What should basic scripts include at a long-term acute care hospital?

Basic Scripts for Long-Term Acute Care Hospitals

Long-term acute care hospitals should establish standardized clinical protocols ("scripts") that address infection evaluation, transfer criteria, emergency response, and documentation requirements, as these facilities care for complex patients with prolonged acute care needs who are at high risk for hospital-acquired infections and clinical deterioration. 1, 2

Essential Clinical Assessment Scripts

Infection Evaluation Protocol

Implement a three-tiered evaluation system involving nursing assistants, charge nurses, and physicians for any suspected infection or clinical status change. 1

• Document vital signs (temperature, pulse, respiratory rate, blood pressure) immediately when infection is suspected and communicate findings directly from licensed nurses to physicians or advanced practice providers in a timely manner 1

• Obtain complete blood count with differential for all residents suspected of infection, looking specifically for WBC >14,000 cells/mm³ or left shift (band neutrophils ≥6% or absolute band count >1500/mm³) as indicators requiring careful bacterial infection assessment 1

• Perform pulse oximetry for any resident with respiratory rate ≥25 breaths/minute to document hypoxemia (oxygen saturation <90%), which predicts 30-day mortality and need for acute care transfer 1

Pneumonia-Specific Script

When pneumonia is clinically suspected 1:

• Obtain chest radiograph if hypoxemia is documented or suspected to identify new infiltrates and exclude complications (multilobar involvement, large effusions, congestive heart failure, masses)
• Collect respiratory secretions (expectorated sputum or nasopharyngeal aspirate) at onset for purulence assessment, with Gram stain and culture if purulent and transport available within 1-2 hours
• Initiate antimicrobials within one hour of recognition if sepsis criteria are met 3, 4

Transfer Decision Script

Complete advance directives at or shortly after LTACH admission outlining parameters for acute care transfer. 1

Mandatory Transfer Criteria

Transfer to acute care hospital when 1:

1. Clinical instability requiring aggressive interventions consistent with resident/family goals
2. Critical diagnostic tests unavailable at the LTACH
3. Required therapy intensity or monitoring frequency exceeds LTACH capacity
4. Comfort measures cannot be assured in the LTACH setting
5. Specific infection-control measures (e.g., negative-pressure isolation for active tuberculosis) are unavailable

Documentation Requirements

Document the specific reason(s) for any acute care transfer in the medical record. 1

Emergency Response Scripts

Sepsis Recognition and Management

Screen all acutely ill, high-risk patients for sepsis to enable earlier treatment. 5, 4

When sepsis is identified 3, 4:

• Obtain at least two sets of blood cultures before antimicrobials, but do not delay treatment >45 minutes
• Measure serum lactate levels as tissue hypoperfusion marker
• Administer IV antimicrobials within one hour of sepsis recognition
• Initiate crystalloid fluid resuscitation at 30 mL/kg for hypotension or lactate ≥4 mmol/L
• Target mean arterial pressure ≥65 mmHg using norepinephrine as first-choice vasopressor

Hemodynamic Monitoring Script

Never leave septic patients alone; ensure continuous observation. 1

• Perform clinical examinations multiple times daily with documented vital signs at meaningful intervals 1
• Set continuous monitor alarms at appropriate limits when available, with age-appropriate ranges for pediatric patients 1

Infection Control Scripts

Hand Hygiene Protocol

Wash hands before and after each patient contact and whenever contaminated, preferring alcohol rubs or running water with soap 1

Use sterile barrier precautions for all invasive procedures or surgical interventions. 1

Specimen Collection Standards

• Do NOT obtain surface swab specimens from pressure ulcers 1
• For poorly healing pressure ulcers with persistent purulent drainage, obtain cultures from deep infected tissue during surgical debridement or biopsy 1

Medication Administration Scripts

Pain Management Protocol

For morphine sulfate injection 6:

• Verify concentration and calculate both mg dose and volume to prevent fatal dosing errors between different concentrations
• Start with 0.1-0.2 mg/kg IV every 4 hours as needed in adults
• Administer slowly to avoid chest wall rigidity
• Use lower starting doses in hepatic or renal impairment with careful titration

Antimicrobial Stewardship

Administer broad-spectrum antimicrobials covering all likely pathogens within one hour of sepsis recognition. 3, 5

• Reassess antimicrobial regimen daily for potential de-escalation once culture results available 3, 4
• Limit empiric combination therapy to 3-5 days maximum 3
• Target typical therapy duration of 7-10 days, with longer courses only for slow clinical response 3

Documentation and Communication Scripts

Daily Documentation Requirements

Maintain patient records documenting 1:

• Vital signs at meaningful intervals
• Clinical status changes noted by licensed nurses
• Direct nurse-to-physician communication of status changes
• Assessment by licensed healthcare provider for suspected infections

Quality Control Script

Keep emergency drug and equipment supply on the ward available 24 hours/day, checked and replenished daily 1

Document key aspects of sepsis care and outcomes to identify local strengths and weaknesses 1

Common Pitfalls

Avoid transferring based on fever alone without other clinical parameters, as fever in severely disabled LTACH residents may result from noninfectious causes (drugs, atelectasis, mucus plugging) manageable in the LTACH 1

Recognize that LTACH patients have multiple comorbidities and high rates of multidrug-resistant organisms, requiring enhanced infection control vigilance 2

Understand that one-year mortality after LTACH admission following critical illness exceeds 50%, informing realistic goals-of-care discussions 7