A 58-year-old man is evaluated on the medical-surgical ward for transition of care. He was… — USMLE Step 3

A 58-year-old man is evaluated on the medical-surgical ward for transition of care. He was admitted 8 days ago for a severe right diabetic foot infection complicated by osteomyelitis of the first metatarsal. He underwent a partial ray amputation on hospital day 2. The surgical site was intentionally left open and currently requires complex wet-to-dry dressing changes twice daily. He is receiving intravenous vancomycin via a peripherally inserted central catheter (PICC) for methicillin-resistant Staphylococcus aureus (MRSA); the planned antibiotic course is 6 weeks.

Vital signs are normal, and he is afebrile. Laboratory studies show a leukocyte count of $7,800/\mu L$ and a C-reactive protein (CRP) of $35 \text{ mg/L}$ (normal: $<10 \text{ mg/L}$ ), which has steadily decreased from $150 \text{ mg/L}$ on admission.

From a mobility standpoint, the patient is strictly non-weight-bearing on the right lower extremity. Physical therapy has trained him to be independent with wheelchair mobility on level surfaces; however, he cannot use crutches or a walker due to pre-existing severe bilateral shoulder osteoarthritis. He lives alone in a second-floor apartment accessible only by a steep flight of stairs. He is clinically stable and eager to leave the acute care hospital.

Which of the following is the most appropriate next step in the disposition of this patient?

Transfer to a skilled nursing facilityAnswer
B
Discharge home with home health services
C
Transfer to an inpatient rehabilitation facility
D
Retain in the acute care hospital until the C-reactive protein normalizes
E
Delay disposition to obtain an MRI of the right foot to confirm complete infection clearance

Answer

Transfer to a skilled nursing facility

The most appropriate disposition for this patient is a transfer to a skilled nursing facility (SNF). Disposition planning requires evaluating three domains: medical needs, functional capacity, and the social/home environment. Medically, this patient requires skilled nursing care for 5 more weeks of intravenous antibiotics via PICC and twice-daily complex wet-to-dry dressing changes. While these medical needs could technically be managed at home by a visiting home health nurse, his functional and environmental limitations prohibit this. He is newly restricted to a wheelchair and lives alone in a second-floor apartment accessible only by stairs. Discharging him home would strand him, creating a highly unsafe situation. An SNF provides the required skilled medical care in a safe, accessible environment until he can bear weight, safely use a prosthesis, or arrange alternative housing.

Step-by-Step Solution

Evaluate the patient's ongoing medical requirements.

The patient requires 6 weeks of intravenous antibiotics and twice-daily complex wound care.

Establishing medical acuity determines if the patient needs continued acute care, skilled nursing, or can be managed in an outpatient setting.

Assess the patient's functional status and environmental barriers.

The patient is strictly wheelchair-bound and lives alone in a second-floor apartment without an elevator.

Environmental constraints can render an otherwise appropriate home discharge critically unsafe.

Synthesize data to select the optimal post-acute care setting.

A skilled nursing facility (SNF) is selected.

An SNF provides the necessary skilled nursing for wound care and IV medications while bypassing the insurmountable environmental barrier of the patient's home.

Key Concept

Safe transitions of care require synthesizing a patient's medical needs with their functional capacity and specific environmental constraints.

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