Chest
Clinical Investigations in Critical CarePrognostic Judgments and Triage Decisions for Patients With Acute Congestive Heart Failure
Section snippets
Design
The Predictions and Outcomes of Congestive Heart Failure study22 prospectively identified patients with new or exacerbated CHF presenting to the emergency departments (EDs) of three hospitals, and followed them forward through time. We have previously described its methods.
Settings
The three study hospitals–a large urban university hospital that provides care for a large indigent population, a large urban Veteran's Administration (VA) hospital affiliated with the same medical school that operates the
Patient Selection, and Patient and Physician Characteristics
Figure 1shows how we arrived at the patient cohort (n = 1,032) for the present study. The patient characteristics of patients in the cohort are shown in Table 1. The mean ± SD patient age was 66.86 ± 11.39 years. There were 370 patients (35.9%) seen at the university hospital, 544 patients (52.7%) seen at the VA hospital, and 118 patients (11.4%) seen at the community hospital. Caring for these patients in the ED were 186 physicians, who each managed from 1 to 60 patients. The physicians'
Discussion
We found that the physicians who made triage decisions for patients with acute CHF frequently and substantially overestimated the probability that individual patients would die or have a severe complication that would require care usually available in the ICU to maintain life. We found substantial overestimation regardless of whether we stratified patients by the physicians' probability estimates, or by triage destination.
Furthermore, we found that physicians had only a modest ability to
Conclusion
Our study found that physicians in the ED have trouble judging the short-term probability of death or severe complications for patients with acute CHF. Current guidelines suggest that such judgments should strongly influence decisions about admission to intensive care. Furthermore, we found that, after excluding patients who presented in extremis, only a few presenting patients died or had severe complications develop within 4 days.
These findings have implications for both physicians and
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2013, American Heart JournalCitation Excerpt :The majority of acute decompensated heart failure (ADHF) patients present initially to the emergency department (ED) and the time to treatment varies across hospitals.1,2
Supported by a grant from the Agency for Health Care Policy and Research (HS-06274). Dr. Smith was supported by a Robert Wood Johnson Generalist Faculty Scholar Award from 1993–97.
Portions of these findings were presented at the 19th Society for General Internal Medicine Meeting, May 2–4, 1996, Washington, DC.
Work performed at Virginia Commonwealth University.