Kabrhel Christopher, Sacco Weston, Liu Shan, Hariharan Praveen
Int J Emerg Med. 2010 Oct 19;3(4):239-64. doi: 10.1007/s12245-010-0206-8.
Clinical decision rules for the disposition of patients with pulmonary embolism (PE) are typically validated against an outcome of 30-day mortality or disease recurrence. There is little justification for this time frame, nor is it clear whether this outcome reflects emergency department (ED) decision making.
To determine which outcomes emergency physicians (EP) consider most relevant to disposition decisions.
Survey of attending EPs in geographically diverse US states using acute PE as the diagnostic framework. Responses required single-answer multiple choice, a numerical percentage, rank-ordered responses, or a five-point Likert scale. We distributed the survey via e-mail to 608 EPs.
We 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 5-day (in hospital) outcomes [192/265, 72% (95% exact CI = 66%-78%)] than 30-day outcomes [39/261, 15% (95% exact CI = 11%-20%)] or 90-day 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 5-day (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 deterioration.
Five-day (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 rules.
肺栓塞（PE）患者处置的临床决策规则通常以30天死亡率或疾病复发作为验证指标。这个时间框架缺乏充分依据，而且该结果是否反映急诊科（ED）的决策也不明确。
确定急诊医生（EP）认为与处置决策最相关的结果。
以急性PE为诊断框架，对美国不同地理位置州的主治急诊医生进行调查。回答要求为单项选择题、数字百分比、排序回答或五点李克特量表。我们通过电子邮件向608名急诊医生发放了调查问卷。
我们收到了292名（48%）急诊医生的回复：88%通过了委员会认证，91%接受过急诊医学培训，70%在学术机构工作。受访者报告称，在急诊科将1%的PE患者予以出院，但21%报告称被收治科室要求这样做。急诊医生更关注了解5天（住院期间）的结果[192/265，72%（95%精确可信区间=66%-78%）]，而非30天结果[39/261，15%（95%精确可信区间=11%-20%）]或90天结果[29/263，11%（95%精确可信区间=8%-15%）]。在李克特量表上，212/241（88%，95%精确可信区间=83%-92%）同意或强烈同意，他们在决定将患者从急诊科收治或出院时会考虑5天（住院期间）的临床病情恶化情况，相比之下，分别有184/242（76%，95%精确可信区间=70%-81%）和73/242（30%，95%精确可信区间=24%-36%）的医生在30天和90天时会考虑。除死亡或复发性PE之外，各种各样的临床结果都被认为可表明临床病情恶化。
急诊医生在确定急诊科PE患者的处置时，对包含各种临床病情恶化事件的5天（住院期间）结果感兴趣。研究人员在制定和验证临床决策规则时应予以考虑。
