(P08) Post Acute Care Transitions: Lessons from a Patient with Sepsis

Introduction: Effective transition from acute to post-acute care (PAC) is crucial to preventing adverse outcomes. This case involves a patient admitted to intensive care within three days of PAC transition. With close monitoring and timely escalation of care, the PAC team prevented adverse outcomes for this patient.

Case Description : A 67-year-old male with a chronic spinal cord injury with paraplegia, neurogenic bladder, and autonomic dysreflexia was admitted to the PAC from acute care for management of stage-4 sacral pressure injury complicated by osteomyelitis. He had completed two weeks of intravenous (IV) antibiotics for sacral wound infection. Prior to PAC admission, he reported night sweats, but had a normal chest x-ray, leukocyte count, and temperature. The night sweats were attributed to autonomic dysreflexia.
On admission to PAC, the wound had moderate yellow/tan slough and moderate malodorous drainage. On day 1, the wound had a similar appearance with less drainage and odor. He remained afebrile. On day 2, the necrotic tissue had increased, with copious amounts of malodorous drainage. Vital signs: Temperature(T) 99.3 F, Pulse(P) 103/minute, Respirations (R) 20/minute, and Blood Pressure (BP) 139/72 mm. He reported nausea and chills. Workup revealed a WBC of 18.4 and urine with positive nitrites. The PAC team consulted infectious disease who recommended blood cultures and IV piperacillin/ tazobactam and vancomycin for infection of wound or urine etiology. The resident remained in the PAC with IV hydration, antibiotics, and supportive care.
Later that night, the resident reported chills with vital signs T 100.9 F, P 125/minute, R 23/minute, and BP 97/56 mm. The resident was transferred to the emergency department and was admitted to intensive care for septic shock.

Discussion: This resident developed sepsis on the second day after admission to PAC. On admission, wound odor was attributed to a saturated dressing, and the acuity of wound changes were difficult to determine. A serial photo documentation may have helped identify the acuity of change. The symptom of night sweats in this case also highlights the need to reconsider discharge diagnoses to avoid premature diagnostic closure.
With tachycardia and leukocytosis, the resident met the Systemic Inflammatory Response Syndrome (SIRS) criteria. However, he was negative for Quick Sequential Organ Failure Assessment (qSOFA). This PAC located in the acute care facility had access to an infectious disease specialist and the resources to manage the resident. With close monitoring, the staff timely identified the change in condition and promptly escalated the care.

Conclusion: PAC transition is complex, and 12.6% of readmissions from PAC occur within 4 days of transition. Effective transition process, close monitoring, and access to appropriate resources are necessary to reduce readmissions and improve resident care outcomes.