Dermatologic Emergency And Rates Of Admission To The Hospital
Overview
Dermatologic conditions account for around 8% of emergency department (ED) visits worldwide. While these conditions are rarely life-threatening, some can lead to significant complications. Despite their prevalence, little is known about how patients with dermatological emergencies are managed in the ED and what happens to them afterward.
A study conducted at a Swiss University Hospital over 56 months found that out of 5,096 patients who visited the ED for dermatological issues, 79% were hospitalized after their initial assessment. Several factors were linked to a higher likelihood of admission, including being 45 years or older, male, having abnormal vital signs, a higher body mass index, low oxygen saturation, and the timing of their ED visit. Interestingly, only 2.2% of these patients were admitted to a dermatology ward, even though their conditions were crucial in determining the hospital’s reimbursement. Over time, fewer dermatologists were involved in the care of these patients during their hospital stay.
The study highlights important factors that influence whether patients with dermatological conditions are admitted to the hospital. It also suggests that the role of dermatologists in managing these patients is diminishing in Swiss hospitals, which could have implications for the quality and cost-effectiveness of care. Dermatologists need to be more involved in patient care and work closely with other medical specialists to ensure better outcomes.
Introduction
Dermatologic conditions, while often not immediately life-threatening, are increasingly becoming a significant portion of emergency department (ED) visits worldwide, accounting for about 8% of all such visits. Despite their non-critical nature, dermatologic emergencies (DEs) can lead to high morbidity if not promptly and accurately addressed. The challenges in managing these conditions in an ED setting are multifaceted, and misdiagnosis can exacerbate the situation, leading to inappropriate treatment and unnecessary hospital admissions.
The spectrum of DEs that present in EDs is broad, encompassing conditions such as infectious skin processes, inflammatory skin diseases, urticaria, angioedema, and adverse drug reactions. These conditions require timely and accurate diagnosis to prevent complications and ensure that patients receive the appropriate level of care. The growing volume of patients attending EDs worldwide underscores the importance of optimizing patient flow and disposition. Efficient management of these processes is critical because delays in ED patient flow can have a domino effect, negatively impacting patient outcomes, increasing the workload and stress on healthcare staff, and inflating healthcare costs.
Several factors contribute to bottlenecks in the ED admission process. These include insufficient staffing and available beds in the ED, prolonged wait times for consultations with specialists, and challenges in securing inpatient beds. These issues not only hinder the efficiency of patient care but also strain the healthcare system. Moreover, the changing landscape of healthcare, influenced by evolving compensation models and resource allocation in many countries, could further impact in-hospital patient management and the role of the dermatology specialty.
In this context, the need for specialized care for patients with skin diseases becomes even more pronounced. Patients with dermatologic emergencies are best managed by dermatologists or specialists with advanced training in dermatology, ensuring that they receive the most appropriate and effective treatment. However, the current trends suggest that the dermatology specialty is increasingly marginalized within the hospital setting, which could have significant implications for patient care, outcomes, and the overall cost-effectiveness of healthcare services.
To address these challenges, it is essential to identify the predictive factors that influence the clinical pathways of patients with dermatologic emergencies admitted to the ED. By understanding these determinants, healthcare providers can develop strategies to improve patient disposition after ED triage, ensuring that patients receive timely and appropriate care. This study specifically aimed to achieve two objectives: first, to explore the factors and determinants that lead to hospital admission for patients presenting with dermatologic emergencies, and second, to gain insights into the pathways these hospitalized patients follow within various departments after their initial evaluation in the ED.
The findings from this study are critical for informing hospital policies and improving the management of dermatologic conditions in the ED. By recognizing the factors that contribute to unnecessary hospital admissions and delays in patient care, healthcare systems can implement targeted interventions to streamline processes, enhance the role of dermatologists in patient management, and ultimately improve patient outcomes. This approach not only benefits patients by providing them with the care they need but also helps in reducing the overall burden on the healthcare system, making it more efficient and cost-effective.
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Methods
This single-center retrospective study analyzed all consecutive patients who visited the Emergency Department (ED) at the University Hospital of Bern between February 2016 and September 2020. Dermatologic emergencies (DEs) were classified as skin conditions that were considered serious either by the affected patients or the referring physicians, warranting a visit to the ED. Patients who were eventually hospitalized received a discharge diagnosis that corresponded to a dermatological disease, classified under a Diagnosis Related Group (DRG) code, which determined payment based on the Swiss Diagnosis Related Group (SwissDRG) system.
The study utilized the International Classification of Diseases, Tenth Revision (ICD-10) codes as the primary criterion for selecting patients with dermatological conditions evaluated in the ED. In cases where multiple ICD-10 codes were present, only patients with a primary dermatological diagnosis were included. If an ICD-10 code was not reported, patients were selected based on keywords that matched the corresponding ICD-10 definitions for dermatological conditions, and all records were reviewed by a dermatologist before inclusion in the study.
After the initial evaluation in the ED, patients were either admitted to a specific medical department for further management or discharged with an outpatient management plan. The decision regarding patient disposition was made by the ED team, with input from other specialists as needed. On-call dermatologists were available as consultants within 30 minutes when required.
Exclusion criteria included patients who died shortly after arriving in the ED, those who left the ED without being seen or against medical advice, and cases with missing or inconsistent information. The study received approval from the Ethical Committee of the Canton of Bern.
For this study, de-identified patient data were extracted from the hospital’s electronic medical record system, including demographics (age, gender, ethnicity, language, marital status, employment, and insurance status), referral by a family physician, triage score, time of arrival, length of ED stay, number of ED visits in the past year, physician’s diagnosis, triage anamnesis notes, patient disposition (admission or discharge), hospitalization department, length of hospitalization, body mass index (BMI), vital signs (including body temperature, oxygen saturation, and pain score), dermatological diagnoses, and recorded comorbidities among hospitalized patients. Dermatological diagnoses and comorbidities were recorded using ICD-10 codes, or a surrogate ICD-10 code was derived from matching keywords in the physician’s diagnosis when the code was unavailable. Pain levels were assessed using a 0–10 visual analog scale (VAS).
The primary endpoint of the study was the patient’s disposition—whether they were discharged or hospitalized. The secondary endpoint was whether hospitalized patients with a leading dermatological condition, as indicated by the ICD-10 diagnosis made in the ED and the DRG code assigned for each hospitalization, were admitted to the dermatology department or other departments.
Analysis
For descriptive analysis, continuous data were presented as medians with interquartile ranges (IQR), while categorical data were reported as absolute numbers with corresponding percentages. In analytical procedures, continuous variables were categorized using clinically relevant thresholds. To explore factors influencing patient disposition, generalized estimating equations (GEE) were employed, assuming a binomial distribution and adjusting for age and sex. A multivariable GEE analysis was conducted to identify independent factors associated with patient disposition, including variables with a p-value < 0.25 that did not have zero frequency cells in the age- and sex-adjusted analysis.
Effect sizes were reported as odds ratios (OR) with their 95% confidence intervals (CI) and p-values. Statistical significance was set at p < 0.05. All analyses were performed using MATLAB version 9.1 (MathWorks, Natick, USA).
Results
In a single-center retrospective study conducted over 56 months, a total of 4,105 patients, with a median age of 61 years and 56.2% male, were identified from electronic hospital records for 5,096 dermatology-related emergency department (ED) visits. The study found that hospitalized patients were significantly older (64 vs. 47 years) and had a higher proportion of males (58.9% vs. 49.8%) compared to those discharged. Among the patients, 79.1% were admitted to the hospital, with those categorized under non-dermatological conditions (neurological-psychiatric, infectious, gastrointestinal-gynaecological, and traumatological) showing a higher likelihood of hospitalization than those classified under dermatological conditions.
The likelihood of hospitalization was also higher in patients referred by a family doctor, those with prior ED visits, underweight (BMI < 18.5) or severely obese (BMI ≥ 35.0) individuals, and those with abnormal vital signs such as high heart rate, fever, low oxygen saturation, or severe pain. Hospitalized patients were more likely to present with severe dermatological conditions, including hemorrhagic skin disorders, cutaneous abscesses, and systemic immunological conditions.
Key predictors of hospitalization included male sex, older age, non-dermatological consultations, ED admissions during weekdays, ED stays of 4 hours or more, and severe dermatological diagnoses. Conversely, conditions such as non-complicated erysipelas, mild rashes, and urticaria were associated with a lower likelihood of hospitalization.
Among hospitalized patients, most were transferred to the general internal medicine department (33.1%), with only 2.2% being admitted to the dermatology department. The involvement of the dermatology department for further care significantly declined over the study period, with the transfer rate of primarily dermatological cases decreasing from 12.5% to 5.6%. This trend suggests a decreasing role of dermatology in the hospital management of these cases, raising concerns about the adequacy of specialized care for dermatological conditions.
Conclusion
The study reveals that 79% of patients presenting with dermatologic emergencies (DE) were admitted to a tertiary care center after evaluation in the emergency department (ED). Simple age- and sex-adjusted analyses identified key factors associated with hospitalization, including being 45 years or older, male sex, and referral by a primary care physician. Multivariable analysis further highlighted significant predictors of increased admission rates, such as abnormal vital signs (elevated temperature, pain intensity, abnormal body mass index, low oxygen saturation), specific times of ED admission (especially during the working week in spring), extended ED stays, and the presence of at least four dermatological diagnoses. Specific conditions, including hemorrhagic skin disorders, certain bacterial skin infections, hidradenitis suppurativa, unexplained skin swelling or masses, and cutaneous signs of connective tissue diseases, were also strong indicators of the need for hospitalization.
These characteristics and variables likely reflect the presence of serious underlying diseases and comorbidities, which either present diagnostic challenges or require specialized therapeutic interventions. Recognizing these factors may enhance the efficiency of patient flow through the ED and potentially reduce overcrowding. However, it is noteworthy that only a small proportion (2.2%) of the 4,033 patients hospitalized with a primary dermatological diagnosis, which was critical for reimbursement under the DRG system, were managed by dermatologists.
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