by consulting the on-call consultant/ specialist of the
concerned specialty, before transferring the patient.
3. Resuscitation or admission must not be delayed where the presenting condition is
imminently life-threatening (e.g. profound shock or hypoxia).
4. Until the patient enters the ICU/CCU, his/her medical care will remain the responsibility of

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

the ER physician.
5. If admission is delayed or impossible due to bed unavailability the ICU staff will discuss
and if appropriate, assist in the process of alternative specialized care.
EQUIPMENTS
IV Stand
Cardiac Monitor
Defibrillator
Pulse oxymeter
Oxygen cylinder
CROSS-REFERENCE
Admission Policy APP-MED-001-V3
REFERENCES
1. Ministry of Health
2. CBAHI Standards
3. Hospital Wide Policies * Procedures Manual, Max Super specialty Hospital, New Delhi,
India
4. Criteria for Admission: Queensland Hospital Admission policy, DSU QHAPDC Manual;
01/07/2006; pF1-F7
5. Mosby’s Dental Dictionary, 2nd edition. http://medical- dictionary.thefreedictionary.com
FORMS
Admission Form
General consent
Consent for surgical, medical, interventional procedures Form
Patient Rights and Responsibilities Form
Interdisciplinary Patient/Family Education Record Form
History and Physical Examination
Doctor’s Progress Notes
Physician’s Order Sheet
Admission Assessment Sheet
Nutritional Assessment
Nursing Care Notes
Referral Case to Social Worker
Social Worker’s Notes

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 ADMINISTRATIVE POLICY AND PROCEDURE (APP)
DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
ADMISSION APP-ERD-010
EFFECTIVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1435H 09-06-1437H NEW 7
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR MEDICAL AND NURSING STAFF

APPROVAL:
Name Position Signature Date

Prepared by
Dr. Ali Demerdash ER Director 27-04-1435H
Reviewed by Dr. Khalid
Head of Medical
Mahmoud 29-04-1435H
Department
Abdulsattar
Reviewed by Modhi Aqeel
Nursing Director 01-05-1435H
Shammari
Reviewed by Quality
Dr. Emad Aldin
Management 03-05-1435H
Kotb
Director
Approved By Dr. M. Fouad Medical
05-05-1435H
Lababidi Director
Approved By Hospital
Ayyad Mael’ly 08-05-1435H
Director

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