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Prognostication in urgent intensive care unit referrals: a cohort study
  1. Joao Gabriel Rosa Ramos1,2,3,
  2. Roger Daglius Dias4,5,
  3. Rogerio da Hora Passos2,
  4. Paulo Benigno Pena Batista2,6 and
  5. Daniel Neves Forte1,7
  1. 1 Medical Sciences PhD Program, University of São Paulo Medical School, São Paulo, Brazil
  2. 2 Intensive Care Unit, Hospital São Rafael, Salvador, Brazil
  3. 3 Clinica Florence (Hospice and Rehabilitation Service), Salvador, Brazil
  4. 4 Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil
  5. 5 Emergency Department, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  6. 6 UNIME Medical School, Lauro de Freitas, Brazil
  7. 7 Hospital Sirio-Libanes, Sao Paulo, Brazil
  1. Correspondence to Dr Joao Gabriel Rosa Ramos, University of Sao Paulo Medical School, Sao Paulo 594, Brazil; jgrr25{at}gmail.com

Abstract

Objectives Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician’s prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission.

Methods Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians’ prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality.

Results There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians’ prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification.

Conclusions Physician’s prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.

  • Intensive care triage
  • Decision-making
  • Palliative care
  • goals of care
  • Critically ill

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Footnotes

  • Presented at This work was partially presented as an abstract at the 38th International Symposium on Intensive

    Care and Emergency Medicine, Brussels, 2018.

  • Contributors JGRR and DNF contributed to the designing, acquisition, analysis and interpretation of data, drafting and revising the manuscript. RDD contributed to the analysis and interpretation of data, drafting and revising the manuscript. RdHP and PBPB contributed to interpretation of results, drafting and critically revising the manuscript. All authors have approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval This study was approved by the research ethics committee of the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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