Klara Lorenz-Dant, Care Policy and Evaluation Centre, London School of Economics and Political Science
- Guidelines in England and Germany emphasise the importance of 14 days of isolation for patients discharged from hospital to care homes
- The English Action Plan requires all patients discharged from hospital to residential care to be tested. In Germany, regulations vary by federal state.
- The English guidelines do not describe additional requirements following the 14-day isolation; the Robert Koch Institute, however, requires a medical consultation to ensure that the patient has been free of COVID-19 symptoms for at least 48 hours before the isolation can be lifted. The German recommendations further cater for the case where a person recovered in hospital following a COVID-19 infection. If the person has not shown any COVID-19 related symptoms for at least 48 hours and had two negative PCR tests they can be discharged to a care or nursing home without requiring further isolation.
- In both countries, the receiving care and nursing homes must have the capacity to sufficiently isolate persons following hospitalisation. If this is not possible, in England local authorities need to find alternative arrangements. In Germany rehabilitation hospitals can be used instead.
Hospital discharge to care homes
People with long-term care needs residing in care or nursing homes are among the most vulnerable people in the COVID-19 pandemic. People living in care setting often require considerable medical attention and sometimes have to go to hospital for additional care. Furthermore, outbreaks of COVID-19 in care and nursing homes in England and Germany have meant that some people required transfers to hospitals. In addition, some people who have been treated in hospital for COVID-19 related symptoms or other illnesses require more substantial support following hospitalisation and will benefit from moving to care or nursing home temporarily or for longer.
In all these scenarios, the discharge of a patient from hospital into a residential care setting poses potential risks of infection with COVID-19 for others living there. The governments of England and Germany have recognised the risk and have developed procedures to provide guidance to health and long-term care providers managing these situations (1,2). This document outlines the approaches in the two countries and compared them.
Guidelines issued in England
The first guidance on hospital discharge dates from 19 March 2020 and describes that the existing North of England Commissioning Support (NECS) care home tracker will be expanded to include all care home places. Care home providers must use the tracker from Monday 23 March 2020 (3) (page 5). When patients no longer require hospital care but are in need of temporary or long-term residential care will be discharged to a care home, even if the available care home is not their first choice. People can then be moved to their preferred care home as soon as possible (3) (page 7). The guidance further outlines that funding will be available during this time for people discharged from hospital. The Care Act enables local authorities to meet urgent needs irrespective of whether a care assessment has been completed or where their ordinary residence is. Care homes will receive funding out of the NHS COVID-19 budget to expand their capacity to provide care (3) (page 12).
Guidance published by the Adult Social Care Directorate on 2 April 2020 outlines that when patients are being discharged from hospital to a care home, the Hospital Discharge Service will ‘clarify with care homes the COVID-19 status of an individual and any COVID-19 symptoms’. It further describes that tests will be primarily available for patients in critical care and those requiring hospital admission that show symptoms of pneumonia, acute respiratory distress syndrome (ARDS) or flue like illness as well as if an outbreak occurred in residential or care settings (e.g. long-term care, prisons). The document states explicitly that ‘negative tests are not required prior to transfers/ admissions into the care home’(4) (page 4).
Updated procedures of discharging patients from hospital to residential care setting in England
The COVID-19 Action plan for Adult Social Care published on 15 April 2020 builds on the previously issued guidelines. In the context of hospital discharge into community care, the document emphasises awareness of care providers’ concern about putting other residents at risk (2). The new guidance responds to this concern by ensuring that all patients discharged from hospital to nursing homes will have received a test in advance of their discharge (2) (page 9).
If the result of the test cannot be obtained in time for discharge patients, should be cared for in isolation as if they had tested positive for COVID-19. Even for asymptomatic patients who have tested negative, it is recommended that they are in isolation for 14 days (2) (pages 9 & 10). The same is recommend for patients with COVID-19 symptoms and a positive test result where the patient needs to be discharged from acute NHS care within the 14-day period since the beginning of the symptoms. This type of care would normally be provided in a care home that can meet the necessary isolation strategies or cohorting policies or under alternative appropriate arrangements organised by the relevant local authority (2) (page 10).
Approaches towards discharge of patients from hospital to residential care settings in Germany
In Germany, the authority on these procedures lies with the 16 federal states and a number of different approaches have been chosen. In Lower Saxony for instance, people requiring care in an institutional care setting following discharge from hospital are being sent to one of around 80 rehabilitation-hospitals where they will be receiving short-term care (5). In North-Rhine Westphalia, hospitals must test patients at the point of discharge. The receiving care home must be informed in writing about possible signs of infection. These tests should be marked so that they can be prioritised. Receiving institutions are required to have prepared specific areas of the care home for isolation and quarantine. Patients discharged from hospital into care homes should be placed in isolation or quarantine for 14 days. The care staff looking after people in the designated isolation area will also have access to prioritised tests (6). In Berlin, regular testing of patients being discharged from hospitals into care or nursing homes is not mandatory, due to the limited capacity (7).
Discharge criteria developed by the Robert Koch Institute
Besides the regulations of individual states, the Robert Koch Institute, in coordination with the working group for infection protection of the highest federal health authorities (Arbeitsgruppe Infektionsschutz der Arbeitsgemeinschaft der Obersten Landesgesundheitsbehörden der Länder) has developed criteria for the discharge from hospital following COVID-19 infection into different care settings, including into nursing home care. Following this guidance patients discharged from hospital into residential care settings are required to spend at least 14 days in isolation. After this time, patients can only be released from isolation if they have not displayed any COVID-19 related symptoms for at least 48 hours. The decision to release a patient from isolation within the care or nursing home can only to be made following a medical consultation. Patients discharged from hospital are not required to enter a 14-day quarantine if they have not shown any COVID-19 related symptoms for at least 48 hours and had 2 negative polymerase chain reaction (PCR) tests (8). If care and nursing homes do not have the capacity to enable care in isolation this kind of care can be provided in rehabilitation hospitals (1).
Comparison of measures take in England and Germany
The comparison between the English and German response shows that both countries emphasise the importance of isolating patients discharged from hospital to residential care settings for 14 days. The testing prior to discharge will be useful information for the receiving care or nursing home. However, if a patient had been admitted for hospital for reasons other than COVID-19, they may develop symptoms during the following two weeks. A negative test, in these situations, will only be providing information at one point in time. This is why it is important that residents remain in isolation for 14 days, even if they have tested negative. This is where the ability to test people living in residential settings as they develop symptoms becomes important. In Germany this is available, in England the new guideline stress that this capacity has now been reached (2) (page 9).
It is interesting to contrast the approach recommended by the RKI with the response by the English government. The RKI recommends that people discharged into a residential care setting following hospitalisation for COVID-19 should also go into 14 days of isolation unless they have been symptom free for 48 hours and had two negative tests. The isolation of patients that have been in 14-day isolation following hospitalisation should only be lifted if they have been symptom free for 48 hours and following consultation with a medical doctor. The English guidelines do not specifically outline a specific time frame during which a patient needs to be symptom free, the need for medical consultation prior to releasing a person from isolation or indeed or the requirement of two negative tests prior to discharge of a person hospitalised for COVID-19 for further isolation not to be required.
1. Robert Koch Institut. Prävention und Management von COVID-19 in Alten- und Pflegeeinrichtungen und Einrichtungen für Menschen mit Beeinträchtigungen Empfehlungen für Alten- und Pflegeeinrichtungen und Einrichtungen für Menschen mit Beeinträchtigungen sowie für den öffentlichen [Internet]. 2020. Available from: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile
2. Department of Health and Social Care. COVID-19: Our action plan for adult social care [Internet]. London; 2020. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf
3. HM Government. COVID-19 Hospital Discharge Service Requirements [Internet]. London; 2020. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/874213/COVID-19_hospital_discharge_service_requirements.pdf
4. Adult Social Care Directorate. Admission and Care of Patients during COVID-19 Incident in a Care Hom [Internet]. London; 2020. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/878099/Admission_and_Care_of_Residents_during_COVID-19_Incident_in_a_Care_Home.pdf
5. Niedersächsisches Ministerium für Soziales Gesundheit und Gleichstellung. Entlastung für die Krankenhäuser: Reha-Kliniken in Niedersachsen bieten Kurzzeitpflege an [Internet]. 2020 [cited 2020 Apr 8]. Available from: https://www.ms.niedersachsen.de/startseite/service_kontakt/presseinformationen/entlastung-fur-die-krankenhauser-reha-kliniken-in-niedersachsen-bieten-kurzzeitpflege-an-187154.html
6. Ministerium für Arbeit Gesundheit und Soziales des Landes Nordrhein-Westfalen. Coronavirus: Neue Rechtsverordnung regelt Neu- und Wiederaufnahme in Pflegeheimen [Internet]. Pressemitteilungen. 2020 [cited 2020 Apr 7]. Available from: https://www.mags.nrw/pressemitteilung/coronavirus-rechtsverordnung-regelt-neu-und-wiederaufnahme-vollstationaeren
7. Senatsverwaltung für Gesundheit Plfege und Gleichstellung. Coronavirus (SARS-Covid-19): Antworten auf häufig gestellte Fragen [Internet]. 2020 [cited 2020 Apr 7]. Available from: https://www.berlin.de/sen/pflege/pflege-und-rehabilitation/coronavirus/faq/
8. Robert Koch Institut. COVID-19: Kriterien zur Entlassung aus dem Krankenhaus bzw. aus der häuslichen Isolierung [Internet]. 2020 [cited 2020 Apr 7]. Available from: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Entlassmanagement.html
9. NHS N. Capacity Tracker [Internet]. [cited 2020 Apr 17]. Available from: https://www.necsu.nhs.uk/services/system-wide-transformation/capacity-tracker/
 The care home tracker allows care homes to share their current available capacity (9). The care home tracker is being expanded to enable a real time overview of all beds available in care homes, NHS community hospitals and hospices (3).