Should a patient with a fever be discharged?

Discharge Criteria for Patients with Fever

A patient with a temperature of 100.4°F (37.8°C) should not be discharged from the hospital, as this meets the criteria for an unstable clinical factor that warrants continued hospitalization according to established guidelines. 1

Temperature as a Discharge Criterion

The British Infection Society, British Thoracic Society, and Health Protection Agency guidelines clearly state that patients should be reviewed 24 hours prior to discharge, and those with a temperature >37.8°C (100.4°F) should be considered for remaining in hospital, especially when combined with other unstable clinical factors 1.

This temperature threshold is specifically mentioned as one of the key parameters that indicates clinical instability:

• Temperature >37.8°C (100.4°F)
• Heart rate >100/min
• Respiratory rate >24/min
• Systolic blood pressure <90 mmHg
• Oxygen saturation <90%
• Inability to maintain oral intake
• Abnormal mental status

Risk Assessment Framework

The presence of fever alone may not necessitate continued hospitalization in all cases, but when evaluating discharge readiness, consider:

1. Number of unstable factors: Guidelines specify that having two or more unstable clinical factors (including temperature >37.8°C) should prompt continued hospitalization 1

2. Patient population considerations:

   • For immunocompromised patients, even low-grade fevers warrant special attention as they may indicate serious underlying infections despite minimal symptoms 2
   • In patients with neutropenia, fever (defined as ≥38.0°C for ≥1 hour) requires careful monitoring and often continued hospitalization 2

3. Trend of temperature: A persistent or rising temperature is more concerning than a single isolated reading that is trending downward

Clinical Decision Algorithm

1. Measure temperature accurately:

   • Ensure proper technique and calibrated equipment
   • Document the method used (oral, tympanic, etc.)

2. Assess for other unstable clinical factors:

   • If temperature >37.8°C PLUS any other unstable factor → Do not discharge
   • If temperature >37.8°C as the only unstable factor → Proceed to step 3

3. Evaluate patient risk profile:

   • Immunocompromised status
   • Underlying conditions
   • Recent surgical procedures
   • Presence of indwelling devices

4. Review temperature trend:

   • If temperature has been consistently >37.8°C for >24 hours → Do not discharge
   • If temperature is trending downward but currently at 100.4°F → Consider delaying discharge for 24-hour observation

Special Considerations

• Post-surgical patients: Even low-grade fevers may indicate developing complications that require monitoring
• Patients with recent infections: Recrudescent fever may indicate inadequate treatment or developing complications
• Elderly patients: May not mount typical febrile responses; even low-grade fevers can indicate serious infections 2

Common Pitfalls to Avoid

1. Discharging based on a single normal temperature reading after a period of fever without ensuring stability
2. Failing to consider the patient's baseline temperature - some individuals normally run lower temperatures, making 100.4°F more significant
3. Overlooking other subtle signs of clinical instability that may accompany a low-grade fever
4. Attributing fever to non-infectious causes without adequate investigation
5. Discharging patients on antipyretics that may mask persistent fever

By adhering to these evidence-based guidelines, clinicians can ensure patient safety while optimizing hospital resource utilization. The temperature threshold of 37.8°C (100.4°F) represents an important clinical marker that should prompt careful consideration before proceeding with discharge.