Chest
Volume 121, Issue 5, May 2002, Pages 1610-1617
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Clinical Investigations in Critical Care
Prognostic Judgments and Triage Decisions for Patients With Acute Congestive Heart Failure

https://doi.org/10.1378/chest.121.5.1610Get rights and content

Study objectives

To determine how well triage physicians judge the probability of death or severe complications that require treatment only available in an ICU to maintain life for patients with acute congestive heart failure (CHF).

Setting

An urban university hospital, a Veteran's Administration hospital, and a community hospital.

Patients or participants

Patients were those visiting the emergency department (ED) with acute CHF, excluding those who already required a treatment only available in an ICU to maintain life, and those with possible or definite myocardial infarction. Physician participants were those caring for the patients in the ED.

Measurements and results

We performed chart reviews to ascertain whether each patient died or had severe complications develop by 4 days. We collected judgments of the probability of this outcome from the physicians taking care of the study patients in the ED. The prevalence of death or severe complications was 43 per 1,032 patients (4.2%). The mean ± SD of physicians' judgments of the probability of this outcome was 32.1 ± 28.4%. A calibration curve that stratified these judgments by decile demonstrated that physicians consistently overestimated this probability (p < 0.01). Physicians' judgments were only moderately good at discriminating which patients would have the outcome (receiver operating characteristic curve area, 0.715). Patients admitted to an ICU received the highest average predicted probability (56.4%), followed by those admitted to a telemetry unit (34.1%), to a regular hospital ward (29.8%), and those sent home (17.9%.)

Conclusions

Physicians drastically overestimated the probability of a severe complication that would require critical care for patients with acute CHF who were candidates for ICU admission. Their judgments of this probability were associated with their triage decisions, as they should be according to several guidelines for ICU triage. Overestimation of the probability of severe complications may have lead to overutilization of scarce critical care resources. Current critical care triage guidelines should be revised to take this difficulty into account, and better predictive models for patients potentially requiring critical care should be developed.

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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    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.

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