Intermountain study shows need for guidance on discharge of sepsis patients

Patients with sepsis discharged from emergency departments do not appear to have adverse outcomes, but physicians overseeing their care could benefit from uniform guidelines for making such decisions. to study published in JAMA Network Open on Thursday.
Researchers led by Dr. Ethan Peltan of the University of Utah School of Medicine and Intermountain Healthcare of Salt Lake City studied the characteristics of people with sepsis. discharged from emergency departments, which has not previously been actively investigated. The team examined electronic health record data from four Intermountain Healthcare hospitals in Utah, as well as state and federal death records.

“The obvious assumption is that all of these patients should be hospitalized, and we were really concerned that these patients might have poor outcomes,” Peltan said.

However, results from a limited study show that discharged patients had lower levels of visual acuity and did not experience worse health outcomes due to mortality.

“Discharge to outpatient care for patients who met the criteria for sepsis in the emergency department was more common than previously thought and varied significantly between emergency department physicians, but this was not associated with higher mortality compared to hospitalization,” it says. in the JAMA article.

The researchers determined that sepsis patients sent home were generally less ill and had more mild cases of organ failure than those hospitalized on average. Discharged patients also had lower mortality rates. Any infection can cause sepsis, which can be fatal if not caught in time. New research shows that each type of infection presents different symptoms of sepsis and a different degree of danger.

For example, a discharged patient was four times more likely to have a urinary tract infection than other infections. These patients had lower levels of septic shock, which causes dangerous drops in blood pressure, and other markers that indicate less risk.

Of more than 12,000 patients admitted to four hospitals between July 2013 and December 2017, 16% were discharged.

But among emergency doctors there was a wide practice. Some doctors discharged an average of 8% of patients with sepsis, while others sent home up to 40% of patients with this disease.

“These kinds of variations suggest that there is room for better data to drive decision making in the outpatient setting, and [the creation] criteria that clinicians can apply at the bedside to help them make these decisions,” Peltan said.

The lack of protocols can be problematic. There are inherent risks of hospitalization. If a patient has truly poor visual acuity and can be transferred to outpatient care, they are not at risk for other hospital-related adverse events such as MRSA and central line infections. But patients who are not admitted to the hospital may experience worsening sepsis and return to the emergency room in worse condition.

Recognizing that a subset of sepsis patients may have good outcomes outside of hospitals is just the first step, Peltan said.

Intermountain Healthcare plans to develop a risk score that doctors can use to make decisions, Peltan said. The nonprofit health system is also looking at readmission rates for discharged sepsis patients using data from all payers across Utah. Another key area for further study, he says, is looking closely at where discharged patients receive follow-up care and what conditions are associated with better outcomes.

Meanwhile, the patients most at risk are those who need to be hospitalized but not, Peltan said. “It would be extremely premature to say that we should be pushing sepsis patients into outpatient care,” he said. “It’s a great goal to eventually come to the point that we have proposed criteria for identifying patients who can be safely treated at home and systems for them. We haven’t reached that yet.”

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