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- Title
Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.
- Authors
Peltan, Ithan D.; McLean, Sierra R.; Murnin, Emily; Butler, Allison M.; Wilson, Emily L.; Samore, Matthew H.; Hough, Catherine L.; Dean, Nathan C.; Bledsoe, Joseph R.; Brown, Samuel M.
- Abstract
This cohort study assesses the physician, hospital, and patient factors associated with emergency department discharge or hospital admission of adult patients with clinical sepsis. Key Points: Question: What are the prevalence, characteristics, and outcomes of discharge to outpatient treatment of emergency department (ED) patients with sepsis? Findings: In this cohort study of 12 333 adult ED patients who met sepsis criteria, the 16% of patients who were discharged from the ED rather than admitted to the hospital were younger, less ill, and more likely to have urinary tract infections. Physicians' discharge rates varied significantly, and the adjusted 30-day mortality was noninferior and lower among discharged patients vs admitted patients. Meaning: Findings of this study suggest that outpatient management of sepsis in patients who present to the ED is more common than previously recognized but is not associated with higher mortality compared with hospital admission. Importance: Sepsis guidelines and research have focused on patients with sepsis who are admitted to the hospital, but the scope and implications of sepsis that is managed in an outpatient setting are largely unknown. Objective: To identify the prevalence, risk factors, practice variation, and outcomes for discharge to outpatient management of sepsis among patients presenting to the emergency department (ED). Design, Setting, and Participants: This cohort study was conducted at the EDs of 4 Utah hospitals, and data extraction and analysis were performed from 2017 to 2021. Participants were adult ED patients who presented to a participating ED from July 1, 2013, to December 31, 2016, and met sepsis criteria before departing the ED alive and not receiving hospice care. Exposures: Patient demographic and clinical characteristics, health system parameters, and ED attending physician. Main Outcomes and Measures: Information on ED disposition was obtained from electronic medical records, and 30-day mortality data were acquired from Utah state death records and the US Social Security Death Index. Factors associated with ED discharge rather than hospital admission were identified using penalized logistic regression. Variation in ED discharge rates between physicians was estimated after adjustment for potential confounders using generalized linear mixed models. Inverse probability of treatment weighting was used in the primary analysis to assess the noninferiority of outpatient management for 30-day mortality (noninferiority margin of 1.5%) while adjusting for multiple potential confounders. Results: Among 12 333 ED patients with sepsis (median [IQR] age, 62 [47-76] years; 7017 women [56.9%]) who were analyzed in the study, 1985 (16.1%) were discharged from the ED. After penalized regression, factors associated with ED discharge included age (adjusted odds ratio [aOR], 0.90 per 10-y increase; 95% CI, 0.87-0.93), arrival to ED by ambulance (aOR, 0.61; 95% CI, 0.52-0.71), organ failure severity (aOR, 0.58 per 1-point increase in the Sequential Organ Failure Assessment score; 95% CI, 0.54-0.60), and urinary tract (aOR, 4.56 [95% CI, 3.91-5.31] vs pneumonia), intra-abdominal (aOR, 0.51 [95% CI, 0.39-0.65] vs pneumonia), skin (aOR, 1.40 [95% CI, 1.14-1.72] vs pneumonia) or other source of infection (aOR, 1.67 [95% CI, 1.40-1.97] vs pneumonia). Among 89 ED attending physicians, adjusted ED discharge probability varied significantly (likelihood ratio test, P <.001), ranging from 8% to 40% for an average patient. The unadjusted 30-day mortality was lower in discharged patients than admitted patients (0.9% vs 8.3%; P <.001), and their adjusted 30-day mortality was noninferior (propensity-adjusted odds ratio, 0.21 [95% CI, 0.09-0.48]; adjusted risk difference, 5.8% [95% CI, 5.1%-6.5%]; P <.001). Alternative confounder adjustment strategies yielded odds ratios that ranged from 0.21 to 0.42. Conclusions and Relevance: In this cohort study, discharge to outpatient treatment of patients who met sepsis criteria in the ED was more common than previously recognized and varied substantially between ED physicians, but it was not associated with higher mortality compared with hospital admission. Systematic, evidence-based strategies to optimize the triage of ED patients with sepsis are needed.
- Subjects
HOSPITAL emergency services; OUTPATIENT medical care; RETROSPECTIVE studies; SEPSIS; TREATMENT effectiveness; DISCHARGE planning; DISEASE risk factors
- Publication
JAMA Network Open, 2022, Vol 5, Issue 2, pe2147882
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2021.47882