PREDICTION OF POOR OUTCOME OF INTENSIVE-CARE UNIT PATIENTS ADMITTED FROM THE EMERGENCY DEPARTMENT

Objective: To assess whether physicians can identify very low likeliho od of survival and very low likelihood of favorable functional outcome in adult nontrauma patients before admission to the intensive care un it (ICU) from the emergency department (ED). Design: Prospective surve y. Setting: University hospital ED and ICU. Participants and Patients: Critical care fellows and ED physicians and all adult nontrauma patie nts admitted to the ICU from the ED over 1 yr. Interventions: None. Me asurements and Main Results: The survey compared predictions of poor o utcome from three sources: critical care fellows, ED physicians, and t he admission Mortality Probability Model (MPM0). All patients were fol lowed until hospital death or hospital discharge. Six-month follow-up data were obtained for patients predicted to have a <2% chance of surv iving with favorable functional outcome. In the ED, critical care fell ows and ED physicians predicted likelihood of patient survival and lik elihood of favorable functional outcome. MPM0 estimates of mortality w ere determined. The sensitivities, specificities, and positive predict ive values were calculated for the predictions of <2% survival and the predictions of <2% chance of favorable functional outcome made by eac h prediction group. Complete data were obtained on 236 (96%) of 243 el igible patients. With regard to hospital mortality rate, fellows' pred ictions had a sensitivity of 27%, a specificity of 99%, and a positive predictive value of 88%; ED physicians' predictions had a sensitivity of 24%, a specificity of 98% and a positive predictive value of 81%; and MPM0 predictions had a sensitivity of 2%, a specificity of 100%, a nd a positive predictive value of 100%. With regard to mortality rate combined with poor functional outcome, fellows' predictions had a sens itivity of 35%, a specificity of 99%, and a positive predictive value of 96%; ED physicians' predictions had a sensitivity of 37%, a specifi city of 99%, and a positive predictive value of 96%. Conclusions: If a cutoff point of <2% predicted survival is used in the triage of patie nts away from the ICU, the MPM0 has too low a sensitivity to be used a s an effective screen, The low sensitivities and relatively low positi ve predictive values with wide confidence intervals of physician predi ctions of <2% survival also preclude their use in triage. The addition of functional outcome as an end point improves the sensitivity, speci ficity, and positive predictive value of subjective predictions, makin g triage of patients away from the ICU at the time of ED evaluation a realistic possibility.