Brigham and Women's Hospitals

ED Discharge Planning

Emergency Department Discharge Planning

Discharge Criteria

  1. Clinical assessment
  1. Please see the Emergency Department Disposition Algorithm when deciding on discharge. Decision to discharge includes the following criteria:
  1. Normal vitals signs
  2. Absence of ambulatory hypoxemia
  3. Reassuring clinical appearance or projected trajectory
  4. Assessment of comorbid risk factors
  1. Patients with mild disease and some risk factors should be counseled on symptoms of worsening disease and indications for return evaluation
  2. Patients with moderate disease and some risk factors should be seriously considered for admission
  1. Social assessment
  1. A subset of patients who are medically stable may be suboptimal for returning to home due to social needs. The care coordinator or social worker should be engaged to assist with providing resources for alternative disposition vs admission. Questions to consider:
  1. Is the patient capable of safely conducting ADLs?
  2. Does the patient have a family member or caregiver at home who can assist with recovery if needed?
  3. Does the patient have a separate room at home for in-home isolation?
  4. Does the patient have adequate supply of or access to food, medications, and other necessities for the next 7-14 days?
  5. Can the patient’s family members or housemates adequately practice protective precautions?
  6. Does the patient have household members with high risk of COVID complications and morbidity?
  1. Please see Inpatient Discharge above for Against Medical Advice discharge.

Discharge Instructions and Follow-up

  1. Clinician should offer careful and clear guidance regarding:
  1. Expected clinical course
  2. Symptomatic treatment, expectant management
  3. Signs and symptoms to trigger further medical evaluation if needed
  4. Where further evaluation should be sought (PCP or ED)
  5. Home isolation to avoid family or community spread
  1. Patients who have undergone testing for whom results are pending should be treated as positive until informed otherwise.
  1. How to receive pending testing results
  1. Patients with pending COVID swab results will be contacted by the ED Physician Assistant (PA) Microbiology follow-up program within 24-48 hours of discharge.
  2. Patients discharged from the ED with a positive result do NOT need follow-up testing unless otherwise instructed by PCP or other provider
  1. Consider using the following dot phrases in Epic: SPUCOUNSELING, SPUDISCHARGECOVIDPOSITIVE
  2. Additional Partners Patient Instruction Dot Phrases (Partners login required)
  1. Follow up phone calls on post-discharge days 1, 4, and 8
  1. Day 1: ED PAs will automatically call all patients classified as PUIs at time of discharge to notify them of their COVID result
  2. Days 4 & 8: ED research assistants will automatically call all positive patients to perform medical and social needs assessment
  1. Patients with worsening medical condition will be connected to an ED PA who will either arrange a PCP appointment or encourage return to the ED
  2. Patients with an inadequate social situation such as food or housing insecurity may be connected with a Care Transition Specialist (CTS) who can assist with social needs and/or connecting them with a PCP
  1. Plans are currently underway for additional post-discharge services including follow-up with the Respiratory Infections Clinic (RIC), Remote Patient Monitoring (RPM), and Mobile Integrated Health (MIH) team

ED Suspected or Confirmed COVID-19 Discharge Checklist

  • MD: Advise patients to self-isolate for two (2) weeks unless (or until called back with negative result, if not confirmed)
  • MD: As applicable, provide discharge instructions with Epic Smart Phrases: SPUCOUNSELING, SPUDISCHARGECOVIDPOSITIVE
  • MD: if able, provide warm handoff via phone or in-basket message to patient’s primary care provider and confirm that they are able/willing to answer questions post-discharge
  • MD: provide language-appropriate document reviewing community resources (updated daily by HMS students, available in English, Spanish, Portuguese and Chinese)
  • Registration Staff: Verify and document contact number for patient and primary support person; ensure active phone service, voicemail functioning, and language preference correctly documented
  • MD/PA/RN: Verify residence with private room, ability to adhere to home isolation instructions and risk of transmission to persons with immunocompromising conditions in the home
  • MD/PA/RN: Confirm ability to manage ADL/iADLs with degree of support at home
  • MD/PA/RN/Follow-Up Program: Confirm that patient has resources/social support to receive 1-2 weeks of food and other necessary supplies while under quarantine
  • CCM/SW/Follow-Up Program: Verify patient has a ride by private vehicle or arrange transportation via ambulance (infected person should wear mask in vehicles)