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One might assume patients presenting to an ED with sepsis are automatically admitted to the hospital. However, a presentation at the recent American Thoracic Society's annual international conference in San Diego revealed some surprising statistics and, perhaps, even more shocking patient results.
Intermountain Medical Center researchers determined that about 16% of sepsis patients who are diagnosed with sepsis in the ED were not admitted at the four hospitals they studied. Despite that, study authors emphasized, those patients generally did well without inpatient management.
"We found that many more emergency department patients with sepsis are discharged from the ED than previously recognized, but by and large these patients had fairly good outcomes," explained principal investigator Ithan Peltan, MD, MSc, a pulmonary and critical care medicine specialist and researcher at Intermountain Medical Center.
The crux of the issue might be international guidelines and government mandates, the article suggested. The underlying assumption is that emergency physicians will admit to the hospital all patients diagnosed with sepsis. On the other hand, the study team wrote, “For ED patients with pneumonia, moreover, common triage tools recommend outpatient management for some patients meeting clinical sepsis criteria.”
Determining that little research had been conducted on the matter, researchers performed a retrospective cohort study of adult ED patients at two tertiary hospitals and two community hospitals in Utah between July 2013 and December 2015.
The focus was on patients who met Sepsis-3 criteria in the ED, defined as a Sequential Organ Failure Assessment score 2 or more above baseline, use of IV antibiotics, and blood culture confirmation. Considered admitted were patients transferred to another acute care facility, while transfers to nonacute care, such as skilled nursing or psychiatric facilities, were classified as discharges.
A total of 8,239 eligible ED sepsis patients with complete data for propensity modeling were included in the analysis. The 1,607 patients who were discharged from the ED with sepsis tended to be younger, have fewer comorbidities and physiologic derangements, and were more likely to be female, Hispanic, or nonwhite.
Overall, the researchers noted, crude mortality at 30 days was lower in discharged (1.5%) vs. admitted patients (6.7%). However, after analysis, no significant difference in 30-day mortality was determined for the discharged sepsis patients, compared to those who were admitted, for an odds ratio of 0.86.
"Outpatient management of sepsis is likely not automatically 'wrong.' But wide variation in care provided by different physicians suggests there's room to identify criteria and develop and test tools clinicians can use to guide and optimize sepsis triage decisions," Peltan said.
Researchers found wide variation among ED physicians on which sepsis patients they admitted, with some discharging as many as 39% of those diagnosed. Still, Peltan offered praise for the emergency physicians and their decision-making.
"Physicians seem to do a good job of knowing who can be discharged," he said. "However, there was quite a bit of variation between physicians regarding how many of their patients get discharged, which suggests it may be important to give clinicians guidance to ensure patients who need it are admitted to the hospital, and to identify patients who can be considered for outpatient management and potentially avoid the inconvenience, expense, and risks of hospitalization."
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