Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_705_Библиотеки_им_академика_М_И_Перельмана

The Case Manager met with the patient to perform an initial assessment for discharge needs. During the interview, the patient stated he lived with his spouse in a multi-level home but was able to have rst oor set up. He had been receiving wound care from a home health agency three times a week and using a rolling walker for ambulation. Initial physical and occupational therapy evaluation recommended acute rehab (AR) placement. It is generally our recommen­dation that all new amputees spend at least 7–10 days in an AR to help retrain the mind to acknowledge the missing limb. This helps to reduce falls and in turn reduce risk of dehiscence and hematoma to the residual limb. For those who do not meet criteria for AR (the ability to participate in at least 3 h per day of physical therapy), we recommend a subacute rehab facil­ity (SAR) with eventual upgrade to AR.CM dis­cussed referral process and the patient chose three facilities that are on par (within network) with his insurance. The patient and his wife were informed that he would transfer to the rst accepting facility with a bed, authorized by insurance when medically ready for discharge. Typically, patients stay in the hospital for 4–5 days post-surgery at which time the incisional VAC is removed to assess the incision prior to discharge, pain can be well controlled and all surgical drains can be removed. A discharge summary outlining nal ID recommendations which were oral antibiotics as the infected tissue was completely removed by nature of an ampu­tation, wound care, patient was placed in a short term, one time use incisional Prevena VAC which stays in place for 7 days and is then changed to a dry sterile dressing, and an effec­tive oral pain regimen was written for AR to fol­low. A follow-up in the outpatient clinic was scheduled for 10 days from discharge. Additionally, all amputees are invited to attend a virtual support group which meets monthly. This is especially benecial if the patient happens to still be in- patient at the time of the meeting as they are able to obtain real-time peer support.

The patient was placed in a total contact cast to ofoad the ap as best as possible. The cast itself meant that the clothes he has worn into the hospital were not suitable and he had no one to bring him a proper set. Because of the PICC, he was unable to use traditional crutches and so he was ordered a walker and platform crutches as well as rented a knee scooter. Given the high cost of daptomycin, SW was consulted to assess the patient for nancial need and sub­mitted a request to the case management department to cover the cost of the daptomycin through our contracted home infusion com­pany. Social work was also able to provide him the necessary clothes for discharge and to help guide him through the application process for medical transportation and community food assistance. Weekly follow-up visits were set up to ensure regular follow-up visits and cast changes.

This patient had several outside case managers with whom the social worker and case manager collaborated throughout his admission and even­tually a safe discharge plan was ultimately agreed upon by all involved. After much deliberation his cousin agreed to let him stay with him temporar­ily. Our fear was that this welcome may be short lived and therefore sent him home with dressings and medications that were as low maintenance as possible while still providing him the best possi­ble chance to heal. He was placed in a well- padded profore (multilayer compression) dressing9 with a controlled ankle motion (CAM) boot to ofoad the forefoot. Given his substance abuse history he was placed on oral antibiotics and set up with weekly follow-up visits to ensure proper wound care and frequent monitoring. Much to every­one’s surprise and delight this gentleman went on to heal beautifully.

Navigating the complex world of health insur­ance is an unfortunate reality in health care today. The limb salvage patient is, more often than not, a chronically ill patient whose time is spent in and out of hospitals and rehabs. This compounded with the fact that we work with patients from the District of Columbia, Virginia, and Maryland which requires early inquiry on the part of case management and social work to help carve out the best path. Patients having no insurance or being out of rehab days or not qualifying for home health aide can drastically shift the dis­charge plan at the nth hour.

Similar MD, RN, and CM triads were created for our top ve service lines, in-patient volume­wise, and the executive triad the leadership triad met with lower-volume service line leadership separately. Procedural and consultative services were engaged and a designation and prioritiza­tion of “discharge pending” patients was estab­lished for procedure and consultation workow. The Limb Service, among others, was beneciary of these enhanced throughput strategies.

Kripalani and colleagues point out that the effec­tiveness of a patient transition is often enhanced by the involvement of the attending physician [2]. The limb NPs are in constant communication with the team’s attending surgeons, advising them when they need to see a particular patient to pave the way for that patient’s discharge. Prior to the NP team serving in this capacity, a well mean­ing resident would often walk into a patient’s room and advise them they were being discharged only to be told, “Absolutely. My doctor didn’t say anything about leaving.” By alerting patients to their discharge plan and then bringing attending physicians into the discussion the NP team medi­ates this frequent barrier to discharge.