Jack’s Care Transition Story

By Kindred Healthcare tags:

NOTE: The following care story is purely hypothetical and was crafted specifically for 2013 Clinical Impact Symposium attendees to use as an exercise in care transitions. Any resemblance to a person living or deceased is coincidental. Future CIS posts may refer back to this fictitious story for reference.

Part 1:

Jack is a 66-year-old community dwelling male who was hit by a car while cycling near his home. He has a history of hypertension (HTN), type 2 diabetes (DM2), coronary artery disease (CAD), and chronic obstructive pulmonary disease (COPD). In the accident he sustained multiple orthopedic fractures (rib and right femur). In the short-term acute care hospital he underwent Open Reduction Internal Fixation (ORIF) of his right femur but developed severe diarrhea and had poor wound healing. Diarrhea improved somewhat with oral metronidazole, but nursing noted a 15-pound weight loss compared with his last weight at home. His appetite was very poor, so an NasoGastric Tube (NGT) was placed to help with weight loss and wound healing. He remains non-weight bearing on the affected leg for six weeks; PT evaluation recommended post-acute rehab in a transitional care center (TCC), to which he was transferred.

He receives all regular medications the morning and afternoon of transfer to the TCC. Initial TCC assessment late that afternoon notes poor appetite and NG tube in place. Medication orders from acute care include coumadin,tapering dose of oral metronidazole, insulin NPH twice daily and regular insulin sliding scale before bolus tube feeds. Physical, occupational and speech therapy and medical nutrition therapy consults are all ordered. Blood glucose that night is 412, and he is given sliding scale coverage. Speech therapy clears him for puree diet with thickened liquids but appetite remains poor. The Registered Dietitian recommends discontinuing tube feeding and initiating a consistent carbohydrate/low concentrated sweets pureed diet and weekly weights. Over the next 48 hours he requires 10–15 units of regular insulin daily. No change is made to the longer acting insulin orders. His wife, Mary, states he was always well controlled at home on once daily insulin with a diabetic diet. Rehab staff notes a cough during OT and STOP & WATCH is performed. He is started in nebulizers and continues his regular multi-dose inhaler. On the morning of the third day the patient is lethargic, having trouble clearing secretions, heart rate is 135 and irregular, and stat fingerstick is 38. He is urgently transported back to acute care.

Part 2:

Jack returns to the acute care hospital where he is diagnosed with COPD exacerbation and hypoglycemia. CXR is negative; he is treated for COPD exacerbation with steroids, nebulizers and oxygen. ECG shows new Afib, two small infarcts are seen on head CT and he is started on prophylactic phenytoin. His surgical wound continues to be dressed but there is minimal progress; plastic surgery does not recommend graft or flap at this time. He completes the course of metronidazole but diarrhea is not fully resolved. With rehab he is up out of bed to chair for only one hour a day, and with assistance of two therapists. Discharge to a transitional care hospital for wound care and medical management is recommended.

At the transitional care hospital (TCH) he makes some initial progress with rehab, and his appetite improves. He has one low-grade fever but has no new symptoms. The diarrhea is still present but mild. On day seven at the TCH a call is received from an acute care hospitalist who reports that stool cultures taken prior to discharge from acute care are now positive for Carbapenem Resistant Enterobacteriaceae (CRE). The skilled nursing facility (SNF) physician is called and says he thinks the patient should be transferred back to acute care for infection control.

Part 3:

The team decides treatment for CRE can occur in place at the transitional care hospital. Jack receives IV antibiotics and the diarrhea gradually resolves. He makes more progress in rehabilitation, gains 10 lbs and is ambulating with one person assist household distances. His wound is nearly closed but will need skilled dressings every few days for another 3-4 weeks, so after 28 days the patient is sent home with his wife, private duty nurses, and home health. A home evaluation is completed and a commode and wheelchair were ordered prior to discharge.

At her first home visit, the home health RN observes a restless, agitated male, refusing to take any medications or exercise with aides or therapists, yelling and cursing at his wife whenever she tries to assist with ADLs. Mary, his wife, reports he takes catnaps all day but does not sleep long at night. He was discharged home on his regular home medications plus phenytoin for seizure prophylaxis, hydrocodone/acetaminophen for post-operative pain, and coumadin for Afib. His wife picked up all the medications yesterday at the pharmacy and was administering them according to instructions. She is asking if he can benefit from a return to SNF, long-term acute care (LTAC) or acute care hospital.

Jack’s Care Transition Story