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Predictors of Admission for Patients Who Present With Hand Cellulitis to the Emergency Department: A 13- year Retrospective Review
Oscar J. Manrique, MD1; Joshua Y. Jacobson, MD1; Matthew Doscher, MD1; Ricardo Galan, MD2; Ralph Liebling, MD1
1Division of Plastic and Reconstructive Surgery, Albert Einstein College of Medicine. Jacobi Medical Center, Bronx, NY; 2Division of Plastic and Reconstructive Surgery, Universidad Militar Nueva Granada, Hospital Militar Central, Bogota, Colombia

Purpose: To identify the variables associated with patient admission and discharge after presenting to the Emergency Department (ED) with hand cellulitis and to analyze factors associated with re-admission after failure of conservative treatment.

Patients and Methods: This is a 13-year retrospective review of patients who were diagnosed with hand cellulitis in the ED at the University Hospital of the Albert Einstein College of Medicine, Bronx, New York between 2000 and 2013. Patients were subdivided into three groups: 1. Patients discharged from the ED with oral antibiotic treatment (conservative); 2. Patients admitted for IV antibiotic treatment; 3. Patients who returned to the ER due to failure of conservative treatment. Using the Clinical Looking Glass system sociodemographics including sex, race-ethnicity, alcohol and intravenous drug use were recorded. Comorbidities such as congestive heart failure (CHF), diabetes mellitus (DM), HIV/AIDS, renal disease, liver disease, chronic obstructive pulmonary disease (COPD) were also analyzed. Laboratory findings such as white blood count (WBC) was also recorded. Univariate and multivariate analysis was performed in order to find a correlation between these variables and final outcomes.

Results: In a 13 year period, a total of 1543 patients were diagnosed with hand cellulitis. 560 patients were discharged and 983 patients were admitted. Of those discharged 268 (47.9%) were female and 292 (52.1%) were male. 546 of the 983 patients admitted were male. Univariate analysis showed that alcohol abuse (p=0.016) and IV drug abuse (p<0.001) were more common in patients who were admitted. HTN (p<0.001), DM (p<0.001), CHF (p0.001), COPD (p<0.001), liver failure (p<0.001) and elevated WBC (p0.001) were associated with admission. However, AIDS/HIV (p=0.107), and renal failure were not. Multivariate analysis showed that HTN (AOR: 1.837), rheumatologic disease (AOR: 2.666), coagulopathy (AOR: 2.714), IV drug abuse (AOR:8.756), DM (AOR:1.576) and elevated WBC (AOR:1.116) showed a significant correlation with admission for IV antibiotic treatment. Among the patients who were discharged (n=560), 113 (20.1%) returned to the ED. Significant variables associated with this group were: COPD (p=0.039) and IV drug abuse (p=0.035).

Conclusions: Hand cellulitis is one of the most common reasons for consultation in the emergency room for plastic surgeons. Clinical diagnosis is the gold standard for evaluation. This 13 year retrospective review shows that patients with multiple comorbidities should be evaluated more carefully before discharge. Risk factor identification, prompt evaluation and treatment and appropriate disposition should lead to improved outcomes, minimal resource utilization and reduced ED length of stay.

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