Identification of Clinical Characteristics Associated With High-Level Care Among Patients With Skin and Soft Tissue Infections

• Published in: Annals of emergency medicine Vol. 73; no. 4; pp. 366 - 374
• Main Authors: Mower, William R., Kadera, Samantha P., Rodriguez, Armando D., Vanderkraan, Vera, Krishna, Pravin K., Chiu, Emily, Wilson, McKenzie J., Gupta, Malkeet, Krishnadasan, Anusha, Moran, Gregory J., Talan, David A.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-04-2019
• Subjects: Adult; Aged; Aged, 80 and over; California; Female; Hospitalization - statistics & numerical data; Humans; Length of Stay - statistics & numerical data; Male; Middle Aged; Sepsis - complications; Skin Diseases, Infectious - complications; Skin Diseases, Infectious - therapy; Soft Tissue Infections - complications; Soft Tissue Infections - therapy; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography; California
• ISSN: 0196-0644; 1097-6760
• DOI: 10.1016/j.annemergmed.2018.09.020

Serious adverse outcomes associated with skin and soft tissue infections are uncommon, and current hospitalization rates appear excessive. It would be advantageous to be able to differentiate between patients who require high-level inpatient services and those who receive little benefit from hospitalization. We sought to identify characteristics associated with the need for high-level inpatient care among emergency department patients presenting with skin and soft tissue infections.
We conducted a nonconcurrent review of existing records to identify emergency department (ED) patients treated for skin and soft tissue infections. For each case, we recorded the presence or absence of select criteria and whether the patient needed high-level care, defined as ICU admission, operating room surgical intervention, or death as the primary outcome. We applied recursive partitioning to identify the principal criteria associated with high-level care.
We identified 2,923 patients, including 84 experiencing high-level events. Recursive partitioning identified 6 variables associated with high-level outcomes: abnormal computed tomography, magnetic resonance imaging, or ultrasonographic imaging result; systemic inflammatory response syndrome; history of diabetes; previous infection at the same location; older than 65 years; and an infection involving the hand. One or more of these variables were present in all 84 patients requiring high-level care.
A limited number of simple clinical characteristics appear to be able to identify skin and soft tissue infection patients who require high-level inpatient services. Further research is needed to determine whether patients who do not exhibit these criteria can be safely discharged from the ED.