The admission process of a patient in the NHS
I am going to use an example of community acquired pneumonia and then stable chest pain as an example to explain the admission process of a patient. I have used medicine as an example just because I know this pathway well ( please note that this may differ from trust to trust and from specialty to specialty). This is to give you a general idea.
PRIMARY CARE (General Practice- GP)
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/general-practitioner-gp/general-practice-gp
https://www.nhs.uk/nhs-services/gps/
These healthcare professionals provide consultations for patients who are relatively stable.
For example, if I develop a cough and am bring up yellow phlegm, have a fever but do not feel very breathless, I will call my GP and arrange an appointment. They will assess me and then decide whether this warrants antibiotics.
They will then get me a prescription and I will collect it from my local pharmacy ( https://www.nhs.uk/service-search/pharmacy/find-a-pharmacy )
But this is not what GPs only do - They have a variety of services like
Diabetic checks
Following up on patients with complex diseases ( if they have a specialist interest in them : https://www.rcgp.org.uk/training-exams/practice/general-practitioners-with-extended-roles.aspx )
GP trainees ( https://gprecruitment.hee.nhs.uk/recruitment/training ) rotate not in GP surgeries during their training but also emergency medicine, medicine, surgery, PAEDS, psychiatry and hence have a vast knowledge base.
PARAMEDICS ( AMBULANCE SERVICE)
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-call-999/
https://www.stepintothenhs.nhs.uk/careers/paramedic
https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/roles-allied-health-professions/roles-allied-health-professions/paramedic/paramedic
Now, taking the same example. I call my GP surgery/somehow end up walking to the GP surgery and the receptionist finds out I can hardly speak due to breathlessness. She immediately calls 999. The paramedics assess me and notice that my saturations are 80%. They start me on 15 l oxygen and transfer me to the nearest emergency department . They call the emergency department in advance as I am quite breathless and and I will need an urgent review. The emergency department team asks them to bring me to their resus department
EMERGENCY DEPARTMENT
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-go-to-ae/
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/emergency-medicine
The emergency department is run by emergency physicians
They have the following sections:
1. ED minors ( where patients can walk in and walk out) - this can be in the hospital or in a separate building ( also called urgent treatment centre)
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-visit-an-urgent-treatment-centre-walk-in-or-minor-injury-unit/
2. ED Majors
Where patients who are unwell and cannot walk/mobilize come to
3.ED resus
Where the most unwell patients come to
4. ED Triage bay
Where paramedics bring patients and the team there does cannulas, bloods, ECGs, VBGs and then transfers them to either ED majors or ED resus/ other departments like ambulatory care.
So, given that I am requiring 15 l oxygen, I will most probably end up in ED RESUS. The ED physicians will quickly see me, nurses will put a cannula, do bloods, the ED physicians will do an A to E assessment, do an ABG and request an urgent portable CXR. They will give me fluids, antibiotics and the CXR confirms that I have a left sided consolidation.
I am then referred to the medical team
MEDICAL TEAM ASSESSMENT
The ED team have done their bit - an A to E assessment, initial management and now I need to be admitted to a medical ward.
This is where the medical team come in.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine
The medical registrar will come and assess me, take a full history, examine me and make a management plan. This is known as clerking:
https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html
ADMISSION TO AMU ( acute medical unit) /AAU ( acute assessment unit)/ MSW ( medical short stay ward)
https://www.rcpmedicalcare.org.uk/designing-services/specialties/acute-internal-medicine/services-delivered/acute-medical-unit/
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/acute-internal-medicine
My oxygen requirement has now dropped to 4 litres. My temperature has settled and I can now be transferred to AMU.
A consultant comes and assesses me ( just like the medical registrar earlier) and does a post take. He adds to the plan that I will need repeat bloods tomorrow to ensure my CRP, WCC are coming down. He also wants a sputum C+S.
He agrees with the plan made earlier to continue IV antibiotics, IV fluids. This is known as a post take:
https://omarsguidelines.blogspot.com/2022/01/the-post-take-ward-round-how-to-prepare.html
TRANSFER TO ANOTHER WARD
I have been on AMU for 24 hours. I am still requiring oxygen. The following day, another doctor ( or maybe the same consultant) sees me and suggests that I still need to stay in hospital.
Hence I am transferred to a respiratory ward where the team of doctors see me and assess me like before. This is known as a ward round:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html
I stay there for 24 more hours and the following day, my oxygen requirements improve and I can mobilize slowly without desaturating.
My bloods have improved and I feel much better.
The doctors assess me and deem me fit for discharge. They request a CXR in 8 weeks time ( which the parent team will chase up). They write a letter with medications which will go to my GP so that they are fully aware of what has happened.
I get my medications from the hospital and am discharged.
So as you can see, the admission process is a bit complicated but it is all about patient flow. Getting it right. Ensuring I am seen appropriately. As you can gather, I have been seen by
1.ED physicians the time I arrived to ED resus
2.Medical registrar as soon as ED team has assessed me
3. Medical consultant on call the same day
4. Another doctor on day 2
5. Another medical team on day 3
So 5 different healthcare professionals have seen and assessed me.
A DETIORATING PATIENT
If my saturations had worsened in ED resus, I became acidotic and my blood pressure was dropping despite fluids, the ICU ( Intensive care unit) team would be called ASAP.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/intensive-care-medicine
The ICU registrar would come, again do an A to E assessment, make a plan that I am too unstable to be admitted elsewhere and need ICU admission for inotropic support and possibly ventilatory support. They would then inform the ICU nurse in charge and consultant on call.
I would then be transferred to the ICU unit where a different team of ICU doctors would see me and assess me. They would take a full history, examine me and make a management plan.
I need ventilatory support and am intubated. I am seen on a daily basis by the ICU team and slowly start improving. I am extubated successfully and am requiring a few litres of oxygen.
Hence I do not need to be in ICU but I am not fit for discharge either. So I would be transferred to a medical ward where a different team of doctors will see me.
NOW, ANOTHER EXAMPLE
Patient A has chest pain at 0800 AM
He calls his GP who asks him a few screening questions ( https://www.nhs.uk/conditions/chest-pain/ )
It is found out that patient A has mild chest pain, worse on breathing in, mild shortness of breath and can speak in full sentences, recent long haul flight.
The GP refers him to ambulatory care unit
https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/
ACU ( ambulatory care unit) / SDEC ( Same day emergency care)
This is run by acute medical ( AMU) physicians.
Patient A is seen by the triage nurse in ACU
She cannulates him and does bloods including CRP, U and Es, LFTs, full blood count, D dimer and a coagulation screen. An ECG is performed and a CXR is requested.
Patient A gets his CXR and then waits in the ACU waiting room
The doctor then calls him in
He takes a full history, examines him and makes a management plan.
https://omarsguidelines.blogspot.com/2020/05/working-in-ambulatory-care.html
The D dimer has come back to be raised. The CXR is clear and ECG is normal. The doctor explains to the patient that could be a possible clot in the vessels of the lung and hence we need to do a further investigation. The patient receives treatment for this and a CTPA is organized. The CTPA is performed within a few hours and confirms that patient A has PE without any right heart strain. The doctor calls the patient in again and lets him know. He counsels him for anticoagulation, asks any further questions ( like risk of malignancy, other risk factors, etc )
Patient A is then given a prescription to get the medication. He is discharged and the ACU doctor writes a letter to the GP.
Useful links
https://www.healthcareers.nhs.uk/
I am going to use an example of community acquired pneumonia and then stable chest pain as an example to explain the admission process of a patient. I have used medicine as an example just because I know this pathway well ( please note that this may differ from trust to trust and from specialty to specialty). This is to give you a general idea.
PRIMARY CARE (General Practice- GP)
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/general-practitioner-gp/general-practice-gp
https://www.nhs.uk/nhs-services/gps/
These healthcare professionals provide consultations for patients who are relatively stable.
For example, if I develop a cough and am bring up yellow phlegm, have a fever but do not feel very breathless, I will call my GP and arrange an appointment. They will assess me and then decide whether this warrants antibiotics.
They will then get me a prescription and I will collect it from my local pharmacy ( https://www.nhs.uk/service-search/pharmacy/find-a-pharmacy )
But this is not what GPs only do - They have a variety of services like
Diabetic checks
Following up on patients with complex diseases ( if they have a specialist interest in them : https://www.rcgp.org.uk/training-exams/practice/general-practitioners-with-extended-roles.aspx )
GP trainees ( https://gprecruitment.hee.nhs.uk/recruitment/training ) rotate not in GP surgeries during their training but also emergency medicine, medicine, surgery, PAEDS, psychiatry and hence have a vast knowledge base.
PARAMEDICS ( AMBULANCE SERVICE)
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-call-999/
https://www.stepintothenhs.nhs.uk/careers/paramedic
https://www.healthcareers.nhs.uk/explore-roles/allied-health-professionals/roles-allied-health-professions/roles-allied-health-professions/paramedic/paramedic
Now, taking the same example. I call my GP surgery/somehow end up walking to the GP surgery and the receptionist finds out I can hardly speak due to breathlessness. She immediately calls 999. The paramedics assess me and notice that my saturations are 80%. They start me on 15 l oxygen and transfer me to the nearest emergency department . They call the emergency department in advance as I am quite breathless and and I will need an urgent review. The emergency department team asks them to bring me to their resus department
EMERGENCY DEPARTMENT
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-go-to-ae/
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/emergency-medicine
The emergency department is run by emergency physicians
They have the following sections:
1. ED minors ( where patients can walk in and walk out) - this can be in the hospital or in a separate building ( also called urgent treatment centre)
https://www.nhs.uk/nhs-services/urgent-and-emergency-care-services/when-to-visit-an-urgent-treatment-centre-walk-in-or-minor-injury-unit/
2. ED Majors
Where patients who are unwell and cannot walk/mobilize come to
3.ED resus
Where the most unwell patients come to
4. ED Triage bay
Where paramedics bring patients and the team there does cannulas, bloods, ECGs, VBGs and then transfers them to either ED majors or ED resus/ other departments like ambulatory care.
So, given that I am requiring 15 l oxygen, I will most probably end up in ED RESUS. The ED physicians will quickly see me, nurses will put a cannula, do bloods, the ED physicians will do an A to E assessment, do an ABG and request an urgent portable CXR. They will give me fluids, antibiotics and the CXR confirms that I have a left sided consolidation.
I am then referred to the medical team
MEDICAL TEAM ASSESSMENT
The ED team have done their bit - an A to E assessment, initial management and now I need to be admitted to a medical ward.
This is where the medical team come in.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine
The medical registrar will come and assess me, take a full history, examine me and make a management plan. This is known as clerking:
https://omarsguidelines.blogspot.com/2019/08/how-to-clerk-medial-patients-safely-and.html
ADMISSION TO AMU ( acute medical unit) /AAU ( acute assessment unit)/ MSW ( medical short stay ward)
https://www.rcpmedicalcare.org.uk/designing-services/specialties/acute-internal-medicine/services-delivered/acute-medical-unit/
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/acute-internal-medicine
My oxygen requirement has now dropped to 4 litres. My temperature has settled and I can now be transferred to AMU.
A consultant comes and assesses me ( just like the medical registrar earlier) and does a post take. He adds to the plan that I will need repeat bloods tomorrow to ensure my CRP, WCC are coming down. He also wants a sputum C+S.
He agrees with the plan made earlier to continue IV antibiotics, IV fluids. This is known as a post take:
https://omarsguidelines.blogspot.com/2022/01/the-post-take-ward-round-how-to-prepare.html
TRANSFER TO ANOTHER WARD
I have been on AMU for 24 hours. I am still requiring oxygen. The following day, another doctor ( or maybe the same consultant) sees me and suggests that I still need to stay in hospital.
Hence I am transferred to a respiratory ward where the team of doctors see me and assess me like before. This is known as a ward round:
http://omarsguidelines.blogspot.com/2017/05/guideline-for-junior-doctors-working-in.html
I stay there for 24 more hours and the following day, my oxygen requirements improve and I can mobilize slowly without desaturating.
My bloods have improved and I feel much better.
The doctors assess me and deem me fit for discharge. They request a CXR in 8 weeks time ( which the parent team will chase up). They write a letter with medications which will go to my GP so that they are fully aware of what has happened.
I get my medications from the hospital and am discharged.
So as you can see, the admission process is a bit complicated but it is all about patient flow. Getting it right. Ensuring I am seen appropriately. As you can gather, I have been seen by
1.ED physicians the time I arrived to ED resus
2.Medical registrar as soon as ED team has assessed me
3. Medical consultant on call the same day
4. Another doctor on day 2
5. Another medical team on day 3
So 5 different healthcare professionals have seen and assessed me.
A DETIORATING PATIENT
If my saturations had worsened in ED resus, I became acidotic and my blood pressure was dropping despite fluids, the ICU ( Intensive care unit) team would be called ASAP.
https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/intensive-care-medicine
The ICU registrar would come, again do an A to E assessment, make a plan that I am too unstable to be admitted elsewhere and need ICU admission for inotropic support and possibly ventilatory support. They would then inform the ICU nurse in charge and consultant on call.
I would then be transferred to the ICU unit where a different team of ICU doctors would see me and assess me. They would take a full history, examine me and make a management plan.
I need ventilatory support and am intubated. I am seen on a daily basis by the ICU team and slowly start improving. I am extubated successfully and am requiring a few litres of oxygen.
Hence I do not need to be in ICU but I am not fit for discharge either. So I would be transferred to a medical ward where a different team of doctors will see me.
NOW, ANOTHER EXAMPLE
Patient A has chest pain at 0800 AM
He calls his GP who asks him a few screening questions ( https://www.nhs.uk/conditions/chest-pain/ )
It is found out that patient A has mild chest pain, worse on breathing in, mild shortness of breath and can speak in full sentences, recent long haul flight.
The GP refers him to ambulatory care unit
https://www.england.nhs.uk/urgent-emergency-care/same-day-emergency-care/
ACU ( ambulatory care unit) / SDEC ( Same day emergency care)
This is run by acute medical ( AMU) physicians.
Patient A is seen by the triage nurse in ACU
She cannulates him and does bloods including CRP, U and Es, LFTs, full blood count, D dimer and a coagulation screen. An ECG is performed and a CXR is requested.
Patient A gets his CXR and then waits in the ACU waiting room
The doctor then calls him in
He takes a full history, examines him and makes a management plan.
https://omarsguidelines.blogspot.com/2020/05/working-in-ambulatory-care.html
The D dimer has come back to be raised. The CXR is clear and ECG is normal. The doctor explains to the patient that could be a possible clot in the vessels of the lung and hence we need to do a further investigation. The patient receives treatment for this and a CTPA is organized. The CTPA is performed within a few hours and confirms that patient A has PE without any right heart strain. The doctor calls the patient in again and lets him know. He counsels him for anticoagulation, asks any further questions ( like risk of malignancy, other risk factors, etc )
Patient A is then given a prescription to get the medication. He is discharged and the ACU doctor writes a letter to the GP.
MANAGEMENT IN THE COMMUNITY
There are a lot of other things the NHS does like
Community support
https://www.hee.nhs.uk/our-work/community-district-nursing
I am sure I have missed a lot of things here and there is more to this but I just wanted to give you a basic idea of how a patient is admitted to the NHS and what the admission process looks like. I hope this helps. Please comment below if you feel I have missed anything essential.
There are a lot of other things the NHS does like
Community support
https://www.hee.nhs.uk/our-work/community-district-nursing
I am sure I have missed a lot of things here and there is more to this but I just wanted to give you a basic idea of how a patient is admitted to the NHS and what the admission process looks like. I hope this helps. Please comment below if you feel I have missed anything essential.
https://www.healthcareers.nhs.uk/
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