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Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.

TitlePrevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.
Publication TypeJournal Article
Year of Publication2022
AuthorsPeltan ID, McLean SR, Murnin E, Butler AM, Wilson EL, Samore MH, Hough CL, Dean NC, Bledsoe JR, Brown SM
JournalJAMA Netw Open
Volume5
Issue2
Paginatione2147882
Date Published2022 02 01
ISSN2574-3805
KeywordsAged, Ambulatory Care, Cohort Studies, Emergency Service, Hospital, Female, Humans, Male, Middle Aged, Odds Ratio, Patient Discharge, Practice Guidelines as Topic, Prevalence, Retrospective Studies, Risk Factors, Sepsis, Treatment Outcome, Utah
Abstract

<p><b>Importance: </b>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.</p><p><b>Objective: </b>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).</p><p><b>Design, Setting, and Participants: </b>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.</p><p><b>Exposures: </b>Patient demographic and clinical characteristics, health system parameters, and ED attending physician.</p><p><b>Main Outcomes and Measures: </b>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.</p><p><b>Results: </b>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.</p><p><b>Conclusions and Relevance: </b>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.</p>

DOI10.1001/jamanetworkopen.2021.47882
Alternate JournalJAMA Netw Open
PubMed ID35142831
PubMed Central IDPMC8832179
Grant ListK23 GM129661 / GM / NIGMS NIH HHS / United States
T35 HL007744 / HL / NHLBI NIH HHS / United States