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Emerg Med J. 2018 Jan;35(1):56-61. doi: 10.1136/emermed-2016-205950. Epub 2016 Oct 25.

Skin and soft tissue infection management failure in the emergency department observation unit: a systematic review.

Abetz JW1,2,3, Adams NG1, Mitra B1,2,3.

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Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.



Skin and soft tissue infections (SSTIs) are commonly treated in ED observation units (EDOUs). The management failure rate in this setting is high, as evidenced by a large proportion of patients requiring inpatient admission. This systematic review sought to quantify the management failure rate and identify risk factors associated with management failure.


Searches of six databases and grey literature were conducted with no limits on publication year or language. Manuscripts describing patients admitted to an EDOU setting (≤24 hours planned admission to EDOU) with a primary diagnosis of cellulitis or other SSTIs were included. Variables associated with failure of management, defined as inpatient admission, stay >28 hours (4 hours in ED, 24 hours in EDOU) or death, were extracted. A narrative description of variables associated with failure of EDOU admission was conducted.


There were 1119 unique articles identified through the literature search. Following assessment, 10 studies were included in the final systematic review, 9 of which reported the management failure rate (range 15%-38%). The presence of fever, a high total white blood cell count and known methicillin-resistant Staphylococcus aureus exposure were the most commonly reported variables associated with management failure.


A higher rate of EDOU management failure in SSTIs than the generally accepted rate of 15% was observed in most studies identified by this review. Risk factors identified were varied, but presence of a fever and elevated inflammatory markers were commonly associated with failure of EDOU admission by multiple studies. Recognition of risk factors and the increased application of clinical decision tools may help to improve disposition of patients at high risk for clinical deterioration or management failure.


admission avoidance; emergency care systems, admission avoidance; emergency department operations; musculo-skeletal, soft tissue infection

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