Hospital Evaluation for Facility Patient with Limited Testing Capabilities
Given the limited diagnostic testing capabilities at the facility and recent concerning findings, hospital transfer for comprehensive evaluation is appropriate and should be pursued. 1
Rationale for Hospital Transfer
The Clinical Infectious Diseases guidelines explicitly recognize that long-term care facilities (LTCFs) have inherent limitations in diagnostic capabilities that may necessitate acute-care transfer. 1 The guidelines state that initial diagnostic tests for suspected conditions can be performed in facilities "if hospitalization is not warranted and resources are available for specimen collection, laboratory tests, and radiological studies to be done in a timely manner." 1 When these resources are not available—as indicated in your situation—hospital evaluation becomes the appropriate next step.
Key Considerations Supporting Hospital Transfer
Diagnostic Testing Limitations in Facilities
Complete blood counts with differential, pulse oximetry, chest radiography, and timely specimen processing are recommended for facility residents with suspected infections, but these require specific resources that may not be available. 1
The guidelines acknowledge that certain diagnostic procedures may require specialized centers beyond what facilities can provide, particularly when complex evaluation is needed. 1
When specific diagnostic measures cannot be performed at the facility level, this should be documented and alternative evaluation pathways (hospital transfer) should be pursued. 1
Clinical Scenarios Warranting Immediate Hospital Evaluation
Transfer to acute care should be considered when:
Hypoxemia is documented or suspected (oxygen saturation <90%), which predicts short-term mortality and potential respiratory failure. 1
Multilobe infiltrates, large pleural effusions, congestive heart failure, or mass lesions are suspected but cannot be adequately evaluated at the facility. 1
Recent worsening azotemia is present, requiring medication adjustments and closer monitoring than facility capabilities allow. 1
Marked volume overload requires intravenous diuretic therapy with dose titration that exceeds facility nursing capacity. 1
Family/Relative Input in Transfer Decisions
Upon admission to facilities, discussions outlining general parameters for considering transfer to acute care should be a standard component of care planning, including advance directives. 1
The relative's request for hospital evaluation due to limited facility testing capabilities represents appropriate advocacy and aligns with guideline recommendations for transfer when diagnostic resources are insufficient. 1
Documentation Requirements
The full extent of clinical evaluation and the decision-making process should be documented in the medical record. 1 Specifically:
- Document the recent concerning findings that prompted evaluation
- Note the specific diagnostic limitations at the facility level
- Record the family discussion and their request for hospital evaluation
- Document that transfer is being pursued to obtain comprehensive diagnostic testing not available at the facility
Common Pitfalls to Avoid
Do not delay transfer while attempting inadequate diagnostic workup with limited facility resources—this may worsen outcomes. 1
Do not assume all testing can be deferred—certain time-sensitive conditions require prompt comprehensive evaluation that only hospitals can provide. 1
Ensure advance directives are reviewed before transfer to confirm this level of intervention aligns with the patient's wishes, though the family's request suggests this has been considered. 1