Improving Outpatient to Inpatient Handoffs for Direct Admissions to Internal Medicine Services

From the 2022 HVPA National Conference

Seth Scheetz MD (University of Chicago Department of Medicine), Misha Tran MD, Catherine Waymel MD, Jack Zhao MD, Mikail Siddiki MD, Micah Prochaska MD, Vineet Arora MD, Khanh Nguyen MD


A direct hospital admission is a common process wherein a patient is non-emergently admitted by an ambulatory provider to the hospital ward, bypassing an evaluation in the emergency room. Direct admissions can improve patient satisfaction, improve coordination of care between outpatient and inpatient teams and throughout the hospitalization, and reduce emergency room volume and costs. Non-optimized direct admission processes can lead to safety hazards, such as delays to identifying unstable patients, and create inefficiencies in care, such as increasing the number of clinicians involved in a patient’s care and increasing repeat diagnostic studies.


The purpose of this project was to improve handoffs between outpatient and inpatient teams for direct admissions.


A convenience survey was distributed to internal medicine residents (IMR) and hospitalists at the University of Chicago Medicine to measure the perception of the current state of direct admissions, the inpatient team’s ability to contact the outpatient team, and the quality of handoff information.


A total of 45 participants (17 IMR, 28 hospitalists) responded to the survey. 69% (31/45) of respondents were unsatisfied with the current state of direct admissions. 62% (28/45) of respondents were unsatisfied with the ability to reach or communicate with the outpatient provider. 69% (31/45) of respondents were unsatisfied with the quality of handoff information. 51% (23/45) of respondents reported having experienced a near miss, medical error, or unsafe situation due to the direct admission process. Respondents identified safety hazards including direct admission of patients with unstable vital signs (rather than evaluation in the emergency room), inadequate handoff information regarding the reason for the direct admission or immediate next steps to coordinate care, delays in medication administration, and late notification of patient arrival.


The survey results highlight a general dissatisfaction with the direct admission process for the inpatient internal medicine and hospital medicine physicians, as well as a perceived lack of communication for directly admitted patients at a large academic medical center. This preintervention survey informed the development of a brief note template that outpatient teams may use to convey pertinent information regarding direct admissions to inpatient teams (Fig. 1). Our next steps in this PDSA cycle are to develop a “smart” order set that prompts outpatient teams to complete the direct admission handoff note at the time of placing a bed request order in the electronic health record, direct outreach to outpatient providers, and measure impact with a post-intervention survey.

Clinical Implications

A standardized handoff process for direct admissions can improve clinician communication, a key in reaching high value care aims of reducing healthcare waste, avoiding harm, and improving outcomes.

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