31.1 Introduction

The complexity of the neurosurgical intensive care unit (NICU) patient often leads to an equally complex, and frustrating, process for discharge planning. The old adage of starting discharge planning upon admission is particularly relevant to the NICU patient, where multisystem injuries and issues often exist that require specialized care outside the hospital setting. In general, discharge planning out of the NICU involves the following categories:

1. 
   

   Discharge to the floor for stable, alert, and awake patients, followed by discharge to home, rehabilitation, or skilled nursing facilities.

   
   
2. 
   

   Discharge to an NICU step-down unit for nonventilated patients, followed by discharge to the floor, home, rehabilitation, or skilled nursing facilities.

   
   
3. 
   

   Discharge straight from the NICU to long-term acute care (LTAC) facilities for ventilated and severely disabled patients.

The functional capacity of the neurosurgical patient may be significantly decreased because of cognitive and/or physical impairments related to traumatic brain injury, spinal cord injury, hemorrhagic stroke, brain tumors, and so forth. These patients may have tracheostomy or gastrostomy tubes and limited or no bowel 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 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 (► Table 31.1, ► Table 31.2, ► Table 31.3). ¹