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Three Part Question

In [adult patients discharged from the emergency department] do [discharge vital signs] correlate with [return visits and/or hospital admission within 7 days]?

Clinical Scenario

A 68-year-old man with a past medical history of COPD, hypertension, and diabetes who presents to the emergency department (ED) with a 3-day history of suprapubic pain. Initial vistal signs were T-37.6C, HR: 92, BP: 100/52, RR: 21, 02%: 94%. Patient was in no apparent distress and the abdominal exam was significant for tenderness in the suprapubic region, no evidence of pulsatile mass. Diagnostic workup showed no evidence of leukocytosis or urinary tract infection. He had a computerized tomography scan of the abdomen within two years that showed a normal abdominal aorta diameter. Patient received 1L of fluid, ketorolac, and ondansetron and on re-evaluation after negative workup, he was discharged. On discharge it was noted that his temperature was 38.1C. The patient returned 4 days later in septic shock secondary to a peri-nephric abscess.

Search Strategy

Medline 1966-07/20 using PubMed, Cochrane Library (2020), and Embase
[(exp vital signs AND exp patient discharge AND emergency service)].

Search Outcome

7 studies were identified; two addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hodgson NR, et al May 2019 USA	120,095 ED patients > 18 years old	Retrospective cohort	Return to ED within 72 hours of ED discharge	Patients with tachycardia, tachypnea, or fever more commonly experienced all return ED visits with admission compared to patients without these abnormal vitals. These include: fever (PPV: 6.8%), tachypnea (PPV:4.0%), and tachycardia (PPV:1.2%) with return to ED and subsequent admission. Upgrades in admitted patients to a higher level of care within 6 hours include fever (PPV:2.57%) and tachycardia (PPV:2.13%).	Pulse oximetry data, hypertension or hypothermia were not analyzed; unable to account for discharged patients who may have presented to other EDs
Gabayan GZ, et al July 2017 USA	104,025 ED patients > 65 years old	Retrospective cohort	Relationship between hospital admission within 7 days of discharge and vital sign values measured closest to discharge	Vital signs with at least twice the odds of admission were systolic BP < 97 mm Hg (OR: 2.02), HR > 101 beats/min (OR: 2.00), body temp > 37.3°C (OR: 2.14), and pulse oximetry < 92% (OR: 2.04). Patients with two vital sign abnormalities had the highest odds of admission.	Only elderly patients enrolled; respiratory rate was not included in analysis; all patients were members of one health plan which might not reflect national demographics.

Comment(s)

Awareness of abnormal vital signs and their correlation with repeat visit within seven days should serve as an actionable opportunity for emergency physicians to intervene prior to discharge with possible modification of diagnostic workup and disposition. Electronic medical record interventions such as best practice reminders can serve as a reminder to review abnormal vital signs upon discharge.

Clinical Bottom Line

Patients discharged from the ED with abnormal vital signs: fever >37.3 oC, systolic BP < 97mmHg, and hypoxia < 92% correlated with patients twice as likely to return to the ED within 7 days and have higher rates of subsequent admission.

References

1. Hodgson NR, Poterack KA, Mi L, Traub SJ. Association of Vital Signs and Process Outcomes in Emergency Department Patients West J Emerg Med 2019 May; 20(3): 433–437
2. Gabayan GZ, Gould MK, Weiss RE, Derose SF, Chiu VY, Sarkisian CA. Emergency Department Vital Signs and Outcomes after Discharge Acad Emerg Med 2017 Jul; 24(7): 846–854.