What are the criteria for discharging a patient with pneumonia?

Discharge Protocol for Patients with Pneumonia

Patients with pneumonia should be discharged only when they demonstrate documented clinical improvement for 12-24 hours, maintain oxygen saturation >90% on room air for 12-24 hours, have stable mental status, and can tolerate their home medication regimen. 1

Essential Discharge Criteria

Clinical Stability Requirements

• Overall clinical improvement for at least 12-24 hours, including:
  • Improved level of activity
  • Improved appetite
  • Decreased fever 1
• Respiratory stability as evidenced by:
  • Consistent pulse oximetry measurements >90% in room air for at least 12-24 hours 1
  • No substantially increased work of breathing
  • No sustained tachypnea or tachycardia 1
• Neurological stability with stable and/or baseline mental status 1

Medication Management

• Documentation that patient can tolerate their home anti-infective regimen (oral or intravenous) 1
• For patients requiring home oxygen, documentation of tolerance to the home oxygen regimen 1
• For pediatric patients requiring oral antibiotics, verification that parents can administer and children can comply with taking the medications 1

Special Considerations

Patients with Chest Tubes

• Discharge is appropriate after chest tube removal for 12-24 hours if:
  • No clinical evidence of deterioration since removal
  • If chest radiograph was obtained due to clinical concerns, no significant reaccumulation of parapneumonic effusion or pneumothorax 1

Patients Requiring Ongoing Parenteral Therapy

• Outpatient parenteral antibiotic therapy should be offered to patients who:
  • No longer require skilled nursing care in acute care facility
  • Have demonstrated need for ongoing parenteral therapy 1
• This should be provided through:
  • Skilled pediatric home nursing program, or
  • Daily intramuscular injections at appropriate outpatient facility 1
• When possible, conversion to oral outpatient step-down therapy is preferred over parenteral outpatient therapy 1

Addressing Social Barriers

• Before discharge, identify and address barriers to care, including:
  • Concerns about careful observation at home
  • Inability to comply with therapy
  • Lack of availability for follow-up 1

Transition from IV to Oral Therapy

For patients transitioning from intravenous to oral antibiotics, ensure:

• Patient shows evidence of early clinical improvement 2
• Cough and respiratory distress are improving
• Patient is afebrile for at least 8 hours
• White blood cell count is returning toward normal
• No evidence of abnormal gastrointestinal absorption 2

Pitfalls and Caveats

• Do not discharge patients with substantially increased work of breathing or sustained tachypnea or tachycardia, as this indicates ongoing significant respiratory compromise 1
• Do not rely on fever resolution alone as the sole criterion for discharge, as fever may persist for several days despite adequate therapy, particularly in complicated pneumonia 1
• Verify medication tolerance before discharge, particularly for medications with unpalatable taste (like liquid clindamycin) which may affect adherence 1
• Ensure appropriate follow-up is arranged, especially for patients with complicated pneumonia or those requiring ongoing monitoring 1
• For patients with hyponatremia, ensure electrolyte abnormalities are adequately addressed before discharge to prevent recurrence and early readmission 3

By following these evidence-based criteria, healthcare providers can ensure safe discharge of patients with pneumonia while minimizing the risk of readmission and optimizing outcomes related to morbidity and mortality.