What’s the Right Way to Refuse an Inappropriate Overnight Admission?

The wrong way to refuse an inappropriate overnight admission will haunt you for months. The right way will quietly protect your sanity, your patients, and your reputation.

Here’s exactly how to do it.

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First: Know What Actually Counts as “Inappropriate”

You cannot refuse an admission just because it’s inconvenient or annoying. You can refuse it when it genuinely does not belong on your service, in your hospital, or at that level of care.

Common categories:

1. Wrong service

   • Classic: Surgery trying to “admit to medicine for optimization” when they’re booking an OR tomorrow.
   • Or neurosurgery asking medicine to admit a patient whose only problem is a subdural they plan to operate on.

2. Wrong level of care

   • Patient clearly needs ICU (pressors, unstable airway, escalating oxygen needs) and you’re the floor resident.
   • Or clearly safe for observation/ED hold, but they’re trying to create a full admission to clear the board.

3. Wrong hospital / out-of-network / inappropriate transfer

   • Transfer that doesn’t meet your hospital’s capabilities or agreements (e.g., needs ECMO and you don’t have it).
   • Stable patient transferred solely for “placement” when your hospital doesn’t do custodial care.

4. Straight-up dumping

   • Other service/hospital trying to get rid of a complex patient they don’t want to deal with at night: no clear admitting diagnosis, no active need for inpatient medicine, just “unsafe discharge” with no actual acute issue.

If you can’t clearly articulate why it’s inappropriate, you’re probably not ready to refuse it. Your first job is to define the problem with one crisp sentence.

Example:
“From what you’ve told me, this is a surgical admission with a clear operative plan and no primary medical issue requiring medicine admission.”

That sentence is your anchor.

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The Core Rule: You Never Say “No” Until You’ve Done Three Things

This is the backbone. Every time. Before you refuse:

1. Get the story yourself
2. Offer a medically sound alternative
3. Loop in backup (chief, attending, transfer center, or hospitalist lead)

Once you’ve done those, you can say “no” and sleep at night. Literally.

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Step 1: Get the Story Yourself (Not Just the Label)

Do not refuse based on one line of SBAR or a grumpy nurse’s summary. You need enough detail to defend your decision to your attending the next morning.

Minimum data to gather:

• Vital signs trend (not just last set; ask about trajectory)
• Basic labs and imaging relevant to the admission reason
• Consults already involved (who has seen this patient and what did they say?)
• Code status and major comorbidities
• The stated reason for admission (“What’s the admitting diagnosis and goal?”)

Then ask the key question that gets to the truth:

“What are you hoping medicine will actively manage tonight that cannot be done in the ED or on your service?”

If they start fumbling here, that’s your first red flag.

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Step 2: Decide: Is This “Hard No” or Just “Annoying Yes”?

Residents mix these up all the time. You’re not refusing just because something’s garbage work.

Ask yourself:

• Is there any acute inpatient-level need that fits my service?
• Would my attending back me up if they listened to this story?
• Is patient safety compromised if I say no?
• Is system safety compromised if I say yes? (e.g., boarding an ICU patient on the floor)

If the patient clearly needs:

• Your service: you take it. Even if the consult/transfer was messy.
• A different service: you redirect and help make that happen.
• A different level of care: you escalate to ICU/intermediate/obs appropriately.

Refusal is for cases where admitting to your service would be inappropriate or unsafe, not just unpleasant.

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Step 3: Use the Right Script on the Phone

You need a calm, structured script. Not emotional reactions.

When it belongs to another service

You:
“Based on what you’ve told me, the primary issue is [X: e.g., operative femur fracture requiring OR]. There’s no active medical problem that requires medicine admission at this time.”

Then immediately offer a reasonable plan:

• “The appropriate service is ortho as primary, with medicine consult if needed tomorrow for risk stratification.”
• “I’m happy to see them as a consult in the morning once they’re admitted to [other service].”

Key moves:

• Name the right service explicitly.
• Say what you will do (consult, co-manage) rather than just what you won’t.

When it’s the wrong level of care

You:
“Right now they’re on [X oxygen, on Y pressor, with Z instability]. That meets criteria for ICU. It would be unsafe to admit them to the floor on medicine.”

Then:

• “The safest plan is ICU admission. I recommend you call the ICU directly or involve the ICU triage attending.”
• “If they stabilize to floor-appropriate status, I’m happy to reassess admission at that point.”

You are making patient safety your hill to stand on. That’s hard to argue with.

When the patient doesn’t meet inpatient criteria

You:
“I agree the patient has issues, but from what you’ve described, there’s no clear acute inpatient need tonight.”

Then offer alternatives:

• “This sounds appropriate for continued ED observation with plan for outpatient follow-up in [specialty/clinic] within [timeframe].”
• “We can consider placing observation status if your ED protocols allow, but this doesn’t meet criteria for full inpatient medicine admission.”

You aren’t just blocking; you’re redirecting.

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Step 4: Loop in Backup Before You Draw a Hard Line

You are not a wall. You’re a filter.

Who you call depends on your system, but typical hierarchy:

• In-house senior or night float senior
• On-call chief resident
• Nocturnist/hospitalist attending or your service attending
• Transfer center or bed control, if it’s an outside transfer

Your call sounds like this:

“Hey, I’ve got a proposed admission I think is inappropriate for medicine. Briefly: [30–60 second summary]. ED wants us to admit for [weak reason], but primary issue is [surgical/ICU/placement] and they have [current vitals and stability]. I told them this should go to [other service/ICU/obs]. Before I refuse, I want to make sure you’re aligned.”

Two key benefits:

1. You protect yourself. If attending says, “Take it,” then it’s their name, not your solo decision.
2. You often get better institutional language and leverage: “Tell them our policy is X,” or “We never accept those at night — direct to ICU/obs/ED hold.”

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Step 5: Document Like Someone Will Complain (Because They Might)

You don’t chart an admission that never happened. But you can and should document communication when there’s potential risk or drama.

Typical places:

• A brief telephone encounter note if your EMR allows
• Or at least an internal message/email to your attending or chief summarizing the issue

Include:

• Who called you (name, role, location)
• Time of call
• Key clinical details you were told
• Your assessment of why it was inappropriate for your service
• Who you escalated to and what they said
• Final plan (e.g., “ED to continue management, consider obs,” “Directed to surgical admitting physician,” “Recommended ICU admission”)

One tight paragraph is enough. But it will save you if morning leadership gets an angry call: “Medicine refused our patient.”

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Step 6: Use Policy and Criteria — Not Emotion

The fastest way to lose an argument is to make it personal.

Don’t say:

• “You guys always dump on us.”
• “This isn’t fair.”
• “I’m not taking this.”

Do say:

• “This doesn’t meet our medicine admission criteria because…”
• “Hospital policy is that surgical cases with planned OR are admitted to the surgical service.”
• “Floor-level care cannot safely provide [pressors/BiPAP/whatever they need]. This meets ICU criteria.”

If your hospital has written guidelines, know them. Print them. Bookmark them. Quoting policy calmly beats yelling 100% of the time.

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Step 7: Know the Special Landmines

Some scenarios are notorious for overnight conflict.

“Admit for placement”

Translation: They want you to turn your acute care hospital into a SNF.

Approach:

• “I agree the patient needs placement, but there’s no acute inpatient indication. Placement alone doesn’t meet admission criteria.”
• “They should remain in [ED/obs/unit] under current care while case management works on disposition in the morning.”

“Admit for PT/OT”

Unless your hospital explicitly allows this:

• “PT/OT is not an admission indication by itself. If there’s no acute medical issue requiring inpatient care, we can’t admit just for therapy.”

“Admit to medicine to ‘tune up’ before surgery”

Classic dump from surgical services.

• “Pre-op optimization without an active medical issue is not a medicine primary admission. The surgical service remains primary, and we can consult to assist with risk stratification and management.”

Offer: “I’m happy to see them early in the morning as a consult and give you clear peri-op recommendations.”

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How to Say “No” Without Burning Bridges

The goal isn’t to win the argument. The goal is to keep patients safe and keep the system functional. You’ll work with these people every day.

Good habits:

• Stay neutral in tone. Monotone almost. Emotional charge usually escalates.
• Acknowledge their concern: “I hear that you’re worried about [X]. I agree that needs follow-up. But that doesn’t require a medicine admission tonight.”
• Offer what you can do: “I can call my attending with you,” “We can see them as a consult tomorrow,” “We can re-discuss if they become unstable.”

Bad habits:

• Getting defensive about “how busy you are”
• Saying, “If you really cared about the patient, you’d…”
• Hanging up without a clear, agreed plan

You want to be known as the resident who is firm but reasonable, not the one who fights every handoff.

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When You Actually Should Just Take the Bad Admission

Here’s the uncomfortable truth: sometimes the right move is to swallow the garbage.

Take it when:

• Patient safety could be compromised by further delay.
• It’s a gray zone that could reasonably belong to you or someone else.
• Your attending or chief directly says, “We’re taking this one.”
• It’s 3 a.m., the ED is melting down, and this is a technically-appropriate but annoying admit.

You’re allowed to vent later. On the night? You stabilize the system.

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Quick Decision Framework

Here’s the mental flow I’ve seen senior residents use at 2 a.m.:

Overnight Admission Refusal Framework

Step	Description
Step 1	Call about admission
Step 2	Get full story
Step 3	Direct to other service or ED/obs
Step 4	Accept admission
Step 5	Recommend ICU or higher level
Step 6	Call senior/chief/attending
Step 7	Refuse with clear rationale and alternative
Step 8	Clear medicine issue?
Step 9	Floor appropriate?
Step 10	Leader agrees to refuse?

Use that backbone, and you’ll make fewer enemies and fewer unsafe decisions.

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A Brief Reality Check: Politics vs. Principles

Hospitals are political. Some services are bullies. Some EDs over-admit. Some medicine teams dump back. You’re in the middle of all that.

Your priorities, in order:

1. Patient safety
2. Medical appropriateness
3. Policy alignment
4. Service politics
5. Your personal convenience (yes, it’s last)

You protect yourself with:

• Clear clinical reasoning
• Calm documentation
• Escalation to attendings/chiefs when there’s conflict
• Consistency — you can’t refuse one night and accept the same junk happily the next night

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Common Overnight Admission Conflicts by Type

Category	Value
Wrong service	35
Wrong level of care	25
Placement only	20
Pre-op tune up	15
PT/OT only	5

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A Sample Script You Can Steal

Put your own words on it, but the structure works:

“Thanks for calling me about this patient. Let me just summarize to make sure I’ve got it right: [30-second recap]. Right now, the main issue is [X], and they’re [stable/unstable, on Z support]. Based on that, this doesn’t fit criteria for a medicine floor admission because [clear, clinical reason].

The safest and most appropriate plan is [other service/ICU/ED obs], and I recommend you [call ICU/direct admit to surgery/contact hospitalist]. I’ve discussed this with [senior/chief/attending], and we’re aligned on this plan. If their status changes and they develop an acute medical issue appropriate for medicine, I’m happy to re-evaluate.”

That’s how grown-ups talk in hospitals.

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Bottom Line

Three takeaways and you’re done:

1. Do not refuse blindly. Get the details, decide if it’s truly inappropriate for your service, then anchor your refusal in specific clinical and policy reasons.
2. Never just say “no.” Offer a safer, more appropriate alternative and loop in your senior, chief, or attending before you draw a hard line.
3. Protect yourself: communicate calmly, document key conflicts, and accept that sometimes you’ll take a bad admission — but you should never take an unsafe one.