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Name of Policy: Admission, Discharge and Transfer

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Policy Number: 3364-100-01-01
TOLEDO
Department: Hospital Administration

Approving Officer: Interim Executive Director and Associate Vice

President

Responsible Agent: Interim Executive Director and Associate Vice

President
Effective Date: 2/1/2014
Scope: The University of Toledo Medical Center
Initial Effective Date: 12/1 5/1979

New policy proposal Minor/technical revision of existing policy

X Major revision of existing policy Reaffirmation of existing policy

(A) Policy Statement

1. . All admissions to the hospital will be coordinated by the Nursing Administration Staff (House Supervisor/Admission
Coordinator)
2. Nursing Administration Staff will promote throughput and coordinate admissions, transfers, and discharges as needed
within the hospital.
3. Discharge planning will begin on admission for the patient, to ensure proper planning and the ability for a safe and
appropriate discharge.
4. Patients will be discharged after a final discharge order is received.

(B) Purpose of Policy

The control of inpatient beds is the responsibility of the Nursing Administration Staff to ensure an optimally efficient means
of dealing with patient admissions and discharges.

(C) Procedure

Discharges:

1. The physician will determine when the patient is medically stable for discharge. The physician will complete medication
reconciliation, discharge instructions in Care Manager, and secure the necessary prescriptions in EPW prior to patient
discharge.
A. Physicians will complete medication reconciliation and discharge instructions in Care Manager.
B. Physicians will complete prescriptions for medications, medical equipment, and O2 therapy and consults for further
treatments on the discharge instructions in Care Manager (i.e., Outcome Management, physical therapy,
occupational therapy, and other consulted therapies will document recommendations in the discharge instructions
in Care Manager etc.).
C. Physician will sign and date discharge instructions for patients that need community resources upon discharge and
place discharge forms and prescription work in the chart.

D. Nursing will make a copy of the discharge instructions after all signatures are obtained for the permanent record in
the chart.

E. Follow Up Appointment requirements will be determined by the discharging physician. The clerical specialist,
bedside RN, and/or discharging physician can coordinate follow up appointments and place on the discharge
instructions in Care Manager prior to discharge.

2. The Nursing Units will utilize this for the following:

A. Collaboration with the patient/family to secure transportation home will be communicated by the primary RN.
Policy 3364-100-01-01
Admission, Discharge and Transfer
Page 2

B. Primary RN will notify Outcome Management Staff if they are consulted on the case, and/or a transportation need
is identified.

3. A final discharge order will be completed by the discharging physician on day of discharge, and the primary RN will get
the proper signatures prior to patient discharge.
Admissions:
All admission calls will be triaged through the Nursing Administration Staff at 419-383-2337 O-866-4Q4-BEDS)
1. Pre-scheduled admission information , will be transferred to the Patient Registration Specialist in the patient access
department at Ext. 3881 .
2. Emergency admissions will have priority over all elective admissions. Please call Ext. 23373. Urgent admissions will
be scheduled for the next available elective admission opening at Ext.2337.
4. All pre-scheduled elective admissions will be scheduled through the Patient Registration Specialist in the patient access
department. Patient access department will schedule pre-scheduled elective admissions on the date requested by the
physician or physician designate on a first come, first serve basis.
5. Placement of Admissions is a cooperative effort between the Nursing Administration Staff t and the physician.
Infra-Unit and Inter-Unit Transfers:
1. All requests for intra-unit and inter-unit transfers will be requested through the Nursing Administration Staff.
2. Intra-Unit Transfers: Unless the desired bed has been pre-assigned to an incoming patient, every effort will be made to
assign the transferring patient to the bed requested by the Nursing Unit.
3. Inter-Unit Transfers: The Nursing Administration Staff will be responsible for locating and assigning a bed on the unit
to which the patient is to be transferred. Both units involved in the transfer will then be notified by the Nursing
Administration Staff.
4. Inter-Unit Transfers: The Nursing Administration Staff will assign all ICU, step-down beds as per criteria in policies
3364-100-1-15 and 3364-100-1-9 and any overflow bed use in PACU or the ED (See Nursing Policy #3364-110-1-04).
The Nursing Administration Staff will also coordinate the placement/bed assignment during periods of high census,
prioritization of patient flow and the overall management of beds as cited in Nursing Policy #3364-110-1-04.
Transfer Policy from Another Institution:
1. The admission of patients transferred from an inpatient unit at another health care facility to UTMC is contingent upon
the availability of beds and upon the attending physician at the transferring institution clearing and accepting the patient
for transfer with a member of the UTMC medical staff having admitting privileges, and in compliance with government
mandates such as EMTALA. Regional transfers of non-emergent patients will be managed as cited in Hospital Policy
#3364-100-1-11.
A. Elective Transfers: The admitting physician or his designate will contact the Nursing Administration Staff and
provide the following information:

1. Patient's name, date of birth, address, and telephone number.

2. Admitting diagnosis, copy of the other facility's demographic sheet if available. .
3. Name of the transferring institution.
4. Name of the referring physician.
5. Optimum transfer date and time.
6. Other pertinent facts such as isolation required or specialty unit.
7. Requested level of care and room accommodations.

B. Emergency Department to Emergency Department transfers will be managed as per Hospital policy #3364-100-1-5.

C. Emergency Transfers: The Nursing Administration Staff will contact the the hospital operator as well as the
Emergency Department of all emergency transfers. The following information should be provided at this time:

1. Patient's name, date of birth, address, and telephone number.

2. Admitting Diagnosis.
Policy 3364-100-01-01
Admission, Discharge and Transfer
Page 3

3. Name of the transferring institution.

4. Name of the referring physician.
5. Other pertinent facts such as isolation required or specialty unit.
6. Requested Level of Care and room accommodations.
2. The Nursing Administration Staff will contact the transferring institution and make other necessary contacts to obtain
the patient's demographic information and insurance coverage. Every attempt will be made by the UTMC Nursing
Administration Staff to verify the patient's insurance or agency support. The Admitting physician will be notified if the
patient's insurance plan does not cover services provided at UTMC. The Nursing Administration Staff will notify the
transferring facility if we do not accept the patient's insurance carrier. If the transfer falls under the EMTAL A
regulations, the patient will not be denied admission for lack of third party funding. The admitting physician will be
notified when the admission requirements have been satisfied to confirm the transfer date and time. The Nursing
Administration Staff will notify the caregiver at the referring facility in order to obtain information consent for transfer
from the patient.

3. At no time will an emergency transfer be denied admission because of lack of demonstrated ability to pay.

4. If requested room accommodations are not available, the attending physician who is responsible for the patient will be
notified. The attending physician or his designate will be responsible for arranging for another transfer date or different
room accommodations.

5. All patients transferred from other hospitals will be identified as such in the Hospital Information System. For these
patients, source codes on provider bills will reflect the patient's status as a transfer from another hospital.

Approved by: Review/Revision Date:

7/18/81 10/15/2008
10/3/84 2/1/2014
11/21/84
Nofnia Tomlinson, RN,lllN, NE-BC, FACHE Date 4/11/86
Interim Executive Director and Associate Vice 6/26/87
President J s\/} 6/26/88
2/17/89
3/6/90
10/10/91
Kristop6er 6rickman, M.D. Date 3/24/93
Chief of Staff 7/31/96
3/19/97
Review/Revision Completed By: 4/30/04
HAS
Admitting
8/27/07
Nursing
ChiefofStaff
Next Review Date: 2/1/2017
Policies Superseded by This Policy: 7-01-01 - Admission, Discharge and Transfer
It is the responsibility of the reader to verify with the responsible agent that this is the most current version of the policy.