Low-risk Features of Emergency Department Patients on a Sepsis Pathway: A Retrospective Cohort Study
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Introduction
For adult emergency department (ED) patients initiated on a sepsis care pathway, we sought to identify patient factors associated with favorable clinical and operational outcomes that could help identify patients potentially eligible for sepsis care de-escalation.
Methods
We conducted a retrospective cohort study using an electronic health record (EHR) data query from five hospitals in New York City (2022-2024). Multivariable logistic regression models were used to evaluate association of patient demographics, clinical characteristics, and ED diagnoses with four favorable reference outcomes: shorter hospital length of stay (HLOS), no intensive care unit (ICU) stay, survival to discharge, and no sepsis adjudication according to institutional quality-of-care standards.
Results
Among 9,443 ED visits, 45.9% of participants were <70 years old; 68.1% were normothermic and 64.7% normotensive; 32.0% had a normal white blood cell (WBC) count; and 17.6% had a normal lactate level. Fewer than one-quarter received an ED diagnosis of sepsis. Overall, 84.5% survived to discharge, 65.9% avoided an ICU stay, 8.5% had an HLOS <72 hours, and 28.0% were not adjudicated as having sepsis. Factors associated with favorable outcomes varied across the four reference outcomes, with younger age, temperature >36C, absence of hypotension, WBC count 4,000-15,000/uL, and lactate <2.0mmol/L linked to multiple outcomes. Age 18-49 years had the strongest association for HLOS <72 hours (adjusted odds ratio (aOR) 3.48, p<0.01) and survival to discharge (aOR 3.15, p<0.01); lack of severe diagnosis had the strongest association for no ICU stay (aOR 2.74, p<0.01); and ED diagnosis other than sepsis or infection had the strongest association for no sepsis adjudication (aOR 8.82, p<0.01). WBC count 4,000/uL to 15,000/uL was the only factor associated with all four outcomes (aORs 1.24-1.70). Patients with a primary ED diagnosis of infection other than pneumonia had more favorable outcomes than those diagnosed with sepsis or pneumonia.
Conclusion
Several patient factors may help identify lower risk patients who could be targeted for sepsis care de-escalation after a sepsis pathway has been initiated, although the relevant factors differ by outcome. Further research is needed to evaluate the performance of these factors in prospectively identifying patients most likely to experience favorable outcomes.
