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Question

Difficulty: MediumDisposition and Care Setting Transitions

During morning rounds on the medical ward, the care team discusses the transition plan for a 68-year-old woman. She has been hospitalized for two weeks after presenting with severe sepsis from a perforated diverticulum. Her initial course required an emergent exploratory laparotomy, colostomy creation, and a 10-day intensive care unit stay complicated by acute respiratory distress syndrome that required mechanical ventilation.

She was extubated three days ago and transferred to the floor. Her vital signs are temperature 37.1°C (98.8°F), blood pressure 124/78 mmHg, pulse 80/min, and respirations 16/min. She is breathing comfortably on room air. The surgical incision is healing appropriately, and the colostomy is functioning well.

A physical therapy assessment reveals profound generalized muscle weakness consistent with critical illness polyneuropathy. The patient requires maximum physical assistance from two staff members to transfer from the bed to a chair and cannot bear weight independently. Despite being highly motivated to recover, she becomes visibly exhausted after 30 to 45 minutes of combined physical and occupational therapy. Prior to admission, she lived at home with her husband, who suffers from advanced heart failure and relies on a wheelchair.

What is the most appropriate disposition for this patient?

  1. Transfer to a skilled nursing facilityAnswer
  2. B
    Transfer to an inpatient rehabilitation facility
  3. C
    Discharge home with visiting home health services
  4. D
    Transfer to a long-term acute care hospital
  5. E
    Transfer to an assisted living facility

Answer

Transfer to a skilled nursing facility
The correct disposition is a skilled nursing facility (SNF). This patient is medically stable following a severe illness but suffers from critical illness polyneuropathy. She requires daily skilled nursing and physical therapy to regain her functional independence. An SNF provides subacute rehabilitation for patients who need daily therapy but lack the stamina to endure the 3 hours of intensive daily therapy mandated by inpatient rehabilitation facilities (IRFs). Because she maxes out at 45 minutes of therapy and requires maximum assistance for transfers that her husband cannot provide, an SNF is the safest and most appropriate environment for her ongoing recovery.

Step-by-Step Solution

1
Evaluate the patient's current medical stability and need for ongoing acute medical care.
The patient is extubated, afebrile, and hemodynamically stable with healing wounds.
Determines whether the patient requires a long-term acute care hospital (LTACH) versus a post-acute rehabilitation setting.
2
Assess the patient's functional status and rehabilitation capacity.
The patient has severe weakness and can only tolerate 30 to 45 minutes of therapy before exhaustion.
Differentiates between the need for an inpatient rehabilitation facility (which requires tolerating 3 hours/day) and a skilled nursing facility.
3
Analyze the patient's social support and home environment.
The patient lives with a husband who is wheelchair-bound and unable to assist with transfers.
Determines if discharge home with home health services is safe and feasible.

Key Concept

Patients who require inpatient rehabilitation but cannot tolerate the 3 hours of daily therapy required for an inpatient rehabilitation facility (IRF) should be transferred to a skilled nursing facility (SNF).
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Topics

Disposition and Care Setting Transitions

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