====================================================================
STANDARD OPERATING PROCEDURE
====================================================================
Document Title  : Patient Admission, Triage & Bed Allocation Protocol
Document Number : SOP-OPS-ADM-014
Version         : 2.1
Effective Date  : August 1, 2024
Review Due      : July 31, 2025
Prepared by     : Quality & Patient Safety Department
Approved by     : Medical Director | COO | Head Nurse (ICU & General)
====================================================================
Organisation    : Sunrise MultiSpecialty Hospital, Hyderabad
Applicability   : Emergency Department, OPD, General Wards (IP),
                  ICU/HDU, Front Desk Administration
====================================================================

--------------------------------------------------------------------
1. PURPOSE
--------------------------------------------------------------------

This Standard Operating Procedure (SOP) defines the process for the
admission, triage, and bed allocation of patients at Sunrise Multi-
Specialty Hospital. Its purpose is to ensure that:

  a) Every patient presenting to the hospital receives timely,
     appropriate clinical assessment based on acuity of need.

  b) Bed allocation is systematic, data-driven, and prioritizes
     patient safety over administrative convenience.

  c) All staff involved in the admission process follow a consistent,
     documented workflow that complies with NABH accreditation
     standards and applicable medicolegal requirements.

  d) Accurate records are maintained in the Hospital Management
     Information System (HMIS) from the point of first contact.

--------------------------------------------------------------------
2. SCOPE
--------------------------------------------------------------------

This SOP applies to:
  - Walk-in patients (Emergency and OPD)
  - Patients arriving by ambulance
  - Referral patients from other hospitals or clinics
  - Patients transferred from one department/unit to another
    within the hospital

It does NOT cover:
  - Day-care procedures (refer SOP-OPS-DAY-007)
  - Surgical pre-admission workup (refer SOP-OPS-PRE-002)
  - Neonatal ICU (NICU) admissions (refer SOP-NICU-ADM-001)

--------------------------------------------------------------------
3. DEFINITIONS
--------------------------------------------------------------------

TRIAGE       : The process of prioritising patients based on the
               severity of their condition to ensure that the most
               critically ill are treated first.

ESI          : Emergency Severity Index — a five-level triage tool
               used to categorise patients on arrival at the Emergency
               Department.

HMIS         : Hospital Management Information System (the hospital
               uses MediSync v4.2 as of this version).

BED STATUS   : Classification of hospital bed availability, updated
               in HMIS in real-time: Available / Occupied / Reserved /
               Under Cleaning / Under Maintenance.

ADT          : Admission, Discharge, and Transfer — the core patient
               movement workflow tracked in HMIS.

LAMA         : Leave Against Medical Advice — when a patient chooses
               to leave despite clinical recommendation to stay.

IP           : In-Patient (admitted to a ward or ICU bed).

OP           : Out-Patient (consultation-only, not admitted).

HDU          : High Dependency Unit — step-down care between ICU
               and general ward.

--------------------------------------------------------------------
4. RESPONSIBILITIES
--------------------------------------------------------------------

Role                         Responsibilities
--------------------------------------------------------------------
Front Desk Executive         Patient registration, ID verification,
                             demographic capture in HMIS, insurance
                             pre-authorisation initiation.

Triage Nurse (ER)            ESI scoring, vital signs recording,
                             initial clinical documentation, notifying
                             ER physician for ESI 1 and 2 cases.

ER Physician                 Clinical assessment, admission decision,
                             specialty referral, initial orders entry.

Bed Manager / Coordinator    Real-time bed status monitoring, bed
                             allocation coordination, resolution of
                             bed conflicts, communication with wards
                             and housekeeping.

Ward Nurse (Receiving)       Patient reception at the ward, nursing
                             assessment, care plan initiation.

Housekeeping Supervisor      Timely turnaround of vacated beds
                             (target: under 45 minutes).

HMIS Administrator           System access management, daily bed
                             census report, escalation of system
                             downtime.

Medical Social Worker        Support for unidentified/unconscious
                             patients, LAMA cases, insurance issues.

--------------------------------------------------------------------
5. PROCEDURE
--------------------------------------------------------------------

5.1 STEP 1: PATIENT ARRIVAL AND REGISTRATION

5.1.1 All patients arriving at the hospital — whether at the
      Emergency Department (ER/Casualty), OPD Reception, or directly
      referred to a ward — must be registered in HMIS before any
      clinical service is provided, EXCEPT in the following cases:

      - ESI Level 1 (immediate life threat): Clinical stabilisation
        takes priority. Registration must be completed within
        30 minutes of arrival by the Front Desk Executive
        accompanying the clinical team to the bedside.

      - Unconscious/unidentified patients: Registered as "Unknown
        Male/Female [Date] [Time]" and tagged with a unique wristband
        ID. Medical Social Worker notified immediately.

5.1.2 Information collected at registration:
      - Full name, date of birth, gender
      - Contact number (patient and emergency contact)
      - Address (current residence)
      - Government photo ID number (Aadhaar / Passport / DL)
      - Insurance details (if applicable; copy of card/policy)
      - Referral details (if referred by external physician/hospital)
      - Mode of arrival (walk-in, ambulance, private vehicle)

5.1.3 The patient is issued a unique Patient Registration Number (PRN)
      generated by HMIS. A printed wristband is applied within
      10 minutes of registration. The wristband displays:
        - PRN
        - Patient name
        - Date of birth
        - Allergy alert flag (if known at time of registration)

--------------------------------------------------------------------

5.2 STEP 2: TRIAGE (EMERGENCY PATIENTS)

5.2.1 All patients presenting to the Emergency Department undergo
      triage assessment by the designated Triage Nurse within
      5 minutes of arrival at the ER entrance.

5.2.2 The ESI (Emergency Severity Index) scale used:

      Level  Description            Target Time to Physician
      --------------------------------------------------------
        1    Immediately life-       Immediate (physician at bedside
             threatening             within 0 min — pre-alerted)
        2    High-risk / severely   Within 10 minutes
             distressed
        3    Stable but requires    Within 30 minutes
             multiple resources
        4    Stable, likely 1        Within 60 minutes
             resource needed
        5    No resource needed     Within 120 minutes
      --------------------------------------------------------

5.2.3 Triage Nurse records in HMIS:
      - Chief complaint (free text + coded using ICD-10 symptom codes)
      - Vital signs: BP, pulse rate, respiratory rate, SpO2, temperature
      - ESI level assigned
      - Triage timestamp (auto-captured by HMIS on save)
      - Pain score (NRS 0–10)
      - Allergy history (brief)

5.2.4 ESI Level 1 and 2 patients: Triage Nurse activates the
      ER Rapid Response Protocol:
        - Verbal alert to ER Physician (direct call, not intercom)
        - Code Blue announced over PA if cardiac/respiratory arrest
        - Resuscitation bay or trauma bay assigned immediately

5.2.5 ESI Level 3–5 patients are directed to the ER waiting area and
      called based on their triage level and sequence within level.

--------------------------------------------------------------------

5.3 STEP 3: CLINICAL ASSESSMENT AND ADMISSION DECISION

5.3.1 The ER Physician (or, for OPD patients, the consulting
      specialist) conducts a full history and examination and
      determines one of the following dispositions:

        A. Admit as In-Patient (IP)
        B. Admit to Day Care (referral to Day Care SOP)
        C. Discharge with OPD follow-up
        D. Refer to another hospital (if service not available)
        E. LAMA (if patient insists on leaving)

5.3.2 For Disposition A (IP Admission):
      - Physician completes the IP Admission Order in HMIS,
        specifying:
          * Admitting diagnosis (ICD-10 code mandatory)
          * Specialty / unit (e.g., Cardiology, Orthopedics, General Medicine)
          * Ward preference (General / Semi-Private / Private / ICU)
          * Diet orders (initial)
          * Investigations required pre-admission
          * Attending physician name
      - The Admission Order serves as the legal and financial trigger
        for bed allocation and billing initiation.

5.3.3 For Disposition E (LAMA):
      - Physician counsels patient and documents risks of self-discharge.
      - Patient (or legal guardian if minor/incapacitated) signs the
        LAMA declaration form (Form-MED-LAMA-01).
      - Medical Social Worker is involved if patient appears vulnerable.

--------------------------------------------------------------------

5.4 STEP 4: BED ALLOCATION

5.4.1 Upon IP Admission Order entry by the physician, HMIS
      automatically notifies the Bed Manager via dashboard alert
      and, if after-hours, via pager/SMS.

5.4.2 Bed Allocation Priority Rules:

      Priority 1 — ICU / HDU beds:
        - ESI 1 & 2 patients with critical diagnoses (MI, stroke,
          polytrauma, respiratory failure, septic shock, etc.)
        - Post-operative patients requiring intensive monitoring
        - ICU beds allocated by ICU Intensivist, not Bed Manager

      Priority 2 — HDU beds (step-down):
        - Patients being shifted from ICU as condition stabilises
        - High-dependency post-operative cases

      Priority 3 — Specialty/Observation beds:
        - Allocated by Bed Manager per physician specialty request
        - Patient preference (General/Semi-Private/Private) applied
          when medically equivalent beds are available

5.4.3 If the requested bed type is not available:
        - Bed Manager searches for available equivalent within specialty
        - If no equivalent: discusses with physician and patient/family
          for temporary accommodation in a different category
        - If no beds available (full capacity):
            > Bed Manager activates Surge Protocol (SOP-OPS-SURGE-001)
            > Identifies patients eligible for early discharge
            > Contacts sister facilities within Sunrise Group for
              transfer (if patient consents)

5.4.4 Target Bed Allocation Time (from Admission Order to bed assignment):
        - ICU / HDU    : < 15 minutes
        - General Ward : < 45 minutes
        - Private Room : < 30 minutes

5.4.5 Bed Manager updates HMIS to "Reserved" once allocated.
      Ward receiving nurse is notified via HMIS alert and phone call.

--------------------------------------------------------------------

5.5 STEP 5: PATIENT TRANSPORT TO WARD

5.5.1 ER Patient: Transported by orderly/ward boy with Triage Nurse
      or ER Nurse escort. For ESI 1/2 patients or those on oxygen or
      IV drips, a Nurse must accompany.

5.5.2 Mandatory handover checklist at ward:
        [ ] Patient identity verified (PRN wristband)
        [ ] Current vital signs communicated
        [ ] Active medication / IV infusion details
        [ ] Allergy status communicated
        [ ] Pending investigation results flagged
        [ ] Physician admission orders accessible in HMIS

5.5.3 Receiving Ward Nurse acknowledges handover in HMIS.
      HMIS bed status auto-updates from "Reserved" to "Occupied."

--------------------------------------------------------------------

5.6 STEP 6: INITIAL NURSING ASSESSMENT IN WARD

Upon patient arrival at the ward, the Nurse must complete within
60 minutes:
  - Full nursing assessment (functional status, fall risk — Morse
    Scale, pressure ulcer risk — Braden Scale, pain assessment)
  - Care plan initiation in HMIS
  - Notification to Nutrition team if dietary order is flagged
  - Confirmation of emergency contact and next-of-kin details
  - Patient and family orientation to ward (call bell, visiting
    hours, escalation process)

--------------------------------------------------------------------
6. ESCALATION MATRIX
--------------------------------------------------------------------

Situation                              Escalate To
---------------------------------------------------------
No bed available > 60 min for IP       Medical Superintendent
ESI 1 patient with no ICU bed          ICU In-charge + Medical Director
HMIS system down > 30 min             IT Helpdesk + HMIS Admin + COO
Conflict over bed allocation           Bed Manager → COO
LAMA with medicolegal risk             Medical Social Worker → Medical
                                       Director + Legal Cell
Unidentified / MLC patient             Duty Medical Officer → Hospital
                                       Administration → Police (as reqd)
---------------------------------------------------------

--------------------------------------------------------------------
7. KEY PERFORMANCE INDICATORS (KPIs)
--------------------------------------------------------------------

Metric                                Target        Measurement
---------------------------------------------------------------
Triage completion within 5 min         > 95%        Monthly audit
ESI 1 physician contact < 0 min       100%          HMIS timestamp
ESI 2 physician contact < 10 min       > 95%        HMIS timestamp
Bed allocation time (General) < 45 min > 90%        HMIS timestamp
Bed turnaround time (vacated) < 45 min > 90%        Housekeeping log
Nursing assessment within 60 min       > 95%        HMIS timestamp
Wristband applied within 10 min        > 98%        Random audit
HMIS registration completeness         100%         Daily HMIS report
---------------------------------------------------------------

--------------------------------------------------------------------
8. RECORDS AND DOCUMENTATION
--------------------------------------------------------------------

Record                    Format      Retention     Custodian
---------------------------------------------------------------
Triage Register           HMIS        7 years       Medical Records
Admission Register        HMIS        Permanent     Medical Records
LAMA Declaration Form     Paper+Scan  10 years      Medical Records
Bed Allocation Log        HMIS        3 years       Bed Manager
Handover Checklist        Paper+HMIS  2 years       Ward Nurse
Daily Bed Census Report   HMIS/PDF    1 year        HMIS Admin
---------------------------------------------------------------

--------------------------------------------------------------------
9. REFERENCES
--------------------------------------------------------------------

  - NABH Standards for Hospitals (5th Edition), Chapter 3: Access,
    Assessment, and Continuity of Care (AAC)
  - Digital Personal Data Protection Act, 2023 (for patient data)
  - MCI / NMC Code of Medical Ethics (relevant sections)
  - Sunrise Hospital Policy: Patient Rights and Responsibilities
    (Document: POL-PT-RTS-001)
  - Sunrise Hospital Surge Capacity Protocol (SOP-OPS-SURGE-001)
  - MediSync v4.2 User Manual — ADT Module

--------------------------------------------------------------------
10. REVISION HISTORY
--------------------------------------------------------------------

Version   Date            Author                Changes
--------------------------------------------------------------------
1.0       March 2019      Dr. P. Raghavan       Initial issue
1.1       September 2020  Q&PS Team             COVID-19 addendum
           (addendum)                            (now retired)
2.0       January 2023    Q&PS / Med Director   Full revision: ESI
                                                 adoption, HMIS v4
2.1       August 2024     Q&PS Team             DPDP Act compliance
                                                 notes; KPI section
                                                 added; LAMA process
                                                 updated
--------------------------------------------------------------------

====================================================================
END OF DOCUMENT

Quality & Patient Safety Department
Sunrise MultiSpecialty Hospital | Hyderabad
Document Control System Reference: SOP-OPS-ADM-014-v2.1
====================================================================
