Efigure 1. Study Flow Diagram

ONLINE APPENDIX

eFigure 1. Study Flow Diagram

eFigure2. Vital Sign Instability on Discharge and 30-Day Outcomes, Stratified by Disposition Status

eTable 1. Frequency of Specific and Combinations of Vital Sign Instabilities

eTable 2. Final Model to Assess Association of Vital Sign Instability on 30-Day Outcomes

eTable3.Distribution and Onset of Vital Sign Abnormalities Among Those with Vital Sign Instability at Discharge

eFigure 1. Study Flow Diagram

eFigure 2. Vital Sign Instability on Discharge and 30-Day Outcomes, Stratified by Disposition Statusa

n / % of those with number of instabilities
Home or Home Health / Post-Acute Care
Number of Instabilities
Any / 6,127 / 77.5 / 22.5
0 / 26,708 / 81.9 / 18.1
1 / 5,271 / 78.5 / 21.5
2 / 760 / 73.3 / 26.7
3+ / 96 / 57.3 / 42.7

aDisposition to ‘post-acute care’ was defined as discharge to a nursing home, skilled nursing facility, or long-term acute care hospital.

eTable 1. Frequency of Specific and Combinations of Vital Sign Instabilities

Overall
n (%) / Composite
n (%) / Mortality
n (%) / Readmission
n (%)
Among those with only 1 instability
Heart rate >100/min / 2735 (51.9) / 485 (17.7) / 92 (3.4) / 431 (15.8)
Systolic blood pressure ≤90 mm Hg / 966 (18.3) / 163 (16.9) / 21 (2.2) / 151 (15.6)
Oxygen saturation <90% / 797 (15.1) / 140(17.6) / 19 (2.4) / 129 (16.2)
Respiratory rate >24/min / 484 (9.2) / 64 (13.2) / 8 (1.7) / 59 (12.2)
Temperature >37.8°C / 289 (5.5) / 38 (13.2) / 5 (1.7) / 35 (12.1)
Two-way combinationsamong those with only 2 instabilities
Respiratory rate and heart rate / 156 (20.5) / 33 (21.2) / 6 (3.9) / 30 (19.2)
Heart rate and systolic blood pressure / 153 (20.1) / 34 (22.2) / 8 (5.2) / 27 (17.7)
Temperature and heart rate / 142 (18.7) / 21 (14.8) / 3 (2.1) / 18 (12.7)
Heart rate and oxygen saturation / 134 (17.6) / 29 (21.6) / 4 (3.0) / 26 (19.4)
Respiratory rate and systolic blood pressure / 70 (9.2) / 18 (25.7) / 7 (10.0) / 11 (15.7)
Respiratory rate and oxygen saturation / 36 (4.7) / 8 (22.2) / 3 (8.3) / 6 (16.7)
Systolic blood pressure and oxygen saturation / 35 (4.6) / 11 (31.4) / 3 (8.6) / 8 (22.9)
Temperature and systolic blood pressure / 13 (1.7) / 3 (23.1) / 0 (0) / 3 (23.1)
Temperature and respiratory rate / 11 (1.5) / 2 (18.2) / 0 (0) / 2 (18.2)
Temperature and oxygen saturation / 10 (1.3) / 2 (20.0) / 0 (0) / 2 (20.0)
Three-way combinations among those with 3 or more instabilities
Respiratory rate, heart rate, systolic blood pressure / 35 (36.5) / 8 (22.9) / 3 (8.6) / 7 (20.0)
Respiratory rate, heart rate, oxygen saturation / 19 (19.8) / 6 (31.6) / 1 (5.3) / 5 (26.3)
Temperature, respiratory rate, heart rate / 17 (17.7) / 6 (35.3) / 1 (5.9) / 5 (29.4)
Temperature, heart rate, systolic blood pressure / 16 (16.7) / 3 (18.8) / 1 (6.3) / 2 (12.5)
Heart rate, systolic blood pressure, oxygen saturation / 13 (13.5) / 2 (15.4) / 0 (0) / 2 (15.4)
Temperature, heart rate, oxygen saturation / 8 (8.3) / 2 (25.0) / 1 (12.5) / 1 (12.5)
Temperature, respiratory rate, systolic blood pressure / 7 (7.3) / 2 (28.6) / 0 (0) / 2 (28.6)
Respiratory rate, systolic blood pressure, oxygen saturation / 7 (7.3) / 1 (14.3) / 0 (0) / 1 (14.3)
Temperature, respiratory rate, oxygen saturation / 1 (1.0) / 1 (100) / 0 (0) / 1 (100)
Temperature, systolic blood pressure, oxygen saturation / 0 (0) / 0 (0) / 0 (0) / 0 (0)
eTable 2. Final Model to Assess Association of Vital Sign Instability on 30-Day Outcomes
Adjusted Odds Ratio (95% CI)
30-Day Outcomes
Composite / Mortality / Readmissions
Demographic characteristics
Age, per ten years / 1.13 (1.11 - 1.16) / 1.81 (1.67 - 1.97) / 1.09 (1.07 - 1.12)
Medicaid / 1.53 (1.36 - 1.72) / 1.60 (1.13 - 2.26) / 1.57 (1.39 - 1.77)
Widow / 1.11 (1.01 - 1.22) / 0.77 (0.61 - 0.97) / 1.14 (1.03 - 1.25)
Utilization history
Prior ED visit, per visit / 1.03 (1.02 - 1.04) / 1.01 (0.98 - 1.04) / 1.03 (1.02 - 1.04)
Prior hospitalization, per hospitalization / 1.18 (1.15 - 1.21) / 0.96 (0.89 - 1.04) / 1.18 (1.15 - 1.22)
Hospital and clinical factors from first day
Non-elective admission / 1.29 (1.17 - 1.44) / 2.24 (1.54 - 3.27) / 1.25 (1.13 - 1.39)
Charlson comorbidity index, per point / 1.06 (1.04 - 1.07) / 1.16 (1.12 - 1.21) / 1.05 (1.03 - 1.07)
Laboratory abnormalities within 24 hours of admission
Albumin <2 g/dL / 1.65 (1.29 - 2.12) / 2.24 (1.36 - 3.68) / 1.53 (1.18 - 1.98)
Albumin 2-3 g/dL / 1.30 (1.19 - 1.41) / 1.69 (1.38 - 2.06) / 1.23 (1.13 - 1.35)
Aspartate aminotransferase >40 U/L / 1.24 (1.13 - 1.36) / 1.99 (1.61 - 2.47) / 1.18 (1.07 - 1.29)
Creatine phosphokinase <60 mcg/L / 1.23 (1.12 - 1.35) / 1.32 (1.05 - 1.65) / 1.18 (1.07 - 1.30)
Mean corpuscular volume >100 fL/red cell / 1.29 (1.12 - 1.50) / 1.24 (0.89 - 1.73) / 1.27 (1.10 - 1.48)
Platelets <90 x 103/µL / 1.62 (1.37 - 1.91) / 1.37 (0.92 - 2.05) / 1.61 (1.36 - 1.91)
Platelets >350 x 103/µL / 1.34 (1.21 - 1.48) / 1.56 (1.21 - 2.01) / 1.31 (1.18 - 1.45)
Prothrombin time >35 seconds / 1.49 (1.11 - 2.02) / 0.85 (0.40 - 1.81) / 1.50 (1.11 - 2.04)
Hospital and clinical factors at discharge
Length of stay, per day / 1.06 (1.05 - 1.07) / 1.09 (1.07 - 1.11) / 1.05 (1.04 - 1.06)
Hospital complications
Clostridium difficile infection / 1.52 (1.01 - 2.29) / 1.20 (0.54 - 2.65) / 1.40 (0.92 - 2.14)
Pressure ulcer / 1.42 (1.11 - 1.81) / 1.70 (1.10 - 2.62) / 1.20 (0.93 - 1.56)
Venous thromboembolism / 1.48 (1.12 - 1.97) / 2.00 (1.15 - 3.47) / 1.41 (1.05 - 1.89)
Laboratory abnormalities at discharge
Blood urea nitrogen >20 mg/dL / 1.40 (1.30 - 1.50) / 1.81 (1.50 - 2.17) / 1.33 (1.24 - 1.44)
Sodium <135 mEq/L / 1.26 (1.15 - 1.37) / 1.45 (1.18 - 1.79) / 1.28 (1.17 - 1.40)
Hematocrit <= 27 / 1.21 (1.09 - 1.34) / 1.19 (0.92 - 1.54) / 1.20 (1.08 - 1.34)
Vital sign instability at discharge
Any
1 / 1.31 (1.20 - 1.43) / 2.12 (1.73 - 2.61) / 1.24 (1.13 - 1.35)
2 / 1.68 (1.40 - 2.03) / 3.26 (2.22 -4.78) / 1.40 (1.15 -1.71)
3+ / 1.68 (1.03 - 2.74) / 3.80 (1.65 - 8.78) / 1.36 (0.81 - 2.29)
CI = confidence interval; ED = emergency department

eTable 3. Distribution and Onset of Vital Sign Abnormalities Among Those with Vital Sign Instability at Discharge

Vital sign instability on discharge / Vital sign values on admission and discharge, median (IQR) / Same instability present on admission, % / Composite event rate, stratified by presence on admission, %
Admission / Discharge / Present / Not Present / p-value
Temperature >37.8° C / 37.5 (37.1-38.2) / 38.1 (37.9-38.3) / 37.5 / 14.8 / 15.2 / 0.51
Respiratory rate >24 breaths/min / 26 (21-31) / 28 (26-33) / 59.0 / 18.5 / 16.3 / 0.37
Heart rate >100 beats/min / 112 (101-125) / 108 (103-114) / 75.6 / 18.2 / 18.7 / 0.56
Systolic blood pressure ≤90 mmHg / 91 (83-102) / 86 (82-90) / 49.1 / 19.9 / 17.6 / 0.32
Oxygen saturation <90% / 91 (87-94) / 86 (81-88) / 49.2 / 18.0 / 20.1 / 0.65