title: Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection.
abstract: BACKGROUND
  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.
  
  
  CONCLUSIONS
  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.
authors: Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California.
authors: David A
authors: DA
authors: Talan
authors: Emory University, Department of Emergency Medicine, Atlanta, Georgia.
authors: Bisan A
authors: BA
authors: Salhi
authors: Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California.
authors: Gregory J
authors: GJ
authors: Moran
authors: Ronald Reagan Medical Center, University of California at Los Angeles, Department of Emergency Medicine, Los Angeles, California.
authors: William R
authors: WR
authors: Mower
authors: Johns Hopkins Medical Center, Department of Emergency Medicine, Baltimore, Maryland.
authors: Yu-Hsiang
authors: YH
authors: Hsieh
authors: Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California.
authors: Anusha
authors: A
authors: Krishnadasan
authors: Johns Hopkins Medical Center, Department of Emergency Medicine, Baltimore, Maryland.
authors: Richard E
authors: RE
authors: Rothman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D017192:Skin Diseases, Bacterial / Q000628:therapy*; D018461:Soft Tissue Infections / Q000628:therapy*; D014481:United States; D055815:Young Adult