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Difficulty: HardDisposition and Care Setting Transitions

A 66-year-old man is evaluated for discharge on hospital day 12. He was admitted for a severe acute exacerbation of chronic obstructive pulmonary disease (COPD) requiring intubation and mechanical ventilation. He was successfully extubated three days ago and is currently stable on 2 L/min of oxygen via nasal cannula. He is hemodynamically stable, afebrile, and his acute respiratory infection has resolved. His comorbidities include heart failure with preserved ejection fraction and type 2 diabetes mellitus. During his intensive care unit stay, he developed a new Stage 3 pressure injury on his sacrum that requires daily skilled wound care. Prior to admission, he was fully ambulatory and independent. Currently, he requires moderate assistance with all transfers and can walk only 15 feet with a walker before becoming severely dyspneic and fatigued. A physical therapy evaluation concludes that he has significant rehabilitation potential but can currently tolerate a total of only 60 to 90 minutes of therapy spread throughout the day due to cardiopulmonary limitations. Laboratory studies show a stable serum creatinine of 1.4 mg/dL (baseline 1.3 mg/dL). He lives with his elderly wife, who has severe osteoarthritis and uses a wheelchair, rendering her unable to assist him with mobility or personal care.

Which of the following is the most appropriate disposition plan for this patient?

  1. Transfer to a skilled nursing facilityAnswer
  2. B
    Transfer to an inpatient rehabilitation facility
  3. C
    Transfer to a long-term acute care hospital
  4. D
    Discharge home with comprehensive home health services
  5. E
    Retain in the acute care hospital for intravenous fluid administration until renal function normalizes

Answer

Transfer to a skilled nursing facility
The correct disposition is transfer to a skilled nursing facility (SNF). This patient is medically stable and ready for discharge from the acute care hospital, but he has two significant ongoing needs: daily skilled wound care for a Stage 3 pressure injury and multidiciplinary rehabilitation for severe deconditioning. Because he can only tolerate 60 to 90 minutes of therapy daily, he does not qualify for an inpatient rehabilitation facility (IRF), which strictly requires the ability to participate in at least 3 hours of intensive therapy per day. Furthermore, discharging him home with home health services is unsafe; home health agencies provide intermittent skilled visits, but the patient requires ongoing custodial assistance for transfers and ADLs that his wheelchair-bound wife cannot provide. An SNF provides the appropriate combination of 24-hour custodial care, skilled nursing for wound management, and rehabilitation paced to the patient's tolerance.

Step-by-Step Solution

1
Determine the patient's medical stability for discharge.
The patient is extubated, hemodynamically stable, afebrile, and his infection has resolved.
Establishing medical stability confirms the patient no longer requires acute inpatient hospital care and is ready for post-acute disposition.
2
Assess the patient's functional status, skilled care needs, and therapy tolerance.
The patient requires daily skilled wound care for a Stage 3 pressure injury and physical therapy, but can only tolerate 60 to 90 minutes of therapy per day.
Specific post-acute care facilities have strict admission criteria based on therapy tolerance and medical needs.
3
Evaluate the safety and feasibility of a home discharge.
Home discharge is deemed unsafe because the patient requires moderate assistance with transfers and his wife is physically unable to assist him.
Home health services only provide intermittent care; 24-hour safety and custodial support must be available from family for a safe home discharge in a highly dependent patient.
4
Select the appropriate care setting based on the synthesized criteria.
A skilled nursing facility (SNF) is selected.
SNFs accommodate patients who need daily skilled nursing and therapy but cannot meet the 3-hour daily intensive therapy requirement of an inpatient rehabilitation facility (IRF).

Key Concept

Appropriate disposition for post-acute care requires matching the patient's medical stability, physical therapy tolerance (e.g., 3-hour minimum for IRF), skilled nursing needs, and available home caregiver support to strict facility criteria.
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Topics

Disposition and Care Setting Transitions

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