Accuracy of predictions of survival at admission to the intensive care unit

Purpose: The purpose of this study was to compare the accuracy of outcome p redictions made on the day of intensive care unit (ICU) admission by critic al care physicians, critical care fellows, and primary team physicians. Patients and Methods: Fifty-nine consecutive patients admitted to a Medical -Surgical ICU were included in the study. Two ICU attending physicians and two critical care fellows, not involved in medical management, evaluated ea ch new ICU patient at admission end after 48 to 72 hours. Altogether six IC U attendings and six fellows were involved in the study. Each investigator separately assigned probability to each patient of being discharged alive from the ICU and the hospital. On the day of admission the primary service was also asked to estimate the likelihood of successful ou tcome. All values are expressed in percentiles. Statistical analysis was pe rformed by a logistic regression procedure with a binary outcome. Data are presented as mean +/- SD. Results: Fifty-nine patients were surveyed. Twent y-six (44%) patients died in the ICU, 3 (5%) died in the hospital wards, an d 30 (51%) were discharged alive from the hospital. ICU attendings most reliably and accurately estimated patient outcome on ad mission compared with critical care fellows and primary team physicians. IC U attendings were more consistent than ICU fellows at predicting outcome at 48 and 72 hours. Clinical predictions were better for patients at the extr emes of disease severity, and the accuracy of predictions in these patients was highest. Accuracy was diminished in patients with moderate compromise of clinical status. Conclusion:ICU attendings predicted most accurately and consistently the fi nal outcome of patients, and ICU fellows estimated outcome more reliably th an the primary service. For the most part, the primary service tended to ov erestimate the probability of favorable outcome of patients for whom ICU ad mission had been requested. Additionally, clinical accuracy of survival or mortality was best for those patients at the extremes of clinical compromis e: this point seems to confirm the validity of using clinical judgement as a guide to restricting ICU resources for those severely compromised or mild ly compromised. This study also indicates that predictions of outcome in cr itically ill patients made within days of admission are statistically valid but not sufficiently reliable to justify irrevocable clinical decisions at present. Copyright (C) 2001 by W.B. Saunders Company.