Outcomes considered most important by emergency ph

Authors: Christopher Kabrhel Weston Sacco Shan Liu Praveen Hariharan

Publish Date: 2010/10/19

Volume: 3, Issue: 4, Pages: 239-264

PDF Link

Abstract

Clinical decision rules for the disposition of patients with pulmonary embolism PE are typically validated against an outcome of 30day mortality or disease recurrence There is little justification for this time frame nor is it clear whether this outcome reflects emergency department ED decision makingSurvey of attending EPs in geographically diverse US states using acute PE as the diagnostic framework Responses required singleanswer multiple choice a numerical percentage rankordered responses or a fivepoint Likert scale We distributed the survey via email to 608 EPsWe received responses from 292 48 EPs 88 board certified 91 trained in emergency medicine and 70 work in academics Respondents reported discharging 1 of patients with PE from the ED but 21 reported being asked to do so by an admitting service EPs were more interested in knowing 5day in hospital outcomes 192/265 72 95 exact CI = 66–78 than 30day outcomes 39/261 15 95 exact CI = 11–20 or 90day outcomes 29/263 11 95 exact CI = 8–15 On a Likert scale 212/241 88 95 exact CI = 83–92 agreed or strongly agreed that they considered 5day in hospital clinical deterioration when making a decision to admit or discharge a patient from the ED compared to 184/242 76 95 exact CI = 70–81 and 73/242 30 95 exact CI = 24–36 for 30 and 90 days respectively A wide variety of clinical outcomes beyond death or recurrent PE were considered indicative of clinical deteriorationFiveday in hospital outcomes that incorporate a variety of clinical deterioration events are of interest to EPs when determining the disposition of ED patients with PE Researchers should consider this when developing and validating clinical decision rulesWith every patient encounter emergency physicians EPs must decide on an appropriate disposition In some cases disposition decisions are obvious—clinically unstable patients must be admitted and patients with minor problems may be safely discharged from the Emergency Department ED However for a large number of conditions determining which patients are safe for outpatient treatment is more complexProspectively validated decision rules are available to help clinicians determine which patients with pneumonia syncope transient neurological attacks pulmonary embolism PE and other conditions should be admitted to the hospital and which patients are safe for discharge 1 2 3 4 5 6 7 It is common for these rules to be validated against outcomes such as 30day mortality or disease recurrence However there is little justification for this in the literature Since few patients are hospitalized for 30 days it is not clear how this time frame informs the decision to admit or discharge a patient Narrowly defined outcomes such as death and disease recurrence may not reflect the complexity of the disposition decision either Moreover statistical models that predict allcause mortality may unduly reflect factors with a high fatality rate eg cancer whether or not they are associated with the diagnosis in question Given these issues it is not surprising that physicians tend not to be familiar with clinical decision rules and use them infrequently in practice 8

Keywords: