{"id":395,"date":"2020-09-08T20:51:48","date_gmt":"2020-09-08T20:51:48","guid":{"rendered":"https:\/\/www.hospitalinnovate.org\/covid19\/?p=395"},"modified":"2021-07-15T18:00:47","modified_gmt":"2021-07-15T18:00:47","slug":"01which-clinical-criteria-do-hospitals-use-to-determine-when-it-is-safe-to-discharge-covid-19-patients-to-home","status":"publish","type":"post","link":"https:\/\/www.hospitalinnovate.org\/covid19\/2020\/09\/08\/01which-clinical-criteria-do-hospitals-use-to-determine-when-it-is-safe-to-discharge-covid-19-patients-to-home\/","title":{"rendered":"01. Which clinical criteria do hospitals use to determine when it is safe to discharge COVID-19 patients to home?"},"content":{"rendered":"

[vc_row full_width=”stretch_row_content_no_spaces” equal_height=”yes” content_placement=”bottom” css=”.vc_custom_1600728628461{margin-top: 0px !important;border-bottom-width: 4px !important;padding-top: 0px !important;padding-right: 20px !important;padding-bottom: 0px !important;padding-left: 20px !important;background-color: #f2f2f2 !important;border-bottom-color: #2c5d73 !important;border-bottom-style: solid !important;}”][vc_column width=”2\/3″ css=”.vc_custom_1599247143020{padding-right: 20px !important;padding-left: 10px !important;}”][vc_custom_heading text=”Discharge Criteria Key Clinical Questions” font_container=”tag:h2|text_align:left|color:%23f7941d” use_theme_fonts=”yes” css=”.vc_custom_1599600298425{margin-top: 0px !important;padding-top: 40px !important;}”][\/vc_column][vc_column width=”1\/3″][vc_column_text]<\/p>\n

Home<\/a> \/ Discharge Criteria Overview<\/a> \/ Key Clinical Questions<\/a><\/p>\n

[\/vc_column_text][\/vc_column][\/vc_row][vc_row full_width=”stretch_row_content_no_spaces” gap=”20″][vc_column width=”3\/4″ css=”.vc_custom_1599596059091{padding: 20px !important;}”][vc_custom_heading source=”post_title” use_theme_fonts=”yes”][vc_column_text]<\/p>\n

a. HOMERuN institutions<\/strong><\/h3>\n

Sites varied widely in their guidance, generally falling into one of several categories: 1) little or no guidance (e.g., use clinical judgment); 2) general guidance concerning disease stability and improvement (e.g., hemodynamically stable, and fever or other symptoms are improving, and oxygen requirement is declining or resolved); 3) guidance resembling the Centers for Disease Control and Prevention (CDC) guidelines for the removal of home quarantine using the non\u2013test-based strategy; and 4) detailed clinical guidance or algorithms based on age, comorbidities, immunocompromise, lab values, need for supplementary oxygen, and stability of vital signs (temperature, oxygen saturation, and respiratory rate). The most commonly mentioned criteria were symptom improvement, temperature, and oxygen requirement, although specific definitions varied. For example, some sites specified afebrile for a specific time (range: 24-72 hours), while others simply required afebrile at discharge. Similarly, some sites required specific oxygen saturation levels (range >90%-94%) or supplementation levels (range: 2-4 liters), while others simply required these to be stable or at baseline at the time of discharge. Relatively few sites (36%) addressed laboratory criteria, age (36%), high-risk comorbidities (32%), or infectious disease consultation (18%) as criteria for discharge.[\/vc_column_text][vc_row_inner gap=”30″ css=”.vc_custom_1599596074851{padding: 20px !important;}”][vc_column_inner][vc_column_text]<\/p>\n

b. What is Known<\/strong><\/h3>\n

Some sites (e.g., ChristianaCare<\/a>, Mount Sinai<\/a>) have general guidance that incorporates clinical improvement, temperature, and oxygen requirement, while other sites (e.g., Johns Hopkins<\/a> and University of Michigan<\/a>) provide more specific guidance algorithms to standardize care (acknowledging the absence of evidence to substantiate this approach). None of these guidelines are evidence-based, only incorporating first principles regarding general and disease-specific risk factors for severe disease and markers of clinical stability.<\/p>\n

The literature on risk factors for poor post-discharge outcomes is limited. We identified three studies (two in pre-publication, one published), using different study designs, definitions of readmission, and data collected as potential predictors. The data are summarized below:[\/vc_column_text][vc_column_text]<\/p>\n\n\n\n\n\n\n\n\n\n\n\n
STUDY<\/td>\nSETTING, DESIGN<\/td>\nN<\/td>\nOUTCOME, FREQUENCY<\/td>\nRISK FACTORS<\/td>\n<\/tr>\n
Somani, et al.1<\/sup><\/a><\/span><\/td>\n5 NYC hospitals (Mount Sinai system)<\/p>\n

Retrospective cohort<\/td>\n

2864<\/td>\nReturn to hospital within 14 days (ER visit or readmission)<\/p>\n

3.6%<\/td>\n

Lower BMI
\nCOPD
\nHTN
\n~less anticoagulation
\nLess likely admitted to ICU
\nShorter LOS<\/td>\n<\/tr>\n
Parra, et al.2<\/sup><\/a><\/span><\/td>\n1 tertiary hospital in Spain<\/p>\n

Nested Case-Control (matched by age, sex, time period)<\/td>\n

61 cases and 61 matched controls<\/td>\nReadmitted within 3 weeks<\/p>\n

4.4%<\/td>\n

Immunocompromise
\n~HTN
\nShorter LOS
\nFever in 48 hours prior to discharge
\n~neutrophil\/lymphocyte ratio<\/td>\n<\/tr>\n
Richardson, et al.3<\/sup><\/a><\/span><\/td>\n12 NYC hospitals (Northwell system)<\/p>\n

Retrospective cohort<\/td>\n

2081 patients discharged alive<\/td>\nReadmitted by end of study period<\/p>\n

2.2%<\/td>\n

Older age
\n~DM
\n~HTN<\/td>\n<\/tr>\n
Kingery, et al.4<\/sup><\/a><\/span><\/td>\nQuaternary referral hospital and community hospital in NYC<\/td>\n1344<\/td>\nReadmission, ED visit, or mortality within 30 days<\/p>\n

16.5%, 9.8%, 2.4%<\/td>\n

Readmission:
\nOlder age
\nDiabetes
\nInpatient dialysisMortality:
\nOlder age
\nAsian race<\/td>\n<\/tr>\n
Saab, et al.5<\/sup><\/a><\/span><\/td>\n1 Tertiary hospital in CA (UCLA)<\/td>\n99<\/td>\nReadmission or ED visit within 30 days<\/p>\n

5%, 5%<\/td>\n

*Fever within 24h of discharge, O2 requirement, lab abnormalities were not associated, but small numbers<\/td>\n<\/tr>\n
Lavery, et al.6<\/sup><\/a><\/span><\/td>\nPremier database from 865 hospitals<\/td>\n126,137<\/td>\nSame hospital readmission within 2 months<\/p>\n

9%<\/td>\n

Discharge to SNF
\nDC home with services
\nAge per decade >65
\nPrevious admission within 3 months prior
\nCOPD
\nHeart Failure
\nDiabetes
\nCKD
\nShorter LOS
\nLess likely if ICU
\nLess likely if non-invasive ventilation<\/td>\n<\/tr>\n
Verna, et al.7<\/sup><\/a><\/span><\/td>\nChargemaster data from 297 hospitals across 40 states<\/td>\n29,659<\/td>\nReadmission within 30 days<\/p>\n

3.6%<\/td>\n

Discharge to SNF
\nAge > 60
\nShorter LOS
\nNever on O2
\nNortheast region
\nMedicaid or Medicare
\nCKD
\nCVD
\nHTN less risk
\nDiabetes
\nSmoking
\nIndex presentation with AKI, CHF, DIC, VTE
\nLess likely if ICU<\/td>\n<\/tr>\n
Donnelly, et al.8<\/sup><\/a><\/span><\/td>\nVA Corporate Data Warehouse, 132 VA hospitals<\/td>\n2179<\/td>\nReadmission or death within 60 days<\/p>\n

19.9%, 9.1%<\/td>\n

Readmission:
\nLOS < 7 daysMortality:
\nOlder age
\nMechanical ventilation
\nPressor use<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

[\/vc_column_text][vc_column_text]*NYC: New York City; ER: emergency room; BMI: Body Mass Index; COPD: chronic obstructive pulmonary disease; HTN: hypertension; ICU: intensive care unit; LOS: length of stay; DM: diabetes mellitus
\n~ indicates borderline statistical significance[\/vc_column_text][vc_column_text]Notable findings include the following:<\/p>\n

    \n
  1. The overall rate of readmission is low in these cohorts, with two exceptions (Kingery and Donnelly). This may be due to several factors:
    \na. These patients have less biopsychosocial complexity than typically admitted general medicine patients.
    \nb. These patients tended to have longer lengths of stay than typical inpatients.
    \nc. Once patients have fully recovered from COVID-19, they tend not have recrudescent disease. This may explain why ICU admission predicted lower readmission.<\/li>\n
  2. The presence of hypertension was a risk factor in most (but not all) of these studies. Other possible risk factors include chronic obstructive pulmonary disease, diabetes mellitus, COPD, CKD, CVD, heart failure, smoking, and immunocompromise.<\/li>\n
  3. Being febrile at discharge might be a risk factor for readmission but most studies were too small to evaluate this.<\/li>\n
  4. Lower length of stay was associated with a higher readmission rate in 5 of these studies. This suggests that at least some patients were discharged too soon, when they were still at risk of worsening disease.<\/li>\n
  5. It is notable that the Somani study found a trend toward less anticoagulation at discharge as a risk factor. This was not found in the Parra Ram\u00edrez study, but in that study, 16% of readmissions were due to a thrombotic event.<\/li>\n
  6. Inflammatory markers and vital signs other than temperature (e.g., O2 requirements at discharge) were not significant risk factors in the few studies that looked at them, but most of these studies were small. One study found that never being on supplemental O2 was a risk factor for readmission, likely because these patients were discharged early with mild disease which then worsened in week 2.<\/li>\n
  7. Discharge to SNF or home with services was sometimes associated with readmission, not because they provide poor post-discharge care but rather because these are markers of clinical fragility.<\/li>\n<\/ol>\n

    Notably, none of the larger studies compared the readmission rates in those with and without specific discharge criteria, and none of them compared length of stay and readmission rates in patients who met particular combinations of discharge criteria.[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][vc_column_text]<\/p>\n

    c. What is Not Known<\/strong><\/h3>\n

    Our findings reveal an urgent need for empiric research on clinical factors (including improvement in temperature and oxygen saturation, severity of disease, comorbidities, and laboratory markers), alone and in combination, that might predict poor post-discharge outcomes, including readmission and death. It may be that simple scores are effective. Alternatively, more complicated scores or criteria may be better to minimize length of stay and post-discharge complications. In the absence of such data, discharge practices with high consensus in this brief synthesis may provide useful guidance for hospitals to consider as they develop and refine protocols for a prolonged COVID-19 pandemic. [\/vc_column_text][vc_column_text]<\/p>\n

    d. Spring 2021 Update<\/strong><\/h3>\n