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The Physician Surprise Question in the Emergency Department: prospective cohort study
  1. Sabrina Correa Costa Ribeiro1,
  2. Thiago Augusto Arantes Lopes2,
  3. Jose Victor Gomes Costa1,
  4. Caio Godoy Rodrigues1,
  5. Ian Ward Abdalla Maia1,
  6. Lucas de Moraes Soler1,
  7. Julio Flavio Meirelles Marchini1,
  8. Rodrigo Antônio Brandão Neto1,
  9. Heraldo Possolo Souza1 and
  10. Júlio César Garcia Alencar1,2
  1. 1Disciplina de Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
  2. 2Universidade de São Paulo Faculdade de Odontologia de Bauru, Bauru, Brazil
  1. Correspondence to Dr Thiago Augusto Arantes Lopes, Faculdade de Odontologia de Bauru, Universidade de São Paulo, 17012-901 Bauru, Brazil; thiagoaugustol{at}


Objectives This study aims to test the ability of the surprise question (SQ), when asked to emergency physicians (EPs), to predict in-hospital mortality among adults admitted to an emergency room (ER).

Methods This prospective cohort study at an academic medical centre included consecutive patients 18 years or older who received care in the ER and were subsequently admitted to the hospital from 20 April 2018 to 20 October 2018. EPs were required to answer the SQ for all patients who were being admitted to hospital. The primary outcome was in-hospital mortality.

Results The cohort included 725 adults (mean (SD) age, 60 (17) years, 51% men) from 58 128 emergency department (ED) visits. The mortality rates were 20.6% for 30-day all-cause in-hospital mortality and 23.6% for in-hospital mortality. The diagnostic test characteristics of the SQ have a sensitivity of 53.7% and specificity of 87.1%, and a relative risk of 4.02 (95% CI 3.15 to 5.13), p<0.01). The positive and negative predictive values were 57% and 86%, respectively; the positive likelihood ratio was 4.1 and negative likelihood ratio was 0.53; and the accuracy was 79.2%.

Conclusions We found that asking the SQ to EPs may be a useful tool to identify patients in the ED with a high risk of in-hospital mortality.

  • Advance Care Planning
  • End of life care
  • Hospice care
  • Prognosis
  • Quality of life
  • Clinical decisions

Data availability statement

All data relevant to the study are included in the article.

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Data availability statement

All data relevant to the study are included in the article.

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  • Contributors SCCR, HPS and JCGA were involved in planning and supervised the work. JCGA obtained research funding. SCCR, JVGC and CGR undertook recruitment of participating centres and patients and managed the data, including quality control. JCGA, TAAL, IWAM, LdMS, JFMM and RABN drafted the manuscript and designed the tables. JCGA performed the statistical analysis. All authors discussed the results and commented on the manuscript. SCCR takes responsibility for the paper. TAAL takes responsibility as the guarantor.

  • Funding This study was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP; grant #2023/07846-4).

  • Competing interests None declared.

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