Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.
Prevalence, Characteristics, and Outcomes of Emergency Department Discharge Among Patients With Sepsis.
复制标题
败血症患者急诊科出院的患病率，特征和结果。
DOI：
10.1001/jamanetworkopen.2021.47882
复制
发表时间：
2022-02-01
影响因子：
13.8
通讯作者：
Brown SM
中科院分区：
文献类型：
--
作者：
Peltan ID;McLean SR;Murnin E;Butler AM;Wilson EL;Samore MH;Hough CL;Dean NC;Bledsoe JR;Brown SM
该队列研究评估了与临床脓毒症成人患者急诊出院或入院相关的医生、医院和患者因素。急诊室 (ED) 脓毒症患者出院后接受门诊治疗的患病率、特征和结果是什么？在这项对 12-333 名符合脓毒症标准的成年 ED 患者进行的队列研究中，从 ED 出院而不是入院的患者中有 16% 更年轻、病情较轻且更有可能患有尿路感染。医生的出院率差异很大，出院患者与入院患者相比，调整后的 30 天死亡率并不较差，甚至更低。这项研究的结果表明，急诊室就诊的脓毒症患者的门诊治疗比以前认识的更为常见，但与入院治疗相比，与更高的死亡率无关。脓毒症指南和研究重点关注入院的脓毒症患者，但门诊治疗脓毒症的范围和影响在很大程度上尚不清楚。旨在确定急诊科 (ED) 患者脓毒症的患病率、危险因素、实践差异和出院后脓毒症门诊治疗的结果。这项队列研究在犹他州 4 家医院的急诊室进行，从 2017 年至 2021 年进行数据提取和分析。参与者是 2013 年 7 月 1 日至 2016 年 12 月 31 日期间到参与急诊室就诊的成年急诊患者，在离开急诊室且未接受临终关怀之前符合脓毒症标准。患者人口统计和临床特征、卫生系统参数和急诊主治医生。有关 ED 处置的信息从电子病历中获取，30 天死亡率数据从犹他州死亡记录和美国社会保障死亡指数中获取。使用惩罚逻辑回归确定了与急诊室出院而不是入院相关的因素。使用广义线性混合模型调整潜在的混杂因素后，估计了医生之间 ED 出院率的差异。主要分析中使用治疗权重的逆概率来评估门诊患者管理对 30 天死亡率的非劣效性（非劣效裕度为 1.5%），同时调整多个潜在的混杂因素。在该研究中分析的 12 333 名脓毒症 ED 患者（中位 [IQR] 年龄，62 [47-76] 岁；7017 名女性 [56.9%]）中，1985 名（16.1%）出院。惩罚回归后，与 ED 出院相关的因素包括年龄（调整后比值比 [aOR]，每 10 年增加 0.90；95% CI，0.87-0.93）、乘坐救护车到达 ED（aOR，0.61；95% CI，0.52-0.71）、器官衰竭严重程度（aOR，序贯性器官衰竭每增加 1 分，0.58）评估评分；95% CI，0.54-0.60）、泌尿道（aOR，4.56 [95% CI，3.91-5.31] vs 肺炎）、腹腔内（aOR，0.51 [95% CI，0.39-0.65] vs 肺炎）、皮肤（aOR，1.40 [95% CI，1.14-1.72] vs 肺炎）肺炎）或其他感染源（aOR，1.67 [95% CI，1.40-1.97] vs 肺炎）。在 89 名 ED 主治医生中，调整后的 ED 出院概率差异显着（似然比检验，P < .001），一般患者的范围为 8% 至 40%。出院患者未经调整的 30 天死亡率低于入院患者（0.9% vs 8.3%；P < .001），调整后的 30 天死亡率也不低（倾向调整优势比，0.21 [95% CI，0.09-0.48]；调整风险差异，5.8% [95% CI， 5.1%-6.5%]；P < .001)。另类混杂因素调整策略产生的优势比范围为 0.21 至 0.42。在这项队列研究中，符合急诊室脓毒症标准的患者出院接受门诊治疗的情况比之前认识的更为常见，并且急诊医生之间的差异很大，但与入院相比，这与更高的死亡率无关。需要采用系统的、基于证据的策略来优化脓毒症 ED 患者的分诊。
This cohort study assesses the physician, hospital, and patient factors associated with emergency department discharge or hospital admission of adult patients with clinical sepsis. What are the prevalence, characteristics, and outcomes of discharge to outpatient treatment of emergency department (ED) patients with sepsis? In this cohort study of 12 333 adult ED patients who met sepsis criteria, the 16% of patients who were discharged from the ED rather than admitted to the hospital were younger, less ill, and more likely to have urinary tract infections. Physicians’ discharge rates varied significantly, and the adjusted 30-day mortality was noninferior and lower among discharged patients vs admitted patients. Findings of this study suggest that outpatient management of sepsis in patients who present to the ED is more common than previously recognized but is not associated with higher mortality compared with hospital admission. 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. 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). 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. Patient demographic and clinical characteristics, health system parameters, and ED attending physician. 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. 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. 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.
登录
查看更多内容
影响因子：
120.7
作者：
Jones, Alan E.;Shapiro, Nathan I.;Trzeciak, Stephen;Arnold, Ryan C.;Claremont, Heather A.;Kline, Jeffrey A.
通讯作者：
Kline, Jeffrey A.
影响因子：
39.2
作者：
Carratalà, J;Fernández-Sabé, N;Gudiol, F
通讯作者：
Gudiol, F
影响因子：
168.9
作者：
Aujesky, Drahomir;Roy, Pierre-Marie;Yealy, Donald M.
通讯作者：
Yealy, Donald M.
影响因子：
15.1
作者：
Rhee, Chanu;Kadri, Sameer S.;Klompas, Michael
通讯作者：
Klompas, Michael
影响因子：
2
作者：
Austin, Peter C.
通讯作者：
Austin, Peter C.