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Updated: September 14, 2020

When can a COVID-19 patient be discharged from a hospital?

Summary

The following is a summary of evidence sources that provide high quality information on when a COVID-19 patient can be discharged from hospital. For additional information about each of the sources, see the Table below.

The authors of three reviews and a World Health Organization (WHO) report found that if capacity allows, a healthcare facility may discharge patients if they have clinically recovered (i.e., no fever without fever-reducing medications and improvement in respiratory symptoms) and have tested negative for COVID-19 twice from samples collected at least 24 hours apart [1,2,3,4]. Two of these reviews noted the following additional discharge criteria: 1) blood oxygen saturation should have returned to normal without oxygen support; 2) improved respiratory symptoms; 3) fever resolution for more than three days; and 4) improvement of inflammation on chest CT (Computed Tomography) imaging [2,3]. In its Guidance for stepdown of infection control precautions and discharging COVID-19 patients, Public Health England recommends that if capacity is limited a patient can be discharged if they are stable or have recovered respiratory function and ongoing care needs can be met at home [6]. Alberta Health Services suggest in its Presumed/Confirmed COVID-19 Positive Primary Care Pathway, that if capacity allows, a longer hospital stay could be given where: 1) a home environment is not suitable for self-isolation; 2) a higher risk household member is present; 3) food, water or financial insecurity is identified; 4) challenges with health literacy are identified; or 5) there is a lack of caregiver support [8].

If the decision to discharge is made, Shared Health Manitoba and the European Centre for Disease Prevention and Control (ECDC) note that the discharged patient should be provided with: 1) clear language discharge instructions; 2) transportation to their discharge location; and 3) follow-up visits from healthcare providers or daily wellness calls, as needed [1,7].

Two reviews noted that a patient can be  discharged to their home with symptoms if they self-isolate until the resolution of a fever for at least three days, the improvement of respiratory symptoms and at least ten days after symptom onset for mild cases and 14 days for severe cases or if the patient is discharged to a congregate living facility [1,3]. During isolation, the ECDC’s Guidance for discharge and ending isolation in the context of widespread community transmission of COVID-19 recommended that the patient: 1) wear a mask when interacting with others; 2) reduce all contact with household members; and 3) practice good hand hygiene [1]. Lastly, in its Discontinuing Transmission-Based Precautions, the Centers for Disease Control and Prevention (CDC) recommends that a patient discharged to a long-term care facility should remain in a location preferably designated to care for COVID-19 residents only [5].

Evidence

What‘s Trending on Social Media and Media

Dr. Anthony Crocco, Pediatric Emergency Department Chief at the McMaster Children’s Hospital, produced a video that provides useful information on COVID-19 in children using lay terms and simple terminology to target all audiences. The video highlights common symptoms, facts regarding recovery, potential sources of infection (i.e. surfaces), vulnerable populations, available resources and recommended social isolation measures.

Organizational Scan

The region of Peel has designed a Novel Coronavirus (COVID-19) Health Care Provider Pre-Discharge Checklist. This tool is to be used for patients who have been tested for COVID-19 and are medically suitable to be discharged. The flowchart assesses a patient’s living arrangements and means of transportation to determine whether discharging is appropriate. It also provides patients and household contacts with self-isolation guidelines and expectations [9].  
 
Alberta Health Services has released a COVID-19 Provincial Pandemic Patient Discharge from Hospital Flowsheet. The flowsheet highlights discharge requirements regarding a patient’s health (e.g., Oxygen saturation), as well as the process of ensuring patients have adequate support to fully recover at home (e.g. living situation, transportation, family/friends support). It is advised that patients receive referrals to specialty care providers for follow-up appointments as necessary, and to other community support resources. Upon being discharged, patients are to be provided with guidelines for self-isolation and for their household contacts [10].
 
The University of Calgary Department of Medicine has released a Hospital COVID Discharge Process dated April 18, 2020. The document provides patients with information on the use of home oxygen, appropriate means of transportation, and how patients can continue to obtain their medications [11].  

Review of Evidence

Resource Type/Source of Evidence Last Updated
Guidance for discharge and ending isolation in the context of widespread community transmission of COVID-19 – first update
— ECDC: European Centre for Disease Prevention and Control
Rapid Review

This ECDC review notes that if healthcare facilities have capacity, patients can be discharged where they have clinically recovered and have two COVID-19 negative tests from samples collected at least 24 hours apart. If capacity is limited, patients can be discharged based on clinical criteria per evaluation of treating physician and the discharged patient should self-isolate until the resolution of a fever for at least three days and clinical improvement of symptoms and eight days after symptom onset for mild cases and 14 days for severe cases. During isolation, patient should wear a mask, reduce all contact with household members and practice good hand hygiene. It is recommended that discharged patients have follow-up visits after two and four weeks or daily wellness calls.

This review also notes that to discharge a patient, authorities should consider the existing capacity of healthcare system, laboratory diagnostic resources, the current epidemiological situation and the patient’s capacity to isolate if sent home.

Last Updated: April 7, 2020
Patient Follow-up after Discharge after COVID-19: Pneumonia: Considerations for Infectious Control
— Zheng et al.
Rapid Review

This review describes the following discharge criteria for COVID-19: 1) blood oxygen saturation should have returned to normal without oxygen support; 2) a normal body temperature for more than three days; 3) two negative COVID-19 tests at least a day apart; and 4) a chest Computed Tomography showing lesions that are mostly absorbed.

Telephone follow-up should be carried out at three days, two weeks, three months and six months after discharge, with outpatient follow-ups at one week, two weeks and one month after discharge.

Last Updated: May 7, 2020
COVID-19 Scientific Advisory Group Rapid Response Report
— Alberta Health Services
Rapid Review

The Alberta Health Services review found that common discharge criteria include: 1) fever resolution for 24-72 hours; 2) improved respiratory symptoms; 3) two negative SARS-CoV-2 tests 24 hours apart; and 4) improvement of inflammation on imaging. After discharge, symptomatic patients should self-isolate until predominant symptoms and fever are completely resolved or after 10 days since symptom onset or 14 days if the patient is immunocompromised or returning to a congregate group home.

Last Updated: April 21, 2020
Clinical Management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected
— WHO: World Health Organization
International Guidance

The WHO suggests that for a clinically recovered patient to be discharged from hospital, two negative tests, at least 24 hours apart, is recommended. It is also important to understand patients’ co-morbid conditions when deciding to potentially discharge.

Last Updated: March 12, 2020
Discontinuing Transmission-Based Precautions
— CDC: Centre for Disease Control and Prevention
National Guidance

The CDC notes that if a patient is being discharged to a long-term care facility or nursing home, the patient should adhere to infection prevention and control recommendations including wearing a facemask when interacting with others, and remaining in a location preferably designated to care for COVID-19 residents only.

Last Updated: May 1, 2020
Guidance for stepdown of infection control precautions and discharging COVID-19 patients
— Public Health England
National Guidance

This report notes that a patient can be discharged if the patient has stable or recovering respiratory function and any ongoing care needs can be met at home. If the patient received critical care or are immunocompromised, they should self-isolate until at least 14 days from their first positive test.

Last Updated: May 19, 2020
Instructions for Staff – Discharge of COVID-19 Patients
— Shared Health Manitoba
Professional Organization

This guidance instructs that when determining whether to discharge a patient, it must be determined whether the patient can safely self-isolate at home. If it is deemed that the patient may not be able to self-isolate at home, it is recommended to work with other applicable disciplines (e.g. Social Work, Bed Utilization, Indigenous Health, Homecare) to investigate options. The discharged patient should also be provided with discharge instructions including how the patient can connect with their local Public Health unit, if necessary, and how to self-isolate. Transportation to their discharge destination should be arranged for the patient.

Last Updated: May 13, 2020
Presumed/Confirmed COVID-19 Positive Primary Care Pathway
— Alberta Health Services
Provincial Guidance

This guidance recommends that if capacity allows, a longer hospital stay may be given if the patient: 1) does not have a home environment suitable for self-isolation; 2) the presence of household members who may be at higher risk; 3) food/water/financial insecurity; 4) challenges with health literacy; or 5) lack of caregiver support.

Last Updated: April 5, 2020
Novel Coronavirus COVID-19 Health Care Provider Pre-Discharge Checklist
— Region of Peel
Organizational Scan Last Updated: May 26, 2020
COVID-19 Provincial Pandemic Flowsheet Patient Discharge from Hospital
— Alberta Health Services
Organizational Scan Last Updated: April 28, 2020
Hospital COVID Discharge Process
— Department of Medicine, University of Calgary
Organizational Scan Last Updated: April 17, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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