A Quality Improvement Initiative to Decrease Hospital Admission for Skin and Soft Tissue Infections From an Observation Unit.

Objectives: We evaluated factors associated with the need for full admission (greater than 2 days) for patients with skin and soft tissue infection (SSTI) placed in an emergency department (ED) observation unit (EDOU) in order to inform a new SSTI protocol.

Methods: Retrospective cohort study of adult ED patients assigned to the EDOU for treatment of a SSTI from 2017 to 2018. Data elements included demographics, vital signs, SSTI location and cause, procedures, consults, length of stay, and disposition. Significant relationships identified under univariable analysis were further examined in multivariable logistic regression.

Results: Four hundred eight patient charts were included, of which 100 (24.5%) were admitted. The mean age was 47.3 ± 17.5 years (range, 18-95 years), and 58.0% were men. SSTI complicated by intravenous drug abuse (odds ratio [OR], 1.47; 95% CI, 0.58-3.72) and diabetes (OR, 1.38; 95% CI, 0.41-4.60) had the highest univariable odds of admission for types of infection. Infections treated with a procedure such as incision and drainage had lower odds of admission (OR, 0.56; 95% CI, 0.32-0.98). On multivariate logistic regression, tachycardia (OR, 1.85; 95% CI, 1.09-3.13) was associated with higher odds of admission. SSTI on the torso (OR, 0.23; 95% CI, 0.06-0.80), plan for expert consultation (OR, 0.32; 95% CI, 0.19-0.54), and having a procedure (OR, 0.42; 95% CI, 0.22-0.76) were associated with lower odds of admission. Based on this information, the EDOU protocol for patients with SSTI was updated. In the year after update, admission rate among patients with SSTI was 22.4%.

Conclusion: Tachycardia in the ED may be an early sign of a more complicated SSTI that is more likely to require hospital admission. Adjusting an EDOU protocol to the local population may be helpful for improving EDOU patient selection.