Discharge Planning in the Neurosurgical Intensive Care Unit Patient

Paula Snyder

Discharge planning in the neurosurgical intensive care unit (NICU) should begin upon admission.

Neurologic patients often have increased needs for discharge. Their functional capacity may be significantly decreased because of cognitive and/or physical impairments. These patients may have tracheostomy or gastrostomy tubes, and limited or no bowel and/or bladder control. They may be at increased risk for injury due to cognitive impairment, recent memory deficits, and judgment and impulse control issues and may require constant supervision. Most inpatient rehabilitation programs require that the patient be able to participate in at least 3 hours of therapy each day. Some patients with complex medical problems may not be able to tolerate intensive rehabilitation; others may be medically stable but may not be able to participate in intensive rehabilitation due to the severity of their neurologic injury. Many of these patients may need subacute rehabilitation or skilled nursing with less intensive physical therapy. Generally, the more severe the injury or the longer the NICU/hospital stay, the longer the recovery period and the greater the need for more intensive rehabilitation or long-term care. Patients with only cognitive impairments may not qualify for inpatient rehabilitation.

Early identification of the patient’s resources, community resources and outpatient rehabilitation programs, home situation and adaptability, and family support system is imperative for patients not meeting inpatient rehabilitation criteria. Patients rehabilitated on an outpatient basis will need careful evaluation and planning by the multidisciplinary team. Identification of caregivers among a patient’s family and friends is essential to a smooth discharge plan. Other areas to be assessed include (1) where outpatient therapies will be received; (2) transportation availability to and from therapies and physician visits; (3) whether home therapy is needed and, if so, whether it is covered by insurance; (4) evaluation of the home environment to identify needs for assistive devices, such as a hospital bed, commode, and a shower chair, as well as supplies (for tracheotomy care, feedings, etc.).

The nurse/case manager, in concert with the multidisciplinary team, assesses the anticipated needs of the patient for discharge. The team usually consists of the nurse, physician, physiatrist, physical therapist, occupational therapist, speech pathologist, dietitian, respiratory therapist, and social worker, along with the patient and his or her family. Each team member has a specific area of responsibility related to discharge planning. Areas of particular concern when evaluating a patient for potential rehabilitation needs include motor dysfunction, alteration in sensory perception, altered communication patterns, behavioral issues, altered respiratory function, cranial nerve impairment, and cognitive impairment (Tables 34–1, 34–2, and 34–3).¹

**Table 34–1** Evaluating Patients for Potential Rehabilitation Needs 1
Alteration	Associated with/demonstrated by
Alteration in motor function	Associated with spinal cord injury, traumatic brain injury, and stroke resulting in paresis, paralysis, incoordination, apraxia, spasticity, and abnormal reflexes
Alteration in sensory perception	Blindness and visual disturbances and defects, loss or disturbance in pain, temperature, and pressure perception, position sense, agnosia
Altered communication patterns	Receptive, expressive, and global dysphasias, aphasia, motor dysphasia
Alteration in behavior	Demonstrated by mood disturbances, depression, poor impulse control, dysinhibition, anger, aggressive behavior
Alteration in cranial nerve function	Swallowing and speech defects, ptosis, diplopia, disruption of taste, smell, hearing, cranial nerve (CN) VII palsy
Alteration in cognitive function	Confusion, altered level of consciousness, impaired memory, judgment, concentration, problem solving, higher thought processes

**Table 34–2** Potential Discharge Destinations Based on Diagnosis and/or Deficit 1
Condition/situation	Discharge destination
Spinal cord injury (SCI)	Acute rehabilitation
Stroke with hemiplegia	Acute rehabilitation
Brain injury with paresis, paralysis, apraxia, ataxia, inability to ambulate	Acute rehabilitation vs skilled nursing facility with physical therapy vs home with outpatient therapy
Ventilator dependent (excluding SCI)	Subacute placement with rehabilitation/physical therapy
Persistent vegetative state	Skilled nursing facility vs subacute facility
Mild cognitive impairment	Home with outpatient therapy
Moderate cognitive impairment	Acute rehabilitation vs home with outpatient therapy
Severe cognitive impairment	Acute rehabiltiation vs skilled nursing facility
Sensory impairment: Blindness	Acute rehabilitation
Communication deficits: aphasia, dysphasia	Home with outpatient therapy
Behavioral issues	Home with outpatient therapy and supervision vs skilled nursing facility

Implications

Determining discharge destination early in the acute hospital phase can facilitate treatment decisions, resource allocation, family education, and counseling. It enables families and discharge planners to choose appropriate posthospital facilities or prepare the home environment. Case management increases patient and family understanding of posthospital needs and promotes the family’s ability to meet those needs confidently. It also decreases the length of hospital stay and costs.