Is it safe to discharge a patient home who is dependent on norepinephrine, has acute kidney injury, diastolic dysfunction, decubitus ulcers, and requires ongoing antibiotic therapy with meropenem and vancomycin?

Discharge Home for a Patient on Norepinephrine with Multiple Comorbidities is Unsafe and Inappropriate

This patient cannot be safely discharged home while dependent on norepinephrine, regardless of their wishes. Vasopressor support requires continuous hemodynamic monitoring and immediate intervention capability that cannot be replicated in a home setting 1.

Critical Barriers to Home Discharge

Vasopressor Dependency

• Norepinephrine infusion is an absolute contraindication to home discharge 1
• Patients requiring vasopressors have hemodynamic instability that necessitates intensive care unit or coronary care unit level monitoring 1
• Hypotension (systolic BP <85 mmHg) requiring vasopressor support indicates the patient is not medically stable for discharge 1

Medical Instability Indicators

• Acute kidney injury requires stabilization of fluid and electrolyte requirements before any discharge consideration 1
• Diastolic dysfunction with ongoing volume management issues precludes safe home transition 1
• Decubitus ulcers indicate the patient requires wound care that typically necessitates skilled nursing facility placement rather than home discharge 2

Intravenous Antibiotic Therapy Considerations

While outpatient parenteral antimicrobial therapy (OPAT) can be administered at home, this patient does not meet eligibility criteria:

• Patients must be clinically stable with good cardiopulmonary reserve to qualify for home OPAT 1
• The combination of vancomycin and meropenem carries significant nephrotoxicity risk (7-fold increased AKI risk compared to vancomycin/meropenem alone) 3, requiring close monitoring incompatible with home care 4, 5, 6
• Vancomycin requires careful renal function monitoring, especially in patients with existing acute kidney injury 7

Appropriate Level of Care

Immediate Requirements

• This patient requires continued inpatient hospitalization until vasopressor support is discontinued and hemodynamic stability is achieved 1
• Acute kidney injury must resolve or stabilize before considering any discharge 1
• Decubitus ulcers require assessment for appropriate wound care setting 2

Transition Planning After Stabilization

Once the patient is weaned from vasopressors and medically stable:

• Skilled nursing facility placement is the most appropriate next step given the combination of IV antibiotics, wound care needs, and recent critical illness 2
• Home discharge with home health services could be considered only after: vasopressor discontinuation, AKI resolution, hemodynamic stability for 48+ hours, and demonstration that wound care can be managed at home 1
• For OPAT eligibility: patient must have adequate home circumstances, reliable electricity and running water, ability to communicate with treatment team, and expected compliance with treatment 1

Common Pitfalls to Avoid

• Do not discharge patients based solely on their wishes when medical stability criteria are not met 2
• Do not underestimate the monitoring requirements for combination vancomycin/meropenem therapy, particularly in patients with baseline renal dysfunction 4, 5
• Do not confuse "medically stable for discharge" with actual discharge readiness—this patient has multiple active issues requiring inpatient-level care 2
• Vasopressor dependency alone is sufficient to mandate continued hospitalization regardless of other factors 1