Signs of Imminent Admission

Having trouble complying with the new 4 picosecond rule introduced by UCEM? Do not fret, you can improve your department’s efficiency a thousandfold by religiously employing the ‘Signs of Imminent Admission’ as a disposition decision aid.

Vital signs:

  • Pulse oximetry < Age
  • Blood pressure < Age
  • Age > Body temperature (Fahrenheit)
  • ‘Unable to measure’ is written in the triage note
  • Note that tachypnea, a key indicator of serious illness, may be masked by the phenomenon of synypnea.

End-of-the-Bed Observations:

  • Signs of ‘Homesteading’ such as ‘Positive Suitcase Sign’ (PSS) aka ‘Samsonite Sign
  • The patient’s relative says on his or her mobile phone: “OK, the doctor is here, I’ll call you back once we’ve been moved to the medical ward.”
  • Tinted speculopathy in the absence of a personality disorder.
  • Patient wakes up and pushes away the team of people who have been pressing up-and-down on his or her chest for the last 5 minutes.

History of Presenting Complaint:

  • The patient plays golf with the current Hospital Administrator and the head of the largest law firm in town.
  • The patient was sent in from a nursing home:
  • on a Friday afternoon after 5pm
  • on a public holiday
  • no referral letter or contact number is provided.
  • The patient tells you the names and phone numbers of the seven sub-specialists that usually manage his or her condition – all of whom are currently on holiday.
  • The patient continues to mention new medical problems after having been told that the first 12 complaints were not problems that can be solved in the ED.

Past Medical History:

  • The patient hands you a Differential Diagnosis Printout [DDP] or Adverse Drug Reaction Printout [ADRP].
    • The number of highlighted sections, complete with a time-line of annotations, is directly proportional to likelihood of admission.
  • The patient has a management plan in his or her old notes saying that under no circumstances should they be admitted under Team X. The patient will inevitably have an acute problem requiring admission under Team X.
  • A restraining order was placed on the patient following his or her last visit to the ED – so he or she is not legally allowed within 200m of the department. A code or major trauma call is imminent.
  • The patient’s usual doctor has an eponymous syndrome named after him or her – and the patient has that syndrome.

On Examination:

  • The patient has turned up to the ED in more than one piece – and is still alive.
  • The patient has a New Zealand accent and has presented during an All Blacks game.
  • The patient has right upper quadrant pain in the presence of umbilical jewelry and a tattoo near the groin or lower back, and is wearing a black G string. Immediate referral to Gynecology for inpatient management of Fitz-Hugh and Curtis syndrome is mandatory.

If you are still deliberating over the need for a medical admission, perform Bayesian analysis using the following likelihood ratios:

And, before you decide that a patient is not going to make it and there is no point booking an inpatient bed, remember the ‘Tattoo to Teeth Ratio’ for survivability:

  • A general rule of thumb is that if the tattoo-to-tooth ratio (TTR) is greater than or equal to one, your patient is indestructible.
  • The higher the TTR score, the lower the likelihood of a terminal outcome.
  • A patient with a TTR of just two could be run over by a truck after being shot twice in the back outside of the bar in which they drank six fifths of whiskey, and shortly after admission to the emergency department they would be demanding cigarettes and sexual favors from any nearby persons.

Finally, if, after having made the decision to admit a patient, you run into a wall revisit this fail-safe guide to managing the Patient Without Discernible Pathology.

You’ll be fine.


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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