Examkin

Question

Difficulty: MediumDisposition and Care Setting Transitions

A 54-year-old woman is evaluated for discharge planning on hospital day 14. She was initially admitted to the intensive care unit for severe acute pancreatitis complicated by acute respiratory distress syndrome, which required mechanical ventilation for 7 days. She was successfully extubated 4 days ago and transferred to the general medical floor. The patient is awake, alert, and oriented. Vital signs are within normal limits. Oxygen saturation is 96% on room air. She is tolerating an oral diet, and her pain is well controlled with oral analgesics. All invasive lines and drains have been removed.

Physical and occupational therapy evaluation reveals profound ICU-acquired weakness. The patient requires maximum assistance for bed-to-chair transfers and is unable to bear weight independently. During her evaluation, she becomes easily fatigued and can actively participate in therapy for only 30 to 45 minutes daily before requiring extended rest. Prior to her hospitalization, she lived alone in a single-family home. Her immediate family lives nearby but they work full-time and cannot provide around-the-clock care.

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

  1. Skilled nursing facilityAnswer
  2. B
    Inpatient rehabilitation facility
  3. C
    Long-term acute care hospital
  4. D
    Home with intermittent home health services
  5. E
    Custodial care facility

Answer

The correct answer is a skilled nursing facility, as the patient is medically stable but requires slower-paced, daily skilled rehabilitation that she can tolerate.
The correct answer is a skilled nursing facility. This patient requires daily skilled physical and occupational therapy due to profound ICU-acquired weakness. However, she currently lacks the endurance to participate in 3 hours of intensive therapy per day, tolerating only 30-45 minutes. A skilled nursing facility is the most appropriate setting because it provides necessary medical supervision and a slower-paced rehabilitation program tailored to patients who cannot tolerate the rigorous demands of an inpatient rehabilitation facility.

Step-by-Step Solution

1
Assess the patient's current medical stability and need for ongoing physician intervention.
The patient is medically stable, successfully extubated, tolerating an oral diet, and requires only oral medications.
Determining medical stability differentiates the need for continued acute care (like a long-term acute care hospital) from post-acute care rehabilitation settings.
2
Evaluate the patient's functional status, physical therapy needs, and endurance capacity.
The patient requires maximum assistance for transfers and can only tolerate 30 to 45 minutes of therapy per day due to profound fatigue.
Therapy tolerance is the primary differentiator between an inpatient rehabilitation facility, which requires a minimum of 3 hours of daily therapy, and a skilled nursing facility, which accommodates lower endurance.
3
Assess the patient's social support and home environment to determine if a home discharge is safe.
The patient lives alone and her family members work full-time, meaning she would lack necessary daytime physical assistance.
Patients requiring maximum assistance for mobility cannot be safely discharged home without 24-hour caregiver support.
4
Synthesize medical, functional, and social data to select the most appropriate care setting.
A skilled nursing facility is selected.
It provides the required daily skilled rehabilitation at a slower pace the patient can tolerate, along with a safe environment and nursing care.

Key Concept

Post-acute care disposition depends heavily on medical acuity and rehabilitation tolerance. Medically stable patients needing multidisciplinary rehabilitation who can tolerate at least 3 hours of daily therapy qualify for an inpatient rehabilitation facility (IRF), whereas those needing a slower-paced recovery belong in a skilled nursing facility (SNF).
Rate this question

Topics

Disposition and Care Setting Transitions

More questions from this topic