What are the indications for hospital admission?

Indications for Hospital Admission

Hospital admission criteria vary by clinical condition, but generally include life-threatening complications, inability to maintain oral intake, hypoxemia, hemodynamic instability, severe bleeding, social factors preventing safe outpatient care, and specific disease-severity thresholds.

Community-Acquired Pneumonia (CAP)

Admit patients with CURB-65 scores ≥2 or those meeting major IDSA/ATS criteria (invasive mechanical ventilation need or septic shock requiring vasopressors). 1

CURB-65 Scoring System

• Score 0-1 (mortality 0.7-2.1%): Outpatient management 1
• Score 2 (mortality 9.2%): Short hospital stay or supervised outpatient care 1
• Score 3-5 (mortality 14.5-57%): Hospital admission, assess for ICU 1

CURB-65 Components (1 point each):

• Confusion 1
• Urea >7 mmol/L 1
• Respiratory rate ≥30/min 1
• Blood pressure (SBP <90 or DBP <60 mmHg) 1
• Age ≥65 years 1

Major ICU Criteria (admit if either present):

• Need for invasive mechanical ventilation 1
• Septic shock requiring vasopressors 1

Minor ICU Criteria (admit if ≥3 present):

• Respiratory rate ≥30/min 1
• PaO2/FiO2 ratio ≤250 1
• Multilobar infiltrates 1
• Confusion/disorientation 1
• Uremia (BUN ≥20 mg/dL) 1
• Leukopenia (WBC <4,000/mm³) 1
• Thrombocytopenia (platelets <100,000/mm³) 1
• Hypothermia (core temperature <36°C) 1
• Hypotension requiring aggressive fluid resuscitation 1

Common pitfall: The PSI occasionally underestimates severity in young patients without comorbidities who develop severe respiratory failure, as hypoxia alone does not score highly enough. 1

Transient Ischemic Attack (TIA)

Hospitalize patients with TIA within the past 24-48 hours to facilitate early deployment of lytic therapy if symptoms recur and to expedite definitive secondary prevention. 1

Specific Admission Criteria:

• Crescendo TIAs (multiple, increasingly frequent symptoms) 1
• Duration of symptoms >1 hour 1
• Symptomatic internal carotid stenosis >50% 1
• Known cardiac source of embolus (e.g., atrial fibrillation) 1
• Known hypercoagulable state 1

For patients not admitted: Ensure same-day or within 12-24 hours access to CT/CTA or MR/MRA, EKG, and carotid Doppler examination. 1 Initial assessment should occur within 24-48 hours if imaging is not performed in the emergency department. 1

Diabetes-Related Admissions

Life-Threatening Metabolic Complications:

Admit for diabetic ketoacidosis: Plasma glucose ≥250 mg/dL with arterial pH ≤7.30, serum bicarbonate ≤15 mEq/L, and moderate ketonuria. 1

Other Admission Indications:

• Newly diagnosed diabetes in children and adolescents 1
• Substantial chronic poor metabolic control requiring close monitoring 1
• Hyperglycemia with volume depletion 1
• Persistent refractory hyperglycemia with metabolic deterioration 1
• Recurring fasting hyperglycemia ≥300 mg/dL (16.7 mmol/L) refractory to outpatient therapy 1
• Severe chronic diabetic complications requiring intensive treatment 1
• Uncontrolled or newly discovered insulin-requiring diabetes during pregnancy 1

Note: Modification of fixed insulin regimens or sulfonylurea treatment alone is NOT an indication for admission. 1

Thrombocytopenia

Adult Admission Criteria:

Admit adults with newly diagnosed ITP and platelet count <20 × 10⁹/L who are asymptomatic or have minor mucocutaneous bleeding. 2

• Significant mucosal bleeding: Admit regardless of platelet count 2
• Social concerns or uncertainty about diagnosis: Admit 2
• Significant comorbidities with bleeding risk: Admit 2
• Anticoagulant or antiplatelet medications: Admit 2
• Refractory to treatment: Admit 2
• Limited access to follow-up: Admit 2

Pediatric Admission Criteria:

• Severe, life-threatening bleeding regardless of platelet count 2
• Platelet count <20 × 10⁹/L with mucous membrane bleeding requiring intervention 2

Critical requirement for outpatient management: Follow-up with hematologist within 24-72 hours is essential. 2 All patients must receive education about warning signs requiring emergency care. 2

Post-Procedural Admissions (BIPSS Example)

Most patients undergoing uncomplicated bilateral inferior petrosal sinus sampling can be safely managed as outpatients if hemodynamically stable without significant comorbidities. 3

Admission Indications Post-BIPSS:

• Significant bleeding at catheter insertion sites 3
• Significant comorbidities with increased bleeding risk 3
• Social concerns or lack of adequate home support 3
• Patients on anticoagulant/antiplatelet medications requiring prompt resumption 3

General Emergency Medical Services Criteria

Factors strongly associated with need for hospital admission after EMS transport include: 4

• Bradycardia (90% admission rate) 4
• Hypotension (80% admission rate) 4
• Hypertension (89% admission rate) 4
• Age >55 years (81% admission rate) 4
• Tachycardia (72% admission rate) 4
• Head injury (78% admission rate) 4

Key Principles Across Conditions

Avoid admission based solely on laboratory values or scoring systems without clinical context. For example, the pneumonia severity index has only 16% positive predictive value for detecting inappropriate hospitalizations when used alone, primarily because comorbid conditions often require inpatient care independent of pneumonia severity. 5

Social factors are legitimate admission criteria: Inability to maintain oral intake, lack of home care support, and noncompliance are valid reasons for hospitalization even in otherwise low-risk patients. 6

Common pitfall: Failing to ensure timely outpatient follow-up (within 24-72 hours) when admission is deferred increases risk of adverse outcomes. 1, 2