Hospital Admission vs. Home care

Differentiating between adult patients with COVID-19 eligible for home care management vs requiring hospital admission

Version 1: 19-03-2020

Eligibility

Home care

Age <60 years: [2,4]
Mild disease: absent or mild pneumonia, usually present with symptoms of URTI (low-grade fever, dry cough, sore throat, nasal congestion, malaise, headache, myalgias or malaise)6,8; No warning signs (tachypnea, hemoptysis, increased sputum production, gastrointestinal symptoms, altered mentation) [1]
No underlying health conditions (cardiovascular and respiratory disease, active malignancy, diabetes, hypertension, renal failure, immunocompromising conditions) [1]
HCW needs to determine if:

Residential setting is suitable for home isolation [5]
Whether patient and family can adhere to recommended precautions [5]
Address safety concerns [5]

Hospital admission

Age >60 years[2,4] (males at higher risk than females) [3]
Patient with pneumonia or respiratory distress should be promptly admitted.[1]
Other medical conditions (cardiovascular and respiratory disease, active malignancy, diabetes, hypertension, renal failure, immunocompromising conditions) [7,8]
Secondary infection [7]
Abnormal lab findings: elevated inflammatory markers (cardiac troponin, myoglobin, CK, CRP, IL6, LDH) in blood, normal or decreased WBC (persistent lymphocytopenia is concerning for worsening pneumonia and ARDS) [6], metabolic panel (elevated liver transaminases; decreased albumin, renal impairment), coagulation screen (elevated D-dimer, prolonged PTT)[1]
Abnormal imaging: CXR (unilateral or bilateral lung infiltrates), CT chest (bilateral ground-glass opacity or consolidation)[1]

Treatment and Management

Home care

Treat symptoms (antipyretics such as acetaminophen for fever) [8]
Families should be provided resources to home isolation precautions [5]

Hospital admission

Case-by-case** Refer to management section(s)

Discharging patients to home

Patient can be discharged when clinically indicated.[9]

Decision to discharge requires careful consideration of future risk for medical intervention vs ongoing risk to HCW exposure. Early discharge may result in transfer back to hospital if patient deteriorates at home. This may result in additional risk of exposure during transport.[10]

Decision to discharge is made in consultation with patient’s healthcare team, Public Health and should consider patient’s suitability for homecare, as well as risk of secondary transmission to household members with immunocompromising conditions.[9]

Isolation should be continued at home if patient returns home before the decision to discontinue transmission-based precautions is made.[9]

When to discontinue isolation protocols?

Case-by-case evaluation and should consider disease severity, illness signs and symptoms and lab testing for COVID-19 in respiratory specimens.[9] This is determined by Public Health; refer to most recent recommendations.

Summary: eligibility for home care vs hospital admission

Age <60 years

Patient with mild disease

No underlying health conditions

Health care workers need to; A) Determine if residential setting is suitable for home isolation; B) whether patient and family can adhere to recommended precautions; C) Address safety concerns

Age >60 years

Patient with pneumonia or respiratory distress

Other medical conditions

Secondary infection

Abnormal lab findings

Abnormal image findings

References:

https://bestpractice.bmj.com/topics/en-gb/3000168
Novel, C. P. E. R. E. (2020). The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua liu xing bing xue za zhi= Zhonghua liuxingbingxue zazhi, 41(2), 145.
Shi, Y., Yu, X., Zhao, H., Wang, H., Zhao, R., Cai, Q., ... & Duan, J. Host susceptibility to severe COVID-19: a retrospective analysis of.
Velavan, T. P., & Meyer, C. G. (2020). The COVID‐19 epidemic. Tropical Medicine & International Health
World Health Organization. (2020). Home care for patients with suspected novel coronavirus (‎‎‎‎‎‎‎‎‎‎‎ COVID-19)‎‎‎‎‎‎‎‎‎‎‎ infection presenting with mild symptoms, and management of their contacts: interim guidance, 04 February 2020 (No. WHO/nCov/IPC/HomeCare/2020.3). World Health Organization.
Gong, J., Dong, H., Xia, S. Q., Huang, Y. Z., Wang, D., Zhao, Y., ... & Lu, F. (2020). Correlation Analysis Between Disease Severity and Inflammation-related Parameters in Patients with COVID-19 Pneumonia. medRxiv; https://www.ncbi.nlm.nih.gov/books/NBK554776/#article-52171.s7
Ruan, Q., Yang, K., Wang, W., Jiang, L., & Song, J. (2020). Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Medicine, 1-3.
World Health Organization. (2020). Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance, 13 March 2020 (No. WHO/2019-nCoV/clinical/2020.4). World Health Organization.
Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of Hospitalized Patients with COVID-19. (2020, March 14). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
Marchand-Senécal, X., Kozak, R., Mubareka, S., Salt, N., Gubbay, J. B., Eshaghi, A., ... & Ozaldin, O. (2020). Diagnosis and Management of First Case of COVID-19 in Canada: Lessons applied from SARS. Clinical Infectious Diseases.