The odds are that one day you’ll find yourself as a patient in the hospital.  Things happen. Illness. Accident. Injury. Chances are “hospital admission” isn’t penciled into your daily planner, either.  If you find yourself unexpectedly admitted to the hospital, the likelihood is you started as a patient in the emergency department. So what should you expect when you are the patient?

Emergency Room

First, let’s just squash the first myth of the emergency room – it is nothing like it is on TV.  Brought in by ambulance or walk in the main ER doors – you’ll be triaged in the same way.  Triage? What does this even mean? It is how the ER staff determines which order a patient is seen based on how serious their symptoms or condition is.   

If you walk into the ER front desk, you’ll first be seen in a triage room where they will take a set of vital signs (blood pressure, temperature, pulse, oxygen level, and respiration rate) and then later be placed in an ER room for further care. You might have to wait back in the waiting room until an ER room is available.  Arriving via ambulance may get you directly into an ER room, but it also can get you directly onto a cot in the hallway. 

Depending on what reason, or chief complaint, that brings you into the emergency room, determines the next steps:  

• If you are having a cardiac concern (chest pain, heart attack, racing or irregular heart rate), respiratory distress (severe trouble breathing, difficulty even speaking) or almost unable to stay awake (altered level of consciousness) anticipate having a lot of people attending to you all at once.  
• Expect to be undressed and placed in a gown.  Not just “take off your shirt and put this gown on” but “take off all your clothing and put this gown on”. Don’t worry, the ER has blankets. 
• Your care will be directed by an MD, Physician Assistant or Nurse Practitioner.  They will determine your diagnosis and treatment plan, and ultimately discharge you home or admit you to the hospital. The ER nursing staff will also play an important role in administering treatments and medications, monitoring change of condition, education and coordinating discharge plan. 
• Usually, you will have blood drawn, an EKG if there is a cardiac concern and possibly chest x-ray if you’re having breathing difficulties.  Sometimes this is done before you are seen by a provider because of protocols. This way, by the time you see the provider, they already have some information to determine the next steps. 
• If they do draw blood for labs, they usually leave an IV saline lock in place to administer IV fluids or IV medications later.  This is done to avoid sticking you with a needle twice. 
• You have to be registered in the hospital computer system.  Eventually, someone is going to come into the room to ask you for your ID, insurance card and contact information. They will also ask you for your co-pay – that’s their job, so please be kind. 
• You will be asked a lot of questions.  Past medical history. Past surgical history. Allergies.  The most difficult one can be the medications taken on a daily basis. We do not know what the little blue pills are your take at dinner, so it is helpful to have a medication list available. 
• Once you are initially examined by a provider, orders will be placed to determine your main diagnosis and begin a treatment plan.  This might include more labs, medications, imaging (xray, CT scan, ultrasound).  
• All of this takes time.  You’ll have to wait for your turn for imaging, time for medication to take effect and for lab results to return and be interpreted.  During all of this, the ER staff is constantly re-triaging their patients. As patients conditions change, so does your place in “line”.
• There is a real good chance that until certain diagnoses are ruled out, you will not be allowed to eat or drink anything. The chances that an ER turkey sandwich was the cure for any condition is pretty slim. 
• Nursing staff and their team will ensure that you are stable, comfortable and safe (please use that call light).  The ER nurse will also be the one to review your discharge summary with you before you leave, or give the report to the nursing floor if you are admitted.

Admission

If discharge just isn’t the plan, and you aren’t able to go home, you’ll move into a room elsewhere in the hospital.  Most hospitals nowadays have all private rooms. Don’t be surprised if you do have a roommate, especially if you are admitted to observation.  

Observation? What does that even mean? Thanks to the wonderful world of insurance, once you leave the emergency department you might be considered “observation” instead of “inpatient”.  This doesn’t change the care you receive or your treatment options, but could make a difference on how your insurance is billed (and what you ultimately pay). It gets even more confusing if you have medicare and need your “three midnights” to qualify for a rehab stay.  Let’s stay focused and get through the hospital admission first and save that for another blog post. 

Daily Expectations

So. You’re admitted to the hospital. Now what?  

While each hospital stay can be different, and everyone’s experience is unique – there are some basic hospital expectations you will encounter: 

MD/Specialists 

Your overall care will be managed by the attending doctor – this is usually a hospitalist or general medicine doctor.  If surgery is involved (general surgery, orthopedics, ENT, etc.) they can be the attending. They can also have a general medicine or hospitalist group overseeing your care.  As your team of doctors treat you, other groups can join your care. 

For example, you could have fallen and broken your leg.  You’ll be admitted under the orthopedic surgeon group, but since you have a history of asthma, they prefer the hospitalist group to oversee your medical care (remember, orthopedics focus on bones, not everyday medicine concerns).  So, now you have two doctor groups following you. Orthopedics & Medicine. If they plan on surgery, and you’re old enough not to have your ID checked at a bar, you’ll probably need cardiac clearance before surgery. Now you have Cardiology, Medicine and Orthopedics overseeing your care.  If you are admitted with something such as pneumonia, or an infection, the list of groups following you can grow. 

Your nurses should be able to help keep track of which specialist groups are overseeing your care.  Many hospitals give out little notepads and pens when you are admitted. Use for them would be to start keeping track of who saw you & what their plan is.  Most providers should also hand out a business card so be sure to grab one if offered. 

Nursing Change of Shift

In general, there are two main shifts that nursing can work; 12-hour and 8-hour shifts. These hospitals shifts are usually 7a-7p and 7p-7a, or the 7a-3p, 3p-11p, 11p-7am shifts.  Many hospitals promote bedside handoff – so you can wrap up your care with one RN and meet the next RN. This means you should expect staff in your rooms during these hours for report handoff.  

Nurses are the eyes and ears for the doctors.  They will assess you each shift, carry out treatment plans, administer medications and report change in condition to the providers. Now is not the time to tell them “I feel fine” if you truly do not.  

Pain Management 

The overall goal for pain management is not to be pain free, but to decrease your discomfort to a level that you can function comfortably. Simple functions can range from walking to the bathroom, or moving from the bed to the chair. 

Pain can be good.  It can tell us when something is not right, so completely covering pain can cause more harm than good.  Pain is also expected – if you have an injury or have surgery – you should anticipate to be uncomfortable.  If you had surgery because of an injury – not only do you have to recover from the surgery but also from the injury itself.  

Pain medication use should be expected as well.  Everyone responds to pain medication differently, and you should always take the least amount of pain medications necessary. Your goal is to be able to function and achieve some rest. 

Diet

When we refer to diet in the hospital setting, it isn’t about a weight loss.  If you have anything concerning abdominal pain or issues that require surgery, you won’t be allowed to eat.  We refer to it as “NPO” (“nil per os” for all you latin experts). Nothing by mouth. Sometimes you can have sips of water or ice chips, just don’t get your hopes up until your treatment plan is more concrete.  

Testing

The types of testing that can be done in a hospital could be its own post.  Usually, blood draws are done daily until labs are stable. Yes, they tend to wake you up early so results are ready when providers start making their rounds.  You may also be sent to other areas of the hospital for test – x–rays, CT scans, MRIs, ultrasounds, endoscopy, etc. Each test should be explained, and some may require a consent, or permission form, signed by you before the test occurs.

Sleep

If you want quiet, uninterrupted sleep – the hospital is the last place you want to be.  Every nursing unit will try its best to keep the chatter, alarms, and lights low at night. But the nursing staff is still working and part of the job is to ensure your safety.  This can be checking your vitals overnight, ensuring medications are administered and monitoring your overall status. Even during the day, if you have the chance to nap, that’s usually when someone will walk into the room to visit  

Visitors 

Most Hospitals have open visiting hours – which is wonderful for our busy schedules.  Visitors can be quite helpful being that second set of ears or an extra set of hands to take notes.  Keep in mind – your job is to focus on your recovery, and not entertain guests. If you have trouble asking for visitors to leave, ask your nurse to help encourage them to let you rest. 

Discharge

What determines when you go home?  Who actually has the final say?  

While that all depends on a few factors, your discharge should start the moment you are admitted. This doesn’t mean the hospital wants you out ASAP – but discharge planning takes time.  This is why the discussion needs to begin almost within the first 24hrs of admission, especially if additional help or resources is needed to get you home safely. Hospitals have a general idea of how long your condition will keep you in the hospital, barring any additional complications. You and your family will have contact with the discharge planning team which can include discharge planner, social worker, and care coordinators.

Your attending doctor will be the group that has the final say on when you can go home.  However – every specialist group that has been consulted during your stay also has to give the thumbs up to leave.  Remember the example earlier, with the broken leg scenario? Orthopedics might think you’re ok to discharge “from their standpoint”, but cardiology might be concerned about your blood pressure or heart rhythm.  Maybe your blood work was a little off, and medicine will want the labs checked again the next morning before deciding to send you home.  

Once everyone has given the clearance to discharge you home – both the discharge planning team needs to have everything in place and nursing has to have your discharge orders, teaching and medication review completed and ready to review with you.  

There are two important things you should have at discharge.  The first is your medication list. Each medication should have the reason you are taking it, how much and how often you should take it.  The second item is your list of all your providers (names and specialty) as well as when you should schedule follow-up appointments. You should always schedule a followup appointment with your primary provider within 1-2 weeks after discharge. 

And yes, you will probably be discharged out of the hospital via wheelchair.  Enjoy the ride to freedom and thank the volunteers who usually are your discharge escort.   

Home Sweet Home

Most patients are discharged home as it really is the best place to be for recovery. Sometimes you need extra help once home, and your discharge plan could include scheduled home health care services.  They can provide both nursing and/or physical therapy services at home 2-3 days per week. However, you might need more intense therapy or nursing care before you are ready to be home. The bridge between hospital and home when more care required is referred to as skilled nursing or extended care facility.  They will provide both nursing and therapy services to ensure you are strong enough to finish your recovery at home.

No matter your discharge path, the most important thing to remember – your recovery will still continue once you are home.  This could take a few days, a few weeks or even a few months. The most important first step is to follow-up with your primary care provider once you are home.  Keep in mind – you will not be 100% back to normal when you first go home. Rest when you need to. Listen to your body. Make certain you are eating and drinking enough each day. Your body will heal at its own rate, and in our fast-paced society it’s never as fast as we want it to be.