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Difficulty: MediumDisposition and Care Setting Transitions

An 81-year-old woman is evaluated on hospital day 5 to determine the appropriate post-acute care setting. She was initially admitted for altered mental status and hypotension secondary to a severe Escherichia coli urinary tract infection. She received intravenous fluids and targeted antibiotic therapy. Currently, her blood pressure is 128/78 mmHg, pulse is 82/min, and respirations are 16/min. She has been afebrile for 48 hours. Her leukocyte count is 8,200/mm³ and serum creatinine has improved from 2.6 mg/dL on admission to 1.0 mg/dL. Her baseline functional status before admission was independent in all activities of daily living. She resides in a single-story house with her 83-year-old husband, who uses a walker due to advanced osteoarthritis. Currently, the patient is easily fatigued, oriented only to person and place, and requires the assistance of two staff members to transfer from the bed to a chair. A physical therapy evaluation notes that she can actively participate in structured exercises for approximately 45 minutes per day before becoming exhausted. Which of the following is the most appropriate disposition for this patient?

  1. A
    Discharge to an acute rehabilitation hospital
  2. B
    Maintain the acute inpatient admission until independent mobility is achieved
  3. C
    Discharge to a long-term acute care hospital
  4. Discharge to a skilled nursing facilityAnswer
  5. E
    Discharge to a private residence with daily home health services

Answer

Discharge to a skilled nursing facility
The correct answer accurately synthesizes the patient's current needs: she is medically stable (resolving her acute infection and organ dysfunction) but has acquired a severe, temporary functional deficit. She requires 2-person assistance to transfer, meaning she cannot safely return home where her only caregiver is a frail spouse. Furthermore, because she can only tolerate 45 minutes of physical therapy per day due to fatigue and resolving delirium, she does not qualify for an acute inpatient rehabilitation facility, which mandates active participation in at least 3 hours of therapy per day. Therefore, a skilled nursing facility (SNF) is the optimal disposition, as it provides the necessary 24-hour nursing care and a slower-paced subacute rehabilitation program.

Step-by-Step Solution

1
Evaluate the patient's current medical stability.
The patient is hemodynamically stable, afebrile, and her laboratory values (WBC, creatinine) have normalized.
To determine if continued acute inpatient care is medically justified.
2
Assess the patient's functional status and rehabilitation capacity.
The patient requires 2-person assistance for transfers and can only participate in 45 minutes of physical therapy per day.
To identify the appropriate level of therapy intensity and nursing care required.
3
Analyze the patient's home support system.
The patient lives with a frail 83-year-old husband who uses a walker, indicating profound limitations in home caregiver support.
To determine if a discharge to home with outpatient or visiting nurse services is safe and feasible.
4
Match the patient's clinical and social profile to the appropriate post-acute care setting.
A skilled nursing facility (SNF) is selected.
An SNF provides the required 24-hour nursing care and lower-intensity subacute therapy appropriate for her fatigue, avoiding the unsafe home environment and the overly rigorous demands of an acute rehabilitation hospital.

Key Concept

Appropriate patient disposition relies on synthesizing medical stability, objective physical therapy tolerance (e.g., ability to perform 3 hours of daily therapy), and available home support to ensure safe and effective care transitions.
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Topics

Disposition and Care Setting Transitions

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