Writing about Hospitalization

Medical Team Working On Patient In Emergency Room

How Authors Can Put Their Characters in the Hospital (The Right Way)

When writing about hospitalization, the top question I get from authors is: “I need this character in the hospital for seven days. Will this ______ (injury or disease) do that?

I get the unfortunate task of telling them, “Sorry, no, they won’t even be admitted.”

Most Americans don’t know how many gears turn when someone is hospitalized, and why would they?  Dramatic changes have occurred in the last few decades, and continue to evolve.

For example, allogeneic (meaning another person donates) bone marrow transplants used to require a stay of about THREE MONTHS. Some still do. But newer chemo regimens have reduced the severe side effects of high-dose chemotherapy – the preparative regimen to wipe out the patient’s marrow before the transplant.

Some patients now have OUTPATIENT allogeneic transplants.

Mind-blowing.

How does hospitalization admission work?

• Direct admit – Your doctor schedules you for admission on a particular date. Used for inpatient surgeries and procedures like bone marrow transplants,  chemotherapy, or any other treatment you have to stay in the hospital to get. Your “bed” is ready, much like a hotel room reservation. Nurses know you’re coming, and doctor’s orders are written.
• Emergency Room Admission – Probably the most common one used by authors, someone is injured or becomes ill and the treatment they need can only be done in the hospital. Patients can be treated in an ER for a certain time, usually no more than 36 hours.
• Transfer admission – When you are in another hospital’s ER of another hospital, or are admitted to a rehab facility or nursing home, and the treating doctor requests a transfer to a specific hospital. Often done for care that can’t be performed in the local hospital.
  • Not all hospitals have cardiac catheterization labs. Severe heart attacks will  be sent by ground (ambulance) or air (helicopter) to a “higher level of acuity” hospital for  a cardiac catheterization.

Did you know the person who decides on admission to a hospital is always a staff physician? Learn more at Novel Malpractice. Click To Tweet

This staff doctor must be either

1) an emergency room physician, or

2) a physician on the hospital medical staff.

See my free handout Which Doctors Do What for a fuller explanation.

 

While an ER doctor may decide to admit, the patient has to be ACCEPTED by a physician service to care for them in-house, like an ICU physician, hospitalist, internist, pediatrician, or surgeon, etc. A bed must be available for the patient. During busy seasons, ERs get backed up with patients in the halls waiting on a room.

These doctor collections are called services –  cardiology service, or internal medicine service, etc.

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Most confusion occurs with reimbursement. The hospital relies on the insurer’s decision because they want to be paid. In insurance , it’s called reimbursement, but it’s not final. The doctor and/or the patient has the right of appeal. A doctor must not commit medical malpractice by refusing to admit a sick or injured patient just because their insurance company refuses to pay.

A person can be admitted without insurance approval, and later receive payment approval, even after the patient has been discharged.

It’s always up to the physician to admit, or not admit, a patient to the hospital. 

Getting health insurers to pay for admission or even outpatient procedures is called authorization or determination. 

Level of carerefers to where the care is being given – ICU (critical care) being the most serious, next is called a Step-down Unit or Progressive Care Unit (can go by other names), a monitored bed with telemetry, a regular bed, rehab bed, or even a skilled nursing facility or hospice inside the hospital.

Hospital Areas

These used to be called hospital “wards” but that term is outdated unless your book is set before the 1980s. Patients are admitted to either a general hospital bed, or a specific area such as:

• ICU
• Labor/Delivery
• NICU (neonatal ICU)
• SICU (surgical ICU)
• TICU (transplant ICU) – can be medical ICU for BMTs’, bone marrow transplant OR a transplant SICU for organ transplants.
• Post-surgical floor, progressive care or step-down unit where they don’t need the ICU but are still too sick to go to a general floor
• Telemetry or monitored bed (patient is on continuous EKG called telemetry)
• Chemotherapy
• Neuro ICU – stroke and brain -injury patients
• Pediatrics
• PICU (pediatric ICU)
• Bone Marrow Transplant
• Burn ICU
• Dialysis Unit

Large hospitals may have other specialty floors for orthopedic surgery, solid organ transplant, bone marrow transplant, GI – gastrointestinal, Cardiac – Heart patients, neurology floor, burn unit, and even spinal rehabilitation. If you go to the website of a hospital in the area of your novel, or one that’s similar, you can see what they offer. Obviously, the largest hospitals are found in or near cities.

 

BEST SUGGESTION? Check out a hospital website in the area where your story is placed. 

 

What determines admission? Not long ago, your diagnosis or surgery would tell how many days in the hospital insurance would cover. During my training, if a patient had a big surgery the next day, we admitted them the night before to do IV hydration, testing, and labs. That rarely happens now.

For a spinal fusion, three to four days is likely. But I just went home the next morning after mine in October, 2023.  If you had a heart attack, three days was automatic. It still is, if you have one. Strokes were at least three days, but often patients stayed longer. That was before clot buster stroke drugs became available.

Today, the care you need and your medical status determines hospitalization. Click To Tweet

AUTHORS writing about hospitalization should keep in mind CARE LEVEL is specific – the patient must need:

> intravenous or intramuscular medications or fluids that cannot be given in a lower intensity setting such as the home or a nursing home. This includes antibiotics, blood pressure medications, pain medications, chemotherapy, total parenteral nutrition or TPN (all your “food” via IV), etc.

> blood products – blood, platelets, clotting factors, white blood cells, etc.  Reactions to these products are common, therefore they are done inside the hospital setting, although you can get these as an OUTPATIENT, in the hospital, without being admitted, if you’re stable and not seriously ill.

> continuous or around the clock nursing observation – this means vital signs have to be monitored continuously or frequently, like every two hours.

> telemetry (constant ECG monitoring) but this can be done in the ER for short periods if needed for less than 24 hours. This monitoring is looking for abnormal heart rhythms and/or ECG changes that indicate issues with ischemia – lack of blood flow to the heart muscle. (heart attack, or unstable angina)

> orthopedic stabilization  – Rarer now with modern surgical hardware, but some patients with certain injuries such as a femur fracture or pelvis fracture need special nursing care and may require traction set ups.

> frequent procedures such as dressing changes, central lines, wound care, dialysis, temporary pacemaker insertion, and vascular intervention procedures to name a few.

As for surgeries – hospital admission is based partly on the type of surgical procedure and partly on your physical status afterwards.

 

 

If you have a simple appendectomy, are young, in good health,  up walking, eating and drinking – you may not be admitted, but will likely get what is called a 24-hour observation stay.

If you’re eighty, have heart, lung and kidney issues, and your blood pressure can’t be controlled afterwards, you will likely be a full admit, or at least have to complete an observation stay before being changed to a full admission.

If you  have an extensive abdominal surgery such as a Whipple,  age won’t matter – you will be admitted.

EXAMPLES:

1. A skilled nursing home patient in a long-term arousable state coma needs a new G-tube (gastrostomy tube) placed in the stomach. This is usually an outpatient procedure BUT this patient’s stomach has developed chronic bleeding and an infection. A surgeon agrees to accept the patient for admission to the hospital and do the surgery in the operating room due to the risk of further bleeding.  TRANSFER ADMIT
2. A skilled nursing home patient in a long-term arousable state coma suddenly starts bleeding profusely around the G-tube in the stomach. EMERGENCY ROOM ADMIT if it’s determined further therapy needed such as surgery, blood products, etc. are needed.
3. A skilled nursing home patient in a long-term arousable state coma has seen recent steady improvements in responding to stimuli such as nurses talking or noises. The patient has a brain shunt to drain extra fluid from the brain (V-P shunt) but needs it replaced. Surgery is scheduled for this. DIRECT ADMIT

For more info on coma, click here:

https://www.killernashville.com/articles/novel-malpractice-coma-by-ronda-wells

QUESTIONS FOR THE WRITER:

1. WHY do I need this character in the hospital? Don’t put them there to just get them out of the way for a few days, unless the injury/illness is integral to your story’s plot and theme. Get creative, and list ten other ways you could remove this character from “circulation” in your story. Obviously, if your character’s struggle is to survive a liver transplant, you’ll need to put them in the hospital. And probably more than once.
2. WILL they have a complication? What really keeps patients hospitalized are things that happen in the course of an illness or recovery. My grandfather, who’d been admitted for pneumonia, got confused and tried to get out of bed to go to the bathroom — and fell and broke his hip. He stayed a whole lot longer than originally planned.

These unexpected complications –

fever

new onset of confusion or change in mental status,

falls,

medication reactions,

bleeding,

slow recovery,

vomiting/diarrhea/dehydration,

organ failure,

blood clots,

INFECTIONS,

etc. are why patients end up staying in the hospital longer.

3. CAN their treatment change? Obviously, my grandfather needed surgery in addition to antibiotics for the pneumonia. Often, patients don’t respond to the first attempt at treating their condition – like a urinary tract infection, and the first set of antibiotics doesn’t work. Or a cancer patient whose tumor doesn’t respond to the first-round chemotherapy or radiation and they must switch to another regimen.

4. WHAT is my character’s age? As always, kids in general recover faster and do better than adults, but there are rare exceptions. I did a Pediatrics internship before switching to Family Practice. I remember being frustrated by how long it took my elderly patients to improve, when a child would be better overnight. Keep age in mind when writing these scenes. Yes, there are 80 year-old marathoners who bounce back fast – but their organs are still eighty years old. They can still go into acute renal failure even if they’re up running around on a broken foot.

5. WHO is my character? Are they a smoker? A heavy drinker? Do they use street drugs? Do they have diabetes, or other serious illnesses? Asthma? High blood pressure? Knowing your character’s health profile can help you design a plausible hospitalization. These types of issues are called co-morbid conditions.

6. WHERE is this hospital? As stated, larger hospitals go with cities. Hospitals in a super-large metropolis like New York or Chicago can be more like a chain of hospitals, and have massive facilities all linked by one computer system. Rural hospitals are smaller, with less resources, and can only handle basic admissions and surgeries.

7.  WHEN is my character going to be in the hospital?  What era is your story? If before 1960, hospital care was fairly limited and almost primitive. Antisepsis was the supreme focus, in order to prevent infections because there were only a few antibiotics available. After 1960s, technology took over and rapid advances occurred, which dramatically changed what hospitals looked like and how they worked.

An excellent, thoughtful essay on care from the 1960s forward, written by an internist, is here: https://www.caringfortheages.com/article/S1526-4114(20)30087-1/fulltext

FYI: You won’t find brain surgery being done at any local hospital in the boonies –unless there’s some sort of pre-planned outreach to send a neurosurgical team there.

Often, large hospitals are linked with a university medical school. For an example, look up the history of Methodist Hospital of Indianapolis – where I trained – and Indiana University Hospitals. Methodist was the third largest private hospital in the USA when I was there in the mid-1980s.

They later merged with Indiana University Hospitals. The emphasis shifted to IU Hospital on the main IUPUI campus, but ironically now Methodist is the primary hospital where a brand-new medical school, office building, and a new “Methodist” hospital complex is being built.

https://indyencyclopedia.org/indiana-university-health-methodist-hospital/

https://iuhealth.org/find-locations/iu-health-methodist-hospital

Not that I’m complaining, because I’m now at the age where I often need . . .  as much as I hate to be in one . . . the hospital.