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Question

Difficulty: MediumDisposition and Care Setting Transitions

A 7878-year-old man is evaluated for discharge planning. He was admitted one week ago for fever and severe localized lower back pain and was subsequently diagnosed with methicillin-susceptible *Staphylococcus aureus* (MSSA) vertebral osteomyelitis of L3-L4. He has been treated with intravenous cefazolin. He is now afebrile, hemodynamically stable, and his back pain has significantly improved. He requires an additional five weeks of intravenous antibiotic therapy. His medical history is significant for hypertension and moderate Alzheimer dementia. Prior to admission, he lived alone, and his son visited on weekends to help with chores. The patient is able to ambulate independently with a cane, which is his baseline, and is independent in basic activities of daily living such as eating and dressing. However, he is oriented only to person, has significant short-term memory deficits, and requires supervision for medication administration. Which of the following is the most appropriate disposition for this patient?

  1. Transfer to a skilled nursing facilityAnswer
  2. B
    Discharge home with outpatient parenteral antimicrobial therapy and daily home health visits
  3. C
    Continue acute inpatient hospitalization until the antibiotic course is complete
  4. D
    Transfer to an inpatient rehabilitation facility
  5. E
    Discharge home with a prescription for a prolonged course of oral cephalexin

Answer

The most appropriate disposition is transfer to a skilled nursing facility.
This patient requires five more weeks of intravenous antibiotics for vertebral osteomyelitis. Although he is medically stable for discharge from the acute care hospital, his moderate Alzheimer dementia and living situation (living alone with limited support) make a discharge home with outpatient parenteral antimicrobial therapy (OPAT) unsafe. He requires daily skilled nursing care for intravenous medication administration and monitoring, which is appropriately provided in a skilled nursing facility.

Step-by-Step Solution

1
Assess the patient's ongoing medical needs.
The patient requires five more weeks of intravenous antibiotics for vertebral osteomyelitis.
Determines the level of skilled care required.
2
Evaluate the patient's functional and cognitive status.
He is at his physical baseline but has moderate dementia with short-term memory deficits.
Determines rehabilitation needs and capacity for self-care.
3
Assess the patient's social support and home environment.
He lives alone with only weekend visits from family.
Determines if home discharge is safe.
4
Match the combined needs to the appropriate care setting.
Skilled nursing facility (SNF) provides the necessary daily skilled nursing (IV administration) for a patient who is physically stable but cognitively unsafe for home treatment.
Identifies the correct disposition pathway.

Key Concept

Patients who require prolonged intravenous antibiotics but lack the cognitive capacity and caregiver support to safely manage outpatient parenteral antimicrobial therapy (OPAT) at home should be transitioned to a skilled nursing facility.
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Topics

Disposition and Care Setting Transitions

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