What are the initial steps in managing patients admitted to the hospital?

Initial Management of Hospitalized Patients

All patients admitted to the hospital require immediate assessment of vital signs, neurological status, and risk stratification within the first 24 hours, with specialized care pathways determined by admission diagnosis and clinical stability. 1

Immediate Actions Upon Admission (First 30-60 Minutes)

Documentation and Initial Orders

• Document the primary admission diagnosis clearly in the medical record, including specific disease type when applicable (e.g., type 1 vs type 2 diabetes, ischemic vs hemorrhagic stroke). 1
• Establish intravenous access and obtain baseline laboratory studies: complete blood count, comprehensive metabolic panel, coagulation studies if indicated, and glucose. 2, 3
• Perform A1C testing on all patients with diabetes or hyperglycemia (blood glucose >140 mg/dL) if not done in the prior 3 months, as this directly impacts insulin dosing and discharge planning. 1

Vital Sign Monitoring Protocol

• Assess vital signs and neurological status frequently during the first 24 hours—at minimum every 4 hours for stable patients, more frequently for unstable patients. 1, 2
• Implement continuous automated monitoring of oxygen saturation, blood pressure, heart rhythm, and temperature for high-risk patients (stroke, cardiac events, critical illness). 2, 3
• Maintain oxygen saturation ≥92-94% with supplemental oxygen 2-3 L/min via nasal cannula as needed. 3

Risk Assessment and Specialized Care Pathways

Stroke Patients

• Transfer to a specialized stroke unit within 24 hours of arrival (ideally immediately), as stroke unit care reduces mortality and morbidity comparable to thrombolytic therapy effects. 1
• Complete non-contrast CT head within 30 minutes of admission to distinguish ischemic from hemorrhagic stroke. 2, 3
• Assess for reperfusion therapy eligibility immediately, targeting door-to-needle time ≤60 minutes for thrombolysis candidates. 2, 3

Diabetes/Hyperglycemia Management

• Never use sliding scale insulin (SSI) alone—this practice is strongly discouraged. 1
• For critically ill patients: initiate insulin therapy at blood glucose threshold >180 mg/dL, targeting 140-180 mg/dL range. 1
• For non-critically ill patients: use basal plus correction insulin for poor oral intake/NPO status; use basal, nutritional, and correction components for patients with good nutritional intake. 1
• Implement validated written or computerized insulin protocols that allow predefined dose adjustments. 1

Interdisciplinary Assessment (Within 48 Hours)

Core Team Evaluation

• The interdisciplinary team must assess patients within 48 hours of admission using standardized, validated assessment tools. 1
• Core team should include physicians, nurses, occupational therapists, physiotherapists, speech-language pathologists, social workers, clinical nutritionists, and pharmacists. 1

Mandatory Assessment Components

• Dysphagia screening before allowing oral intake—use bedside water swallow test as impaired swallowing increases pneumonia and death risk. 1
• Mood and cognition screening. 1
• Mobility and functional status assessment. 1
• Nutrition status and hydration needs. 1
• Bowel and bladder function. 1
• Skin integrity and pressure ulcer risk. 1
• Venous thromboembolism (VTE) risk assessment. 1

Prevention of Hospital-Acquired Complications

VTE Prophylaxis (Initiate Within 24 Hours)

• Apply intermittent pneumatic compression (IPC) devices bilaterally for all immobilized patients, continuing until independently mobile, discharge, or 30 days. 2, 3
• Add pharmacological prophylaxis (low-molecular-weight heparin or unfractionated heparin if renal failure) for high-risk patients. 2, 3

Early Mobilization

• Begin mobilization as soon as clinical stability allows—typically within 24 hours for most patients—to prevent pneumonia, deep vein thrombosis, pulmonary embolism, pressure sores, and contractures. 1
• Use frequent turning and alternating pressure mattresses for immobile patients. 1
• Implement fall prevention measures during mobilization. 1

Nutrition and Hydration

• Keep patients NPO until swallowing assessment is completed for those at aspiration risk (brainstem infarction, depressed consciousness, cranial nerve palsies, dysphonia). 1, 3
• Administer intravenous fluids (normal saline 75-100 mL/hour) to maintain adequate hydration and prevent dehydration-related complications. 3

Medication Safety and Reconciliation

Admission Medication Review

• Hospital pharmacists must perform medication reconciliation on admission, reviewing for drug interactions, adverse effects, and adherence issues. 1
• Discontinue or adjust medications based on admission diagnosis (e.g., hold anticoagulation for hemorrhagic stroke, avoid antithrombotics before brain imaging). 3

Computerized Order Entry

• Use structured order sets with computerized physician order entry (CPOE) to reduce medication errors and improve glucose control without increasing hypoglycemia. 1

Discharge Planning (Begins at Admission)

• Initiate discharge planning at hospital admission, not at time of discharge. 1
• Assess patient's self-management knowledge and provide education on medications, monitoring, and recognizing complications. 1
• Arrange follow-up within appropriate timeframe based on condition severity. 1

Critical Pitfalls to Avoid

• Never delay essential imaging or treatment for non-essential tests (e.g., chest X-ray) unless specific clinical concerns exist. 2, 3
• Never give antithrombotics before brain imaging rules out hemorrhage in patients with neurological symptoms. 3
• Never use anti-embolism stockings alone without IPC or pharmacological prophylaxis—this is inadequate VTE prevention. 2
• Never allow hyperthermia to persist untreated—treat fever >37.5°C with acetaminophen as it worsens outcomes. 3
• Never skip swallowing assessment before oral intake in at-risk patients—aspiration pneumonia significantly increases mortality. 1