Clinical Algorithms for Admission and Discharge
Main clinical criteria for discharge to home
- Overall improvement in the fever curve without antipyretics. No fever spikes ≥ 101 F for ≥ 48 hours
- Improved or stable respiratory symptoms (e.g. improved shortness of breath or cough) and improved or stable oxygen requirement for ≥ 48 hours
- Improved or stable laboratory data including inflammatory markers if they were followed during the admission (especially C-reactive protein, ferritin and lactate dehydrogenase)
- When making a decision to discharge a patient, the team should include time since onset of initial symptoms. Patients within 6-9 days since symptom onset are at highest risk for
- All known COVID-infected patients with no PCP or with a BMC PCP who are discharged home will automatically receive at least one follow-up call within 24-48h of discharge to assess for symptoms. Community health centers (CHC) patients have a separate workflow; please notify the CHC in question at the time of discharge.
|o||Working phone and up-to-date contact information on Epic
(please note that clinicians can now modify the demographics section to update phone numbers)
|Information on primary care team up-to-date on Epic|
|Appropriate home setting
· Patient can adhere to home isolation (separate bedroom)
· No household members are either pregnant, immunosuppressed, or have a history of end-stage renal disease
· Appropriate caregivers are present in the home, if applicable
· For patient experiencing homelessness, please follow separate guidelines providing guidance for this group
|Quarantine education provided at discharge to patient and family. Patient and family have access to face covering, and patient has surgical mask for transport.|
- COVID positive/high probability patients experiencing homelessness who leave against medical advice (AMA):
- Monday through Friday from 7 AM to 7 PM: Contact Deanna Faretra (pager 0735) who will coordinate with Boston Public Health Commission (BPHC)’s Homeless Services Bureau and BMC Infection Control. Deanna is also a resource for patients who are contemplating leaving AMA.
- Nights and weekends: The floor team should call BPHC’s Homeless Services Bureau at 617-645-9680 as soon as possible and email BMC infection control (DG-HospitalEpidemiology and cc: Deanna.Faretra@bmc.org).
Testing considerations at Discharge
Please see the BMC protocol on “COVID-19 Removal of Isolation Precautions PUI and COVID-19 patients” for access to updated and full guidance.
Consider hospital admission for the following findings:
- Any patient with dyspnea or increase respiratory rate (≥30 breaths per min)
- Any patient with oxygen saturation ≤ 94% on RA or decrease in saturation to < 90% with ambulation
- Overall clinical concern by ED attending for risk of outpatient failure based on high risk for complications from severe COVID-19
Patients at high risk for complications from severe COVID-19
- Established risk factors:
Age 65 years or older, serious cardiovascular disease (heart failure, coronary artery disease, cardiomyopathies), chronic obstructive pulmonary disease, diabetes, malignancy, obesity (BMI ≥30 kg/m2), chronic kidney disease, immunocompromised state with solid organ transplantation, recipient of immunosuppressive therapy, pregnancy and sickle cell disease.
- Possible risk factors:
Asthma (moderate to severe), cerebrovascular disease
Criteria for safe discharge to home from the ED:
None of admission criteria listed above AND
- Reliable phone number where the patient could be reached for post-discharge follow-up
- Ability to understand and follow self-isolation recommendations
- Patient and family members with access to face covering at home
- Food security (enough for time in isolation, or ability to have someone procure it)
- Ability to care for own ADLS without assistance from someone outside their household
- No household members who are either pregnant, immunosuppressed or have a history of end-stage renal disease
- Meds-to-bed for required medications (new or chronic meds needing extra doses)
If the patient is being discharged and you would like the patient to be contacted by the COVID-infected follow up monitoring program, please select “COVID-19 Follow Up” under the “Nurse Follow Up” section of DISPO.
If the patient does not meet criteria for safe discharge home, please contact Social Work for help with disposition planning.