Guidance

Stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients

Updated 17 January 2022

This guidance was withdrawn on 1 April 2022

This guidance has been superseded by COVID-19: infection prevention and control (IPC) and Infection prevention and control in adult social care: COVID-19 supplement.

What has changed

The advice on ending isolation for coronavirus (COVID-19) patients remaining in hospital has changed. Inpatients can end self-isolation after 10 days subject to a clinical risk assessment.

There are additional recommendations on stepping down isolation for severely immunocompromised patients.

1. Scope

This guidance has been written by UK Health Security Agency (UKHSA) primarily for a health and care professional audience in England with input from NHS England. Country specific advice may be available for each country across the United Kingdom. Please refer to Health Protection Scotland, Public Health Wales, or Public Health Agency in Northern Ireland.

This guidance provides advice on appropriate infection prevention and control (IPC) precautions for patients recovering or recovered from symptomatic or asymptomatic COVID-19, and who are remaining in hospital, being discharged to their own home, or being discharged to residential care. Hospital discharges are covered by the NHS hospital discharge service: policy and operating model.

Immunocompetent individuals can be advised on discharge to follow the self-isolation requirements from the date of symptom onset or the date of their positive COVID-19 test if they did not have any symptoms.

For patients who have remained asymptomatic or whose fever has resolved, the risk that they remain infectious after the 10th day of isolation is low, and the majority can end their isolation after 10 days. A longer isolation period is recommended for individuals with severe immunocompromise whose condition may delay them clearing the virus.

Patients who are still within their isolation period but who are otherwise clinically fit for discharge can be discharged to their home or to a social care setting with appropriate isolation advice.

For patients being discharged to social care settings refer to guidance for designated settings and the ‘safe discharge from the NHS to social care settings’ section in the Department of Health and Social Care (DHSC) adult social care plan.

2. Stepping down COVID-19 isolation precautions for patients staying in hospital

For inpatients with COVID-19, isolation should continue until 10 days after the onset of symptoms (or their first positive COVID-19 test if they do not have any symptoms), provided the clinical criteria below are met.

Clinical criteria:

• clinical improvement with at least some respiratory recovery
• absence of fever (temperature greater than 37.8°C) for 48 hours without the use of medication
• no underlying severe immunosuppression

A cough or a loss of, or change in, normal sense of smell or taste (anosmia), may persist in some individuals for several weeks, and are not considered an indication of ongoing infection when other symptoms have resolved. This guidance does not apply if there are any additional indications for ongoing isolation and transmission based precautions (for example MRSA carriage, C.difficile infection, diarrhoea).

For clinically suspected COVID-19 patients who have tested negative and whose condition is severe enough to require hospitalisation, the isolation period should be measured from the day of admission.

2.1 Immunocompetent patients

Immunocompetent patients do not routinely need to be re-tested by PCR test before stepping down isolation.

A risk assessment using the hierarchy of controls is required for those patients who meet the clinical criteria for stepping down isolation after 10 days. Consideration should be given to the vulnerability of other patients, the wearing of masks by patients, physical distancing and ventilation. Additional mitigations such as the use of LFD testing may be considered.

2.2 Severely immunocompromised patients

See the section below for the definition of severe immunosuppression.

It is possible for severely immunocompromised patients to remain infectious for prolonged periods, even if they do not display any symptoms of COVID-19. The isolation period for these patients whilst in hospital should be at least 14 days.

In severely immunocompromised patients, resolution of symptoms should not be used as a marker of decreased infectiousness and these patients should be isolated in side rooms, cubicles or cohorted until they return a negative PCR test. Staff should strictly adhere to recommended IPC measures throughout the inpatient stay.

Severely immunocompromised patients can end their isolation after a single negative PCR test result taken no earlier than 14 days after the onset of symptoms (or their first positive COVID-19 test if they do not have any symptoms). Asymptomatic patients with a positive PCR test result after 14 days can end their isolation if:

• the Ct value of their PCR test is greater than 35, and
• they have either a positive anti-spike-antibody test or a negative LFD antigen test

Some severely immunocompromised patients may have been treated with monoclonal antibodies (mAb). For re-testing advice refer to the clinical commissioning policies for monoclonal antibodies or the UKHSA surveillance protocol.

2.3 Other immunocompromised patients

The evidence on duration of infectiousness in patients who are mildly immunocompromised is less clear. Testing in this patient group can be considered, especially:

• to support the optimal use of side rooms, or where side rooms are not available
• to support transfer or discharge including for those being discharged to a household where someone has an underlying health condition that puts them at higher risk of severe illness if they were infected with COVID-19
• if they have had monoclonal antibodies or new antiviral agents as part of their treatment of COVID-19. Refer to clinical commissioning policies on Ronapreve and the UKHSA surveillance protocol for more information

3. Discharge of COVID-19 patient to own home

This can be done when the patient’s clinical status is appropriate for discharge, for example, once assessed to have stable or recovering respiratory function, and any ongoing care needs can be met at home. Consider testing the patient 48 hours prior to discharge if:

• they will require repeated hospital day case or other care, especially if severely immunocompromised
• a member of their household has an underlying health condition that puts them at higher risk of severe illness if they were infected with COVID-19

They should be given clear safety-netting advice for what to do if their symptoms worsen.

Immunocompetent patients should follow the People with COVID-19 and their contacts guidance on discharge. If patients are febrile on discharge, they should continue to self-isolate until their fever has resolved for 48 consecutive hours without antipyretic medication (unless otherwise advised by a healthcare professional, for example if another reason for persistent fever exists).

When discharging patients, it is best practice to provide written instructions on any ongoing isolation recommendations.

3.1 How to transfer COVID-19 patients home

Transport home can be arranged via a variety of routes.

If the patient has their own car at the hospital, and is well enough, they may drive home.

If they are taking shared transport, their status and isolation needs should be communicated with transport staff (for example, ambulance crews and relatives). Those transporting them should not themselves be at greater risk of severe infection.

If isolation is to continue in a residential setting, the following guidelines apply to all methods of transport:

• the patient should be given clear instructions on what to do when they leave the ward to minimise risk of exposure to staff, patients and visitors on their way to their transport
• the patient should wear a surgical facemask for the duration of the journey, and advised that this should be left on for the entire time if tolerated (not pulled up and down)
• the patient should sit in the back of the vehicle with as much distance from the driver as possible (for example, the back row of a multiple passenger vehicle)
• where possible use vehicles that allow for optimal implementation of social distancing measures, such as those that have a partition between the driver and the passenger or larger vehicles that allow for a greater distance between the driver and the passenger
• vehicle windows facing the outside environment should be (at least partially) open to facilitate a continuous flow of air
• vehicles should be cleaned appropriately at the end of the journey
• ensure the patient has a supply of tissues and a waste bag for disposal for the duration of the journey; the waste bag should then be taken into their house, put into another waste bag and held for a period of 72 hours before disposal with general household waste

3.2 Other household members in an individual’s home setting

If the discharged patient is returning to a shared household during their isolation period, other household members should follow the stay at home guidance.

If there are any individuals with an underlying health condition that puts them at higher risk of severe illness with COVID-19 who live in the household and are currently not infected, it is highly advisable, where possible, for patients to be discharged to a different home until they have finished their self-isolation period. If these individuals cannot be moved to a different household, then ensure that the discharged patient is advised on strict infection prevention control measures as outlined in the stay at home guidance.

4. Discharging COVID-19 patients to a single occupancy room in a care facility, including nursing homes, residential homes and designated settings

This can be done when the patient’s clinical status is appropriate for discharge, for example, once assessed to have stable or recovering respiratory function, and any ongoing care needs can be met at the residential care facility.

Any COVID-19 patient who is being discharged to a care facility within their isolation period should be discharged to a designated setting, where they should complete their remaining isolation.

Immunocompetent patients who have tested positive for COVID-19 and have already completed their isolation period should be exempt from testing by PCR prior to hospital discharge within 90 days from their initial illness onset or test, unless they develop new COVID-19 symptoms. In this case, a clinical assessment should be made to determine subsequent onward movement.

However, if the positive COVID-19 test was more than 90 days ago, the patient should be tested again 48 hours prior to discharge and the result of this repeat test relayed to the receiving organisation.

5. Additional measures

5.1 Ongoing medical needs for discharged COVID-19 patients within their isolation period

Should any patient deteriorate following discharge, either at home or in a care setting, they or their carer should seek advice from NHS 111 online or by telephone, or through pre-existing services such as GP practice links with care homes. In an emergency, they or their carer should call 999 for assistance. In either case, they should inform the call attendant that they have been recently discharged from hospital with confirmed COVID-19.

If there are professional care needs at the patient’s own home, visiting carers should follow the appropriate PPE precautions outlined in the home care guidance.

5.2 Specific instructions for ongoing medical needs for severely immunocompromised COVID-19 patients and those who have received critical care

The isolation policy for patients admitted to hospital is longer than those in the community, as there are uncertainties about the duration of infectiousness for patients with underlying immune problems that may delay them clearing the virus.

As described in section 2.2, testing for virological clearance is encouraged in severely immunocompromised patients. For these patients, IPC measures should be continued unless there has been virological evidence of clearance prior to discharge. This is different to other advice sections but reflects the complex health needs of such patients and likelihood for prolonged shedding, with risk of spread in healthcare settings. Such patients may be retested at first follow-up appointment to help inform actions at any next medical appointment.

6. Severe immunosuppression definitions

Severe immunosuppression is defined in the Green Book on Immunisation as:

• immunosuppression due to acute and chronic leukaemias and lymphoma (including Hodgkin’s lymphoma)
• severe immunosuppression due to HIV/AIDS (British HIV Association advice)
• cellular immune deficiencies (such as severe combined immunodeficiency, Wiskott-Aldrich syndrome, 22q11 deficiency/DiGeorge syndrome)
• being under follow up for a chronic lymphoproliferative disorder including haematological malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma and other plasma cell dyscrasias
• having received an allogenic (cells from a donor) stem cell transplant in the past 24 months and only then if they are demonstrated not to have ongoing immunosuppression or graft versus host disease (GVHD)
• having received an autologous (using their own stem cells) haematopoietic stem cell transplant in the past 24 months and only then if they are in remission
• those who are receiving, or have received in the past 6 months, immunosuppressive chemotherapy or radiotherapy for malignant disease or non-malignant disorders
• those who are receiving, or have received in the past 6 months, immunosuppressive therapy for a solid organ transplant (with exceptions, depending upon the type of transplant and the immune status of the patient)
• those who are receiving or have received in the past 12 months immunosuppressive biological therapy (such as monoclonal antibodies), unless otherwise directed by a specialist
• those who are receiving or have received in the past 3 months immunosuppressive therapy including:
  • adults and children on high-dose corticosteroids (>40mg prednisolone per day or 2mg/ kg/day in children under 20kg) for more than 1 week
  • adults and children on lower dose corticosteroids (>20mg prednisolone per day or 1mg/kg/day in children under 20kg) for more than 14 days
  • adults on non-biological oral immune modulating drugs, for example, methotrexate >25mg per week, azathioprine >3.0mg/kg/day or 6-mercaptopurine >1.5mg/kg/day
  • children on high doses of non-biological oral immune modulating drugs

7. Associated legislation

Please note that this guidance is of a general nature and that an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation, including the Health and Safety at Work etc. Act 1974.