Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection

David A. Talan, Bisan A. Salhi, Gregory J. Moran, William R. Mower, Yu-Hsiang Hsieh, Anusha Krishnadasan, Richard Rothman

Research output: Contribution to journalArticle

Abstract

Introduction: Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI. Methods: We conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI in which physicians were surveyed as to reason(s) for admission, and clinical characteristics were correlated with disposition. We employed chi-square binary recursive partitioning to assess independent predictors of admission. Serious adverse events were recorded. Results: Among 619 patients, median age was 38.7 years. The median duration of symptoms was 4.0 days, 96 (15.5%) had a history of fever, and 46 (7.5%) had failed treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0-7.0). Upon presentation, 39 (6.3%) had temperature >38°C, 81 (13.1%) tachycardia, 35 (5.7%), tachypnea, and 5 (0.8%) hypotension; at the time of the ED disposition decision, these findings were present in 9 (1.5%), 11 (1.8%), 7 (1.1%), and 3 (0.5%) patients, respectively. Ninety-four patients (15.2%) were admitted, 3 (0.5%) to the intensive care unit (ICU). Common reasons for admission were need for intravenous antibiotics in 80 (85.1%; the only reason in 41.5%), surgery in 23 (24.5%), and underlying disease in 11 (11.7%). Hospitalization was significantly associated with the following factors in decreasing order of importance: history of fever (present in 43.6% of those admitted, and 10.5% discharged; maximal length of erythema >10cm (43.6%, 11.3%); history of failed treatment (16.1%, 6.0%); any co-morbidity (61.7%, 27.2%); and age >65 years (5.4%, 1.3%). Two patients required amputation and none had ICU transfer or died. Conclusion: ED SSTI patients with fever, larger lesions, and co-morbidities tend to be hospitalized, almost all to non-critical areas and rarely do they suffer serious complications. The most common reason for admission is administration of intravenous antibiotics, which is frequently the only reason for hospitalization. With the increasing outpatient intravenous antibiotic therapy options, these results suggest that many hospitalized patients with SSTI could be managed safely and effectively as outpatients.

Original languageEnglish (US)
Pages (from-to)89-97
Number of pages9
JournalWestern Journal of Emergency Medicine
Volume16
Issue number1
DOIs
StatePublished - 2015

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Soft Tissue Infections
Hospital Emergency Service
Skin
Anti-Bacterial Agents
Hospitalization
Fever
Outpatients
Erythema
Intensive Care Units
Morbidity
Tachypnea
Amputation
Tachycardia
Intravenous Administration
Hypotension
Therapeutics
Prospective Studies
Physicians
Costs and Cost Analysis
Temperature

Keywords

  • Abscess
  • Admission
  • Cellulitis
  • Emergency department
  • Hospitalization
  • Methicillin-resistant staphylococcus aureus
  • MRSA
  • Skin and soft tissue infection
  • SSTI
  • Wound infection

ASJC Scopus subject areas

  • Emergency Medicine

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Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. / Talan, David A.; Salhi, Bisan A.; Moran, Gregory J.; Mower, William R.; Hsieh, Yu-Hsiang; Krishnadasan, Anusha; Rothman, Richard.

In: Western Journal of Emergency Medicine, Vol. 16, No. 1, 2015, p. 89-97.

Research output: Contribution to journalArticle

Talan, David A. ; Salhi, Bisan A. ; Moran, Gregory J. ; Mower, William R. ; Hsieh, Yu-Hsiang ; Krishnadasan, Anusha ; Rothman, Richard. / Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. In: Western Journal of Emergency Medicine. 2015 ; Vol. 16, No. 1. pp. 89-97.
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abstract = "Introduction: Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI. Methods: We conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI in which physicians were surveyed as to reason(s) for admission, and clinical characteristics were correlated with disposition. We employed chi-square binary recursive partitioning to assess independent predictors of admission. Serious adverse events were recorded. Results: Among 619 patients, median age was 38.7 years. The median duration of symptoms was 4.0 days, 96 (15.5{\%}) had a history of fever, and 46 (7.5{\%}) had failed treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0-7.0). Upon presentation, 39 (6.3{\%}) had temperature >38°C, 81 (13.1{\%}) tachycardia, 35 (5.7{\%}), tachypnea, and 5 (0.8{\%}) hypotension; at the time of the ED disposition decision, these findings were present in 9 (1.5{\%}), 11 (1.8{\%}), 7 (1.1{\%}), and 3 (0.5{\%}) patients, respectively. Ninety-four patients (15.2{\%}) were admitted, 3 (0.5{\%}) to the intensive care unit (ICU). Common reasons for admission were need for intravenous antibiotics in 80 (85.1{\%}; the only reason in 41.5{\%}), surgery in 23 (24.5{\%}), and underlying disease in 11 (11.7{\%}). Hospitalization was significantly associated with the following factors in decreasing order of importance: history of fever (present in 43.6{\%} of those admitted, and 10.5{\%} discharged; maximal length of erythema >10cm (43.6{\%}, 11.3{\%}); history of failed treatment (16.1{\%}, 6.0{\%}); any co-morbidity (61.7{\%}, 27.2{\%}); and age >65 years (5.4{\%}, 1.3{\%}). Two patients required amputation and none had ICU transfer or died. Conclusion: ED SSTI patients with fever, larger lesions, and co-morbidities tend to be hospitalized, almost all to non-critical areas and rarely do they suffer serious complications. The most common reason for admission is administration of intravenous antibiotics, which is frequently the only reason for hospitalization. With the increasing outpatient intravenous antibiotic therapy options, these results suggest that many hospitalized patients with SSTI could be managed safely and effectively as outpatients.",
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T1 - Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection

AU - Talan, David A.

AU - Salhi, Bisan A.

AU - Moran, Gregory J.

AU - Mower, William R.

AU - Hsieh, Yu-Hsiang

AU - Krishnadasan, Anusha

AU - Rothman, Richard

PY - 2015

Y1 - 2015

N2 - Introduction: Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI. Methods: We conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI in which physicians were surveyed as to reason(s) for admission, and clinical characteristics were correlated with disposition. We employed chi-square binary recursive partitioning to assess independent predictors of admission. Serious adverse events were recorded. Results: Among 619 patients, median age was 38.7 years. The median duration of symptoms was 4.0 days, 96 (15.5%) had a history of fever, and 46 (7.5%) had failed treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0-7.0). Upon presentation, 39 (6.3%) had temperature >38°C, 81 (13.1%) tachycardia, 35 (5.7%), tachypnea, and 5 (0.8%) hypotension; at the time of the ED disposition decision, these findings were present in 9 (1.5%), 11 (1.8%), 7 (1.1%), and 3 (0.5%) patients, respectively. Ninety-four patients (15.2%) were admitted, 3 (0.5%) to the intensive care unit (ICU). Common reasons for admission were need for intravenous antibiotics in 80 (85.1%; the only reason in 41.5%), surgery in 23 (24.5%), and underlying disease in 11 (11.7%). Hospitalization was significantly associated with the following factors in decreasing order of importance: history of fever (present in 43.6% of those admitted, and 10.5% discharged; maximal length of erythema >10cm (43.6%, 11.3%); history of failed treatment (16.1%, 6.0%); any co-morbidity (61.7%, 27.2%); and age >65 years (5.4%, 1.3%). Two patients required amputation and none had ICU transfer or died. Conclusion: ED SSTI patients with fever, larger lesions, and co-morbidities tend to be hospitalized, almost all to non-critical areas and rarely do they suffer serious complications. The most common reason for admission is administration of intravenous antibiotics, which is frequently the only reason for hospitalization. With the increasing outpatient intravenous antibiotic therapy options, these results suggest that many hospitalized patients with SSTI could be managed safely and effectively as outpatients.

AB - Introduction: Emergency department (ED) hospitalizations for skin and soft tissue infection (SSTI) have increased, while concern for costs has grown and outpatient parenteral antibiotic options have expanded. To identify opportunities to reduce admissions, we explored factors that influence the decision to hospitalize an ED patient with a SSTI. Methods: We conducted a prospective study of adults presenting to 12 U.S. EDs with a SSTI in which physicians were surveyed as to reason(s) for admission, and clinical characteristics were correlated with disposition. We employed chi-square binary recursive partitioning to assess independent predictors of admission. Serious adverse events were recorded. Results: Among 619 patients, median age was 38.7 years. The median duration of symptoms was 4.0 days, 96 (15.5%) had a history of fever, and 46 (7.5%) had failed treatment. Median maximal length of erythema was 4.0cm (IQR, 2.0-7.0). Upon presentation, 39 (6.3%) had temperature >38°C, 81 (13.1%) tachycardia, 35 (5.7%), tachypnea, and 5 (0.8%) hypotension; at the time of the ED disposition decision, these findings were present in 9 (1.5%), 11 (1.8%), 7 (1.1%), and 3 (0.5%) patients, respectively. Ninety-four patients (15.2%) were admitted, 3 (0.5%) to the intensive care unit (ICU). Common reasons for admission were need for intravenous antibiotics in 80 (85.1%; the only reason in 41.5%), surgery in 23 (24.5%), and underlying disease in 11 (11.7%). Hospitalization was significantly associated with the following factors in decreasing order of importance: history of fever (present in 43.6% of those admitted, and 10.5% discharged; maximal length of erythema >10cm (43.6%, 11.3%); history of failed treatment (16.1%, 6.0%); any co-morbidity (61.7%, 27.2%); and age >65 years (5.4%, 1.3%). Two patients required amputation and none had ICU transfer or died. Conclusion: ED SSTI patients with fever, larger lesions, and co-morbidities tend to be hospitalized, almost all to non-critical areas and rarely do they suffer serious complications. The most common reason for admission is administration of intravenous antibiotics, which is frequently the only reason for hospitalization. With the increasing outpatient intravenous antibiotic therapy options, these results suggest that many hospitalized patients with SSTI could be managed safely and effectively as outpatients.

KW - Abscess

KW - Admission

KW - Cellulitis

KW - Emergency department

KW - Hospitalization

KW - Methicillin-resistant staphylococcus aureus

KW - MRSA

KW - Skin and soft tissue infection

KW - SSTI

KW - Wound infection

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U2 - 10.5811/westjem.2014.11.24133

DO - 10.5811/westjem.2014.11.24133

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JO - Western Journal of Emergency Medicine

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