Intermountain study shows need for sepsis discharge guidelines

Patients with sepsis who are discharged from emergency departments appear not to have adverse outcomes, but doctors overseeing their care could benefit from uniform guidelines for those decisions, according to a study published in JAMA Network Open on Thursday.
Researchers led by Dr. Ithan Peltan of the University of Utah School of Medicine and Salt Lake City-based Intermountain Healthcare reviewed the characteristics of people with sepsis discharged from emergency departments, which hasn’t been vigorously researched before. The team reviewed electronic health records data from four Intermountain Healthcare hospitals in Utah along with state and federal death records.

“The obvious assumption is that these patients all should be admitted, and we were really, we were worried that these patients might have bad outcomes,” Peltan said.

The results from the limited study, however, show discharged patients had lower acuity levels and didn’t face worse health outcomes based on mortality.

“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,” the JAMA article says.

Sepsis patients who were sent home were less sick overall and had more mild cases of organ failure than those admitted on average, the researchers determined. Discharged patients also had lower mortality rates. Any infection can cause sepsis, which can be fatal if not caught quickly. Emerging research indicates that every type of infection presents different sepsis symptoms and varying degrees of danger.

For instance, the odds of a discharged patient having a urinary tract infection was four times higher than other infections. These patients had lower levels of septic shock—which causes dangerous drops in blood pressure—and other markers that pointed to less risk.

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

But there were wide practice patterns among emergency physicians. Some doctors discharged an average of 8% of sepsis patients while others sent home up to 40% of patients with the condition.

“This kind of variation does suggest that there is opportunity for better data to guide the outpatient decision-making process, and [the creation] of criteria that clinicians can apply at the bedside to assist them in making those decisions,” Peltan said.

A lack of protocols can be problematic. There are inherent risks to being admitted to a hospital. If a patient is truly low acuity and can transferred to outpatient care, they aren’t at risk for other adverse events associated with hospital stays, such as MRSA and central-line infections. But patients who aren’t admitted might experience worsening sepsis cases and return to emergency departments in poorer health.

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

Intermountain Healthcare plans to develop a risk score that clinicians could use to guide decisions, Peltan said. The not-for-profit health system also is examining readmission rates of discharged sepsis patients using all-payer data from across Utah. Another key area of further study is scrutinizing where discharged patients get follow-up care and what settings are linked to better outcomes, he said.

In the meantime, the patients at greatest risk are those who need to be admitted but aren’t, Peltan said. “It would be extraordinarily premature to say we should be pushing sepsis patients towards outpatient care,” he said. “It’s a great goal to eventually get to a point where we have suggested criteria for identification of patients that can be safely managed at home, and systems in place for those. We’re not there yet.”