Device Assignment Criteria
- Exertional O2 sat > 95% on RA – No device. Patient given follow up instructions
- Exertional O2 sat 92 – 95% on RA – Pulse Oximeter or Roth Score assessment by telemedicine in 24 hours
- Exertional O2 sat < 92: Enter into below protocol
Discharge Criteria
- Disease Factors
- O2 saturation > 90% w/ < 5L via NC
- Walk test: Patient can walk 50 ft w/ O2 on w/o O2 sat < 90%
- Stable saturation on < 5 L NC in ED for 4 hours
- Patient Factors
- Age < 65
- Non-smoker going back to non-smoking household
- Returning to safe private residence and has a working phone number (Stable address and phone number which excludes homeless, shelter or temporary housed patients)
- Language restriction: English or Spanish speaking or has English speaking family member available for follow up appointments
- Clinical decision instrument (see below)
Clinical Decision Instrument Proposed Cutoffs
PORT/PSI:
- Moderate risk or lower (< 130 points)[Link is HERE]
MuLBSTA
- Will need to use a cutoff based on your comfort
- Department endorses a cutoff of < 15% mortality at 90 days [Link is HERE]
NB: Important to remember that while mortality or morbidity numbers may be high, there’s no evidence that hospitalization reduces this risk.
Necessary Supplies
- Oxygen Tank or Compressor (and ability to deliver additional tanks)
- Nasal Canula
- Oxygen Saturation Monitor (ideal)
Follow Up
- Telemedicine appointment with Provider
- First call within 12-16 hours of discharge
- Subsequent calls Q24 X 3 days. If stable, move to Q3 days until symptom resolution
- Must have first appointment booked prior to discharge
- Must have video capability (i.e. Facetime, Skype, Zoom etc)
- Telemedicine evaluation
- Each call should include expectant management (i.e. Come to hospital now, return for increasing symptoms, etc.)
- If patient has a primary care physician, consider a warm handoff to that physician after the first 2 follow up calls
- Discuss symptoms: should return for worsening shortness of breath or dyspnea or decreased exercise tolerance
- Check O2 tank: if running low, will have to arrange replacement
- Check Oxygenation (see below)
- Return to hospital criteria
- Worsening shortness of breath or dyspnea
- Decreased exercise tolerance
- RR > 30 with exertion
- O2 Sat Monitor: sat < 90% on 5L NC
- No O2 Sat Monitor: Roth Score (see below)
- Max counting number < 7 OR
- Counting time < 5 seconds
- NB: we recognize that the ROTH score is suboptimal but, we need an option in low resource settings where pulse oximeters are not available for patients to go home with
References:
- Chorin E et al. Assessment of Respiratory Distress by the Roth Score. Clin Card 2016; 39(11): 636-9. PMID: 27701750
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)
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