Clinical Algorithms for Admission and Discharge

    COVID19_Clinical Criteria for Discharge updated Dec 2, 2020

    Main clinical criteria for discharge to home

    1. Overall improvement in the fever curve without antipyretics. No fever spikes ≥ 101 F for ≥ 48 hours
    2. Improved or stable respiratory symptoms (e.g. improved shortness of breath or cough) and improved or stable oxygen requirement for ≥ 48 hours
    3. Improved or stable laboratory data including inflammatory markers if they were followed during the admission (especially C-reactive protein, ferritin and lactate dehydrogenase)

    Additional comments

    • 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.

    Special considerations/populations

    • 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.

     

    Admission criteria updated Dec 2nd 2020

    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.