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The challenges of covid discharges

December 2020

IN QUINCY ILL., hospitalist Mary Frances Barthel, MD, MHCM, and her colleagues at Blessing Hospital always know when a covid patient is being discharged: That’s when the hospital plays Pharrell Williams’ “Happy” over the loudspeakers.

“We play the whole song, not just a few bars,” says Dr. Barthel, chief quality and safety officer for Blessing Health System and the hospital’s lead for infection prevention. “I get a charge out of hearing it.”

But speaking in mid-November, Dr. Barthel made it clear that those discharges just aren’t happening fast enough. Every one of the hospital’s 300-plus beds is full, and one out of three patients has covid. And many covid patients “just linger” and can’t be discharged, even to a SNF, “for a long, long time.”

“They need a lot of oxygen, and they can be here for weeks, whether on a vent or BiPAP or high-flow oxygen,” Dr. Barthel says. “That’s part of the reason why the beds are so full: Patients just stay longer.”

“Covid discharge planning is regular discharge planning on steroids.”

~ Christopher Song, MD
Lawrence+Memorial Hospital

As hospitalists face the winter surge, which is expected to be the worst yet, some say that many of the discharge hurdles they faced earlier in the pandemic have been smoothed out. Hospital administrators and state agencies, for instance, have stepped in to ensure that hospitalists at least have some skilled-nursing options to move those patients out of the hospital.

It’s a similar story with home health and with turning test results around. But the fact that coronavirus is so transmissible—and that some patients being discharged home may still need to isolate when they get there—means that covid discharges can have a lot of moving parts.

Put more simply: “Covid discharge planning is regular discharge planning on steroids,” says Christopher Song, MD, associate director of the TeamHealth hospitalist program at Lawrence+Memorial Hospital in New London, Conn.

Discharge criteria
In a session this summer during the Society of Hospital Medicine’s virtual annual conference, speakers presented preliminary results of a survey on covid discharge practices. Respondents were hospitalists at more than 20 sites that are part of the Hospital Medicine Reengineering Network (HOMERuN), a national consortium of academic centers.

The vast majority (more than 80%) were following CDC guidelines for isolation and quarantine for patients being discharged. (More on those below.) More than 70% said their centers required drivers transporting discharged patients to wear masks and provided PPE for patients to use at home.

“Families are often reluctant to have patients, particularly elderly ones, discharged home.”

Mary Frances Barthel, MD, MHCM

~ Mary Frances Barthel, MD, MHCM
Blessing Hospital

But as for clinical criteria for covid discharges, responses varied widely. One-quarter (27%) gave little or no guidance (“use clinical judgment”), while 14% had specific criteria or discharge algorithms. And while most sites based discharge decisions (at least for patients going home) on an assessment of symptom improvement, temperature and oxygen requirements, the parameters for all those varied.

Some centers required patients to be afebrile for a specific time period, ranging from 24 to 72 hours; others just wanted patients to not have a fever at discharge. Some required patients to meet specific oxygen saturation thresholds (more than 90%-94%) or supplementation levels (between two and four liters). But others just looked for patients to be stable or at baseline.

According to Dr. Song, many discharge decisions about covid patients “are definitely not black and white. Looking for full resolution of symptoms is unrealistic, but you are looking for improvement. It’s a matter of probabilities.”

In her hospital, Dr. Barthel and her colleagues don’t use any set of criteria when discharging covid patients.

“It’s pretty much the same as for any patient with pneumonia,” she points out, “with this difference: Covid patients need oxygen much longer. Everything about a patient may look just like one going home from a pneumonia stay, but they end up being here several days extra.”

“The idea is to create a well-oiled discharge machine that can run on its own.”

Naznin Jamal, MD

~ Naznin Jamal, MD

Jefferson Regional Medical Center

Test- vs. time-based strategies
In the early days of the pandemic, the CDC advocated for a test-based strategy to determine when covid patients could leave isolation or quarantine—a big issue for discharges.

But given testing constraints and the fact that some patients persistently test positive for weeks or even months, the CDC now recommends a time-based strategy instead. Such an approach takes into account the number of days since symptom onset or a positive test, as well as no fever and symptom improvement.

For patients with mild or moderate illness, here’s the current guidance: Remain in isolation or quarantine for 10 days since symptoms began or a positive test, be afebrile for at least 24 hours, and show symptom improvement—typically improved breathing or needing less oxygen. For patients with severe disease, the CDC recommends continuing isolation and quarantine precautions for up to 20 days.

But test-based strategies are still the order of the day when discharging patients to a SNF, rehab or long-term care facility. In Florida, Joshua Lenchus, DO, a former hospitalist and chief medical officer of Broward Health Medical Center in Ft. Lauderdale, points out that his state’s Agency for Health Care Administration—the governing body that licenses post-acute facilities—requires covid patients to get two negative tests 24 hours apart before they can be discharged to post-acute care. For non-covid patients who’ve never tested positive, SNFs require one negative test before they’ll admit.

“We really have no wiggle room with that,” he says. “If you want to get your patient there, you have to do what they want you to do.”

Post-acute challenges
But Dr. Lenchus notes that discharges to SNFs have at least become less onerous since the last covid surge in Florida this summer. At that time, SNFs and nursing homes were requiring negative tests even for patients they’d sent to the ED only hours before—or else they wouldn’t allow patients to return to their facility.

“It’s helped that we can really focus on this one disease process.”

Justin Glasgow, MD, PhD

~ Justin Glasgow, MD, PhD
University of Alabama Birmingham

Fortunately, “some post-acute facilities this summer began pivoting and earmarking some units for covid-positive patients.” Now, when patients sent from nursing homes test positive, the ED and hospitalists have the option of discharging them to a different post-discharge facility, where patients can be cared for until they have the requisite number of negative tests to allow them return to their original SNF or nursing home.

“Space in dedicated units is obviously a limiting factor,” he says, “but at least we now have that option.” His hospital’s team of social workers and case managers has become “very adept at identifying the places that can take positive patients, both in terms of capability and capacity.”

In producing two negative tests to discharge a patient to a SNF, he opts—if supplies permit—to use two different testing platforms. He and his colleagues have access to three PCR tests, each with different turnaround times.

“By using different tests one day apart,” says Dr. Lenchus, “I feel pretty confident sending patients out to a post-acute facility.”

Testing constraints and persistent positives
In New London, Dr. Song says his local SNFs require only one negative test within 24 hours of discharge before admitting patients from the hospital. But even that requirement can be “a big thorn in our side.”

He and his colleagues do have access to a Cepheid rapid test that turns results around in an hour or two. But “we have an algorithm to follow for which patients can get that test,” says Dr. Song—and discharges to SNFs aren’t approved. Instead, they rely on another platform, a Panther test that’s available at a sister hospital and delivers results in between 12 and 18 hours.”

“You have to carefully gauge when to test someone you want to discharge to a SNF,” he points out, “or they’ll end up having to wait another day in the hospital by the time their results come back.” The hospitalists do have an agreement with case management to score one or two rapid tests per day that are exceptions to the rapid-test algorithm.

“Sometimes,” he says, “we’re allowed an exception for an unexpected discharge to a SNF.”

The persistent positives that can turn up when testing some covid patients have been “a big topic of discussion as to how we should approach them,” Dr. Song says. The state has set up a dedicated nursing facility where his group can send patients still testing positive; unfortunately, it’s far from the hospital, so discharges there are “uncommon.” And one local nursing home does have an isolation unit for recovering covid patients who were already residents there.

“But you’re talking now of select places,” he says. “It’s still limiting.”

SNFs are swamped
Dr. Song describes his hospital—part of Yale New Haven Health—as being on the front edge of a growing statewide surge. Still, only one or two local SNFs have been “overwhelmed” with covid cases. But in Illinois, Dr. Barthel notes that many SNFs in her region have been swamped with cases, complicating physicians’ ability to discharge covid patients to post-acute care, at least locally.

“A number of SNFs and nursing homes have stopped admitting because of outbreaks among staff and residents,” she says. “Others refuse to take covid positive patients.” Ironically, she now has some new SNF-discharge options: two nearby facilities where, “every single staff member and resident has already been infected,” says Dr. Barthel. “They can now take these patients.”

As part of its contingency planning in March, Dr. Barthel says her hospital worked out an agreement with a local nursing home to take over one of its wings for recovering covid patients, if needed. The idea was to have that wing staffed and managed by hospital personnel.

That early surge didn’t materialize. Now that one has, “we don’t have the staff to deploy in that kind of plan,” she says.

Fortunately, her hospital in October did open a new addition that has its own skilled nursing unit; so far, that’s reserved for non-covid patients only. As the number of covid cases continues to rise, however, that may have to change.

But “even if we wanted to take more skilled patients into that unit, I don’t think we have a waiver for that,” Dr. Barthel points out. “We would have to apply for a certificate of need to expand those skilled beds—if we’d have enough personnel to staff them.”

The need for consistent messaging
Dr. Barthel also says that she’s discussed with her medical staff the need to get this message out, consistently and repeatedly, to family members: Patients being discharged to SNFs may not get their first choice. “They may be going to a facility much farther away, and family may have to drive to another town.”

Another message medical staff have been asked to deliver to families: They need to step up and help take care of covid patients being discharged home.

“They don’t want their loved one going to a nursing home because those don’t allow visitors,” she says. “At the same time, families are often reluctant to have patients, particularly elderly ones, discharged home.”

That’s due in large part to not wanting to care for someone who may need to remain isolated at home, potentially exposing household members who must then quarantine themselves. To help them prepare, Dr. Barthel says that physicians and staff now tell families, early and often, to plan to care for discharged patients at home, including setting up areas where patients can be isolated.

Given the complexities around quarantine after discharge for some patients, even a ride home can become an issue. “Family members are worried about driving patients home because they may be exposed,” she notes. “We’ve given them actual medical-grade masks so they’ll feel safer in the car.”

Home oxygen
In Pine Bluff, Ark., Naznin Jamal, MD, medical director of hospital medicine at Jefferson Regional Medical Center, says ICU beds and resources in her hospital are in critically short supply. Fortunately, she and her colleagues—at least so far—have post-acute facilities they can discharge patients to. They also have no problem ordering home health services for discharged covid patients who need them.

“We built in a protocol with our case managers and respiratory therapists for patients on four liters or less,” she says. Respiratory therapists evaluate patients’ oxygen needs during a six-minute exertion test, and “we’ve been able to easily arrange home oxygen for anyone who requires three liters or less.”

More than that, “I feel nervous discharging patients with four or more liters, even with home oxygen,” says Dr. Jamal. With the protocols and a discharge order set in place, “the idea is to create a well-oiled discharge machine that can run on its own,” she adds. “The discharge process was initially a struggle, but we’ve been able to get buy-in from all the parties involved.”

In Fort Lauderdale, Dr. Lenchus says one unintended consequence of treating covid is the “sheer volume of patients leaving the hospital with oxygen. Many patients who appear to get better still have an oxygen saturation level well below the Medicare threshold for requiring oxygen at home.” While it’s taken some doing to get enough vendors lined up, so far oxygen hasn’t been in short supply.

Educating about quarantine
Most sources said their hospitals hadn’t put any specific program in place to monitor covid patients at home after discharge. Medical centers that already had a post-discharge calling system in place before the pandemic have simply incorporated those patients.

Dr. Song’s health system, however, is giving pulse oximeters to discharged patients who need supplemental oxygen or have chronic conditions that put them at higher risk of severe covid. Those patients need to have access to outpatient care and be able to upload daily oximeter readings to their electronic EHR records from home.

In Alabama, Justin Glasgow, MD, PhD, associate chief quality officer and physician advisor for sepsis at the University of Alabama Birmingham, says that discharge planning for covid patients is singular for the amount and type of education patients need before they leave.

“It’s a different focus on educating them about having to quarantine at home,” instead of how to manage often multiple chronic illnesses, Dr. Glasgow says. “It’s helped that we can really focus on this one disease process and not the many chronic conditions we typically are teaching them to manage.”

He and his colleagues, he adds, have been surprised at how relatively few exacerbations of chronic illnesses covid patients have in the hospital. “A COPD patient who comes in with covid tends to have fewer COPD complications than that same patient would with influenza.”

Why? “It doesn’t really make any sense to us,” Dr. Glasgow says. “But it has been one small silver lining.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Ending isolation in the hospital

WHEN IT COMES to scarce resources in the hospital, isolation precautions for covid patients are certainly on the list. But exactly when can patients safely come out of isolation?

The CDC has weighed in. Patients with mild or moderate illness should remain in isolation for 10 days since symptom onset or a positive covid test. They also need to not have a fever for at least 24 hours without any fever-lowering medications, and their symptoms need to be improving. For those with severe illness, isolation is warranted for up to 20 days.

“We take an assertive approach to moving patients through.”

Joshua Lenchus, DO

~ Joshua Lenchus, DO
Broward Health Medical Center

The problem, says Naznin Jamal, MD, medical director of hospital medicine at Jefferson Regional Medical Center in Pine Bluff, Ark., is the number of patients with severe covid who meet two of those criteria—20 days, no fever—but not the third.

“We’re seeing a lot of patients whose respiratory symptoms persist longer than 20 days,” says Dr. Jamal, who points out that some of those patients are using nasal cannula at five or six liters or more. “We actually had a patient on 15 liters on day 40.”

How does she approach those patients? For those not in the ICU, she’ll see if patients can test negative, using PCRs 24 hours apart.

“And we do expect some of these PCRs to remain positive for up to three months,” she says. She and her colleagues keep those patients in isolation. As for patients in the ICU, “for those patients who have higher oxygen needs, we continue to maintain their isolation.”

In Florida, Joshua Lenchus, DO, chief medical officer of Broward Health Medical Center in Ft. Lauderdale, points out that the CDC calls for maintaining precautions for up to 20 days after symptom onset for severe disease. His medical center has decided to begin to assess if those patients can leave isolation after 14.

“I wanted the ability to flex down,” Dr. Lenchus says. “That way, we may be able to move patients out of
the covid unit who are doing a lot better at the 14-
day mark.” Once those patients come out of isolation, they’re put in private rooms, “so they’re not sharing a room with someone else. And everyone in the hospital now wears masks.”

How many patients with severe disease have been able to come out of isolation at 14 days? Not many, he says. “Just a handful, but we did try to blend different CDC guidelines to safely move patients out of isolation and free up some resources. We take an assertive approach to moving patients through.”

Published in the December 2020 issue of Today’s Hospitalist
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