0
Clinical Investigations in Critical Care |

Prognostic Judgments and Triage Decisions for Patients With Acute Congestive Heart Failure*

Wally R. Smith, MD; Roy M. Poses, MD; Donna K. McClish, PhD; Elizabeth C. Huber, MD; F. Lynne W. Clemo, MD; Donna Alexander, PhD; Brian P. Schmitt, MD
Author and Funding Information

*From the Division of Quality Health Care (Dr. Smith), and Division of General Medicine (Drs. Huber, Clemo, and Alexander), Department of Medicine, and Department of Biostatistics (Dr. McClish), Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, VA; the Division of General Internal Medicine (Dr. Poses), Department of Medicine, Memorial Hospital of Rhode Island and Brown University School of Medicine, Providence, RI; and the Division of General Medicine (Dr. Schmitt), Department of Medicine, Northwestern University Medical School, Chicago, IL.

Correspondence to: Wally R. Smith, MD, Chairman, Division of Quality Health Care, Virginia Commonwealth University, Medical College of Virginia Campus, Box 980306, 1200 E Broad St W10 W 402, Richmond, VA 23298-0306; e-mail: wrsmith@hsc.vcu.edu



Chest. 2002;121(5):1610-1617. doi:10.1378/chest.121.5.1610
Text Size: A A A
Published online

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).

Design: Prospective cohort study.

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.

Figures in this Article

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543