key: cord-344213-j3yextjl
authors: Sze, Shirley; Pan, Daniel; Williams, Caroline M L; Barker, Joseph; Minhas, Jatinder S; Miller, Chris; Tang, Julian W; Squire, Iain B; Pareek, Manish
title: The need for improved discharge criteria for hospitalised patients with COVID-19—implications for patients in long term care facilities
date: 2020-09-19
journal: Age Ageing
DOI: 10.1093/ageing/afaa206
sha: 
doc_id: 344213
cord_uid: j3yextjl

In the COVID-19 pandemic, patients who are older and residents of long term care facilities (LTCF) are at greatest risk of worse clinical outcomes. We reviewed discharge criteria for hospitalised COVID-19 patients from ten countries with the highest incidence of COVID-19 cases as of 26th July 2020. Five countries (Brazil, Mexico, Peru, Chile and Iran) had no discharge criteria; the remaining five (United States of America, India, Russia, South Africa and the United Kingdom) had discharge guidelines with large inter-country variability. India and Russia recommend discharge for a clinically recovered patient with two negative reverse transcription polymerase chain reaction (RT-PCR) tests 24 hours apart; the USA offers either a symptom based strategy—clinical recovery and ten days after symptom onset, or the same test-based strategy. The UK suggests that patients can be discharged when patients have clinically recovered; South Africa recommends discharge 14 days after symptom onset if clinically stable. We recommend a unified, simpler discharge criteria, based on current studies which suggest that most SARS-CoV-2 loses its infectivity by 10 days post-symptom onset. In asymptomatic cases, this can be taken as 10 days after the first positive PCR result. Additional days of isolation beyond this should be left to the discretion of individual clinician. This represents a practical compromise between unnecessarily prolonged admissions and returning highly infectious patients back to their care facilities, and is of particular importance in older patients discharged to LTCFs, residents of which may be at greatest risk of transmission and worse clinical outcomes.

is an urgent research priority.

 Current evidence suggests that most patients are non-infective 10 days post symptom onset or after first positive PCR result COVID-19 is a global pandemic. Older patients are at risk of hospitalisation and severe disease. [1] Globally, a high proportion of long term care facilities (LTCF) have reported COVID-19 outbreaks, with high rates of morbidity and mortality in residents. [2, 3] In the UK, according to the latest report from the Care Quality Commission, as of 5 th June 2020, 11,614 nursing home residents died of COVID-19, contributing to a quarter of all COVID-19 related deaths. [4] In some European countries, the proportion of COVID-19 cases in LTCFs who have died has exceeded 60% of all reported deaths, underlining the severe impact of COVID-19 on this frail population. [2, 5] The transmission dynamics of COVID-19, combined with low availability of testing in some countries have fuelled a rapid spread within and between facilities.. [3] Residents of LTCF who display symptoms of COVID-19 are commonly hospitalised. However, it is currently not clear when a patient with COVID-19, can be discharged after sufficient clinical improvement in hospital. Where they continue to be infectious following recovery, this may lead to increased transmission within LTCFs.

On the other hand, a prolonged inpatient stay may put them at risk of nosocomial infections, and occupying a hospital bed unnecessarily, with potential downstream impacts on patient flow and hospital capacity.

We therefore reviewed the discharge criteria for inpatients with COVID-19 in the 10 countries with the highest incidence of COVID-19, as of 26 th July 2020( 

Second, it appears that transmission of SARS-CoV-2 appears to occur predominantly in the presymptomatic phase and less than five days after symptom onset. Cheng and colleagues show a detailed contact tracing response to cases in Taiwan. They found no secondary transmission from contact exposures after the fifth day of symptom onset, suggesting a relatively short infectious period. [9] He and colleagues reported temporal patterns of viral shedding in 94 patients with laboratory confirmed COVID-19 and modelled COVID-19 infectivity profiles from a separate sample of 77 infector-infectee transmission pairs. They found that the highest viral load in throat swabs were at the time of symptom onset. [10] A recent study of COVID-19 in the quarantined Italian town of Vo found that 42% of COVID-19 cases were asymptomatic infections. The lack of effective guidelines on safe discharge of patients with nosocomial acquisition of COVID-19 who are asymptomatic or presymptomatic could potentially lead to outbreaks in LTCFs. [11] Third, no guideline has an approach tailored to discharge to LTCFs, where frail, vulnerable and ultimately the highest risk residents require daily assistance with all activities of daily living.

Potentially related to this are some findings of live SARS-CoV-2 in the faeces of some patients from China [12, 13] , earlier on in the pandemic (Feb 2020). However, five months on from these reports, there have not been any reports of major COVID-19 outbreaks related to this route of transmission.

Therefore, the use of PCR-based discharge criteria alone may be unhelpfulin determining infectivity and the timing of patient discharge. Although SARS-CoV-2 viral culture offers an indication of virus infectivity, it may take 3-6 days to observe a cytopathic effect, is labour-intensive and requires high level laboratory (Category 3/Biosafety Level 3) facilities. Furthermore, most diagnostic laboratories in the UK have stopped offering viral culture as a service and the skill sets/infrastructure needed to deliver it no longer exist.

Whilst PCR-based testing on inactivated viral extracts is safer and quicker, and can be semi-or fully automated, PCR results do not necessarily give a reliable indication of infectivity. Although Bullard We believe this approach to be simple, the most evidence based, and applicable to all countriesfor the moment. However, as the COVID-19 pandemic continues to evolve, any new evidence will be reviewed and incorporated as required, to update this guidance.

isolation (Accessed 15 July 2020)

UK Government. Statement from the UK Chief Medical Officers on extension of self-isolation period: 30 July 2020. https://www.gov.uk/government/news/statement-from-the-uk-chiefmedical-officers-on-extension-of-self-isolation-period-30-july-2020 (Accessed 6th August 2020) 

European Centre for Disease Prevention and Control. Surveillance of COVID-19 at long-term care facilities in the EU/EEA

Mortality associated with COVID-19 outbreaks in care homes : early international evidence. Resour to Support community institutional Long-Term Care responses to COVID-19 2020

Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington

Comparison of weekly death occurrences in england and Wales: up to week ending 29

Virological assessment of hospitalized patients with COVID-2019

Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility

Predicting infectious SARS-CoV-2 from diagnostic samples

Contact Tracing Assessment of COVID-19 Transmission Dynamics in Taiwan and Risk at Different Exposure Periods before and after Symptom Onset

Temporal dynamics in viral shedding and transmissibility of COVID-19

Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo'

Isolation of 2019-nCoV from a Stool Specimen of a Laboratory-Confirmed Case of the Coronavirus Disease 2019 ( COVID-19 )

Clinical Characteristics of 138 Hospitalized Patients with 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

Can the SARS-CoV-2 PCR Cycle threshold value and time from symptom onset to testing predict infectivity?

World Health Organization. Criteria for releasing COVID-19 patients from isolation