Discharge Readiness Assessment
This patient should NOT be discharged at this time—she fails critical discharge criteria with oxygen saturation of 92-94% on supplemental oxygen, which falls below the required threshold of maintaining SpO2 ≥92% on room air. 1, 2
Why Discharge is Contraindicated
The most relevant guideline for pandemic influenza explicitly states that patients should not be discharged if they have oxygen saturation <90% as one of seven clinical instability criteria 1. However, this threshold applies to patients on room air, not supplemental oxygen. Your patient requires 1L O2 to maintain 92-94%, meaning she cannot maintain adequate oxygenation without support.
Specific Discharge Criteria Not Met
For influenza management, patients must be reviewed 24 hours prior to discharge and should remain hospitalized if they have two or more of the following unstable clinical factors 1:
- Temperature >37.8°C
- Heart rate >100/min
- Respiratory rate >24/min
- Systolic blood pressure <90 mmHg
- Oxygen saturation <90% (on room air, implied)
- Inability to maintain oral intake
- Abnormal mental status
The critical issue: While the guideline states <90% as the cutoff, the more recent and comprehensive guidance clarifies that discharge requires SpO2 >92% on room air 2. Your patient is maintaining 92-94% only with 1L supplemental oxygen, which represents ongoing hypoxemia requiring intervention.
COVID-19 Discharge Criteria Add Further Requirements
For COVID-19, discharge criteria are even more stringent and require all of the following 1:
- Temperature returned to normal for more than 3 days
- Respiratory symptoms significantly improved
- Significant absorption of pulmonary chest lesions on CT imaging
- Two consecutive negative nucleic acid tests from respiratory samples (at least 24 hours apart)
The requirement for "respiratory symptoms significantly improved" inherently includes achieving adequate oxygenation without supplemental support.
Recommended Management Plan
Continue Hospitalization Until:
Oxygen independence achieved: Patient maintains SpO2 ≥92% on room air for at least 24 hours 1, 2
Clinical stability confirmed: All vital signs stable (temperature <37.8°C, heart rate <100/min, respiratory rate <24/min) 1
Functional capacity restored: Patient can ambulate without desaturation and maintain oral intake 1
Monitoring During Hospitalization:
Vital signs at least twice daily: Temperature, respiratory rate, pulse, blood pressure, mental status, oxygen saturation, and inspired oxygen concentration 1, 2
Progressive oxygen weaning: Gradually reduce supplemental oxygen while monitoring for desaturation, aiming for room air tolerance 2
Early Warning Score system: Use standardized scoring to detect clinical deterioration 1
Oxygen Therapy Targets:
- Maintain SpO2 ≥92% at all times 1, 2
- Target PaO2 ≥8 kPa (approximately 60 mmHg) 1
- Consider arterial blood gas if clinical deterioration occurs 2
Common Pitfalls to Avoid
Premature discharge based on "stable" oxygen saturations on supplemental oxygen is the most critical error here. Patients may appear stable on low-flow oxygen but rapidly deteriorate after discharge when oxygen is discontinued 1. The transition from high-flow to low-flow oxygen (as occurred with your patient moving from Optiflow to 1L nasal prongs) represents clinical improvement but not readiness for discharge.
Failing to assess for co-infection complications: With dual influenza A and COVID-19 infection, this patient has higher risk for severe disease and prolonged recovery 3, 4. Co-infection occurs in only 0.54% of cases but can result in more severe outcomes including death and prolonged ventilator dependence 4.
Ignoring the 24-hour observation period: Guidelines specifically require reviewing patients 24 hours prior to discharge to ensure sustained clinical stability 1. Your patient just came off Optiflow today—insufficient time has passed to confirm stability.
Timeline for Reassessment
- Reassess in 24-48 hours: Attempt progressive oxygen weaning with ambulation testing 1
- If tolerating room air: Observe for additional 24 hours before discharge 1
- If requiring ongoing oxygen: Continue hospitalization and consider investigating for complications (bacterial superinfection, cardiac dysfunction, pulmonary embolism) 1, 2