Should a patient with severe symptoms at a Skilled Nursing Facility (SNF) be sent to the Emergency Room (ER) or can they be kept at the SNF and started on Intravenous (IV) antibiotics if they are stable?

Decision: Transfer to Emergency Room Immediately

For a patient with severe symptoms at a Skilled Nursing Facility, immediate transfer to the Emergency Room is strongly recommended rather than initiating IV antibiotics at the SNF, regardless of apparent stability. 1

Critical Rationale for Transfer

Diagnostic Limitations at SNF

• SNFs lack the immediate diagnostic capabilities essential for severe infections, including CT imaging, advanced laboratory testing, and real-time assessment of organ dysfunction that determine appropriate antimicrobial selection and identify complications 1
• The inability to perform imaging studies promptly can delay identification of infection sources requiring surgical intervention or drainage, which directly impacts mortality 1
• Without access to blood cultures, lactate levels, and hemodynamic monitoring, you cannot accurately risk-stratify the patient or determine if they meet criteria for septic shock 1, 2

Time-Critical Nature of Severe Infections

• Each hour delay in administering appropriate antibiotics for septic shock increases mortality measurably 1
• High-risk sepsis patients (NEWS2 ≥7) require antimicrobials within 1 hour of recognition, which necessitates immediate diagnostic workup to guide selection 1, 2
• The Surviving Sepsis Campaign emphasizes that effective antimicrobials must be given within the first hour, but "effective" requires knowing the likely pathogen and resistance patterns—information unavailable without proper cultures and assessment 1

"Stable" is Deceptive in Severe Infection

• Patients with severe symptoms may appear stable but can deteriorate rapidly, particularly elderly SNF residents with multiple comorbidities 1
• The guidelines explicitly warn that clinical stability does not preclude the need for intensive monitoring and advanced care capabilities 1, 2
• SNF residents experiencing severe illness have high mortality risk regardless of initial appearance, and delayed recognition of deterioration is common 1

Specific Transfer Indications

Transfer immediately if ANY of the following are present:

• NEWS2 score ≥5 with suspected infection 1, 2
• Severe symptoms including altered mental status, respiratory distress, hypotension, or signs of organ dysfunction 1, 3
• Suspected septic shock (hypotension not responding to initial fluids, lactate elevation if measurable) 1, 2
• Need for source control procedures (abscess drainage, infected device removal) 1
• Uncertainty about diagnosis or infection source 1

What NOT to Do at SNF

Avoid Starting Empiric IV Antibiotics Without Transfer

• Starting antibiotics at SNF without proper cultures and diagnostic workup can mask the true pathogen, making subsequent diagnosis more difficult 1, 4
• Inappropriate antibiotic selection due to lack of diagnostic information may be ineffective and contribute to resistance 1, 4
• The SNF environment lacks the monitoring capability to detect antibiotic-related complications (acute kidney injury, allergic reactions, drug interactions) 4

Exception: Remote/Rural Settings Only

• In remote locations where transfer time exceeds 1 hour, consider administering broad-spectrum antibiotics per local protocols WHILE arranging transfer, not instead of transfer 1
• This applies only when the patient meets high-risk criteria and transport is genuinely delayed 1

Common Pitfalls to Avoid

Pitfall 1: Overestimating SNF Capabilities

• SNFs are designed for stable chronic care, not acute severe infections requiring intensive monitoring and rapid diagnostic/therapeutic interventions 1
• Even with IV access and antibiotics available, lack of laboratory support, imaging, and specialist consultation makes managing severe infections inappropriate 1

Pitfall 2: Underestimating Transfer Benefits

• Concerns about "transfer trauma" or deconditioning should not override the mortality benefit of appropriate acute care for severe infections 1
• The risk of death from untreated or inadequately treated severe infection far exceeds the risks of transfer 1, 2

Pitfall 3: Delaying for "Observation"

• Waiting to "see how they do" with severe symptoms wastes the critical first hour when antibiotics must be administered 1
• By the time obvious deterioration occurs at SNF, the patient may be in irreversible shock 1, 2

Practical Transfer Protocol

Immediate Actions While Arranging Transfer:

1. Call 911 or emergency transport immediately upon recognizing severe symptoms 1, 3
2. Ensure airway, breathing, circulation are supported during transport 3
3. Alert receiving hospital about suspected severe infection so they can prepare for immediate assessment 1, 3
4. Send all available medical records and medication lists with patient 1

Do NOT delay transfer to:

• Obtain IV access (can be done en route or in ER) 1
• Wait for family notification 1
• Complete documentation 1
• Attempt diagnostic procedures at SNF 1

The evidence overwhelmingly supports immediate transfer to ER for any SNF patient with severe symptoms, as the diagnostic and therapeutic capabilities required for optimal outcomes are simply not available in the SNF setting. 1, 2