What is the appropriate discharge plan for a 70-year-old female patient with a history of chronic venous insufficiency, lymphedema, obesity, and venous stasis ulcers, who presented with sepsis due to probable skin and soft tissue infection (SSTI) and acute hypoxic respiratory failure due to heart failure with preserved ejection fraction (HFpEF) volume overload?

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Discharge Checklist for 70-Year-Old Female with Sepsis, SSTI, and HFpEF

The patient should be discharged only when hemodynamically stable, euvolemic, established on evidence-based oral medication, and with stable renal function for at least 24 hours before discharge. 1

Infection Management

  • Complete Dalbavancin 1.5g IV x1 prior to discharge (per ID recommendation)
  • Confirm blood cultures are negative after repeat draw
  • Document resolution of leukocytosis (continue daily CBC until discharge)
  • Ensure wound care plan is in place:
    • Continue zinc oxide topical QID
    • Dakins 0.125% solution BID per wound care recommendations
    • Document wound measurements and appearance at discharge
  • Schedule outpatient follow-up with ID in 1-2 weeks

Heart Failure Management

  • Confirm euvolemic status:
    • Daily weights stable for 24 hours
    • Resolution of pitting edema
    • Respiratory rate <25, no dyspnea
    • Oxygen saturation >92% on room air 1
  • Convert from IV to oral diuretics:
    • Transition from Bumex 1mg IV BID to oral equivalent
    • Document plan for diuretic dosing at home
  • Monitor electrolytes and renal function daily until discharge 1
  • Document baseline weight at discharge for home monitoring
  • Schedule cardiology follow-up within 2 weeks of discharge 1

Anemia Management

  • Confirm hemoglobin is stable (goal >7)
  • Document plan for outpatient iron supplementation after infection resolution
  • Schedule hematology follow-up if needed

Respiratory Management

  • Ensure oxygen saturation >92% on room air for 24 hours
  • Document sleep study referral for suspected OSA
  • Document PFT referral for outpatient follow-up

Disposition Planning

  • Resolve discrepancy between PT recommendation (home) and OT recommendation (SNF)
    • Consider patient's functional status and home support
    • Document specific rehabilitation needs
  • Coordinate with APS for Monday 10:00 AM meeting
  • Assess home safety and caregiver capability (son)
  • If discharge to home:
    • Arrange home health services
    • Ensure wound care supplies available
    • Confirm medication access
  • If discharge to SNF:
    • Complete SNF referral paperwork
    • Ensure SNF can manage wound care needs
    • Transfer medication orders appropriately

Medication Reconciliation

  • Complete medication reconciliation
  • Document plan for Bumex dosing at home
  • Ensure prescriptions are sent to pharmacy
  • Document medication teaching completed

Patient Education

  • Provide comprehensive written discharge instructions including 1:
    • Diet (sodium restriction)
    • Medication schedule and side effects
    • Daily weight monitoring instructions
    • Activity recommendations
    • Signs/symptoms requiring medical attention
    • Follow-up appointment schedule
    • Wound care instructions

Follow-up Appointments

  • Schedule primary care follow-up within 1 week of discharge 1
  • Schedule cardiology follow-up within 2 weeks of discharge 1
  • Schedule ID follow-up for infection management
  • Schedule wound care follow-up
  • Document sleep study referral
  • Document PFT referral

Social Support

  • Document APS meeting outcome and recommendations
  • Assess need for additional home support services
  • Evaluate need for medical equipment at home
  • Consider case management referral for complex care coordination

Communication

  • Communicate discharge plan to primary care provider
  • Document handoff to next provider
  • Ensure patient and caregiver understand discharge plan
  • Document contact information for questions after discharge

This checklist addresses the key components needed for a safe discharge based on the patient's complex medical conditions. The most important factors are ensuring infection resolution, euvolemic status, stable renal function, and appropriate follow-up care 1, 2. The decision between home with services versus SNF should be based on functional status assessment and home support availability 1.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Heart Failure Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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