Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Lawrence Center for Quality and Safety, Massachusetts General Hospital and Massachusetts General Physicians' Organization, Boston, Massachusetts, USA.
Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
J Pain Symptom Manage. 2019 May;57(5):944-951. doi: 10.1016/j.jpainsymman.2019.02.007. Epub 2019 Feb 16.
Heart failure (HF) is associated with symptom exacerbations and risk of mortality after an emergency department (ED) visit. Although emergency physicians (EPs) treat symptoms of HF, often the opportunity to connect with palliative care is missed. The "surprise question" (SQ) "Would you be surprised if this patient died in the next 12 months?" is a simple tool to identify patients at risk for 12-month mortality.
The objective of this study was to assess the accuracy of the SQ when used by EPs to assess patients with HF.
We conducted a prospective cohort study in which clinicians applied the SQ to patients presenting to the ED with symptoms of HF. Chart review and review of death records were completed. The primary outcome was accuracy of the surprise question to predict 12-month mortality. A univariate analysis for potential predictors of 12-month mortality was performed.
During the study period, 199 patients were identified, and complete data were available for 97% of observations (n = 193). The one-year mortality was 29%. EPs reported that "they would not be surprised" if the patient died within the next 12 months in 53% of cases. 42.7% of these patients died within 12 months compared to 13.3% in the "would be surprised" group. There was a strong association with death in the "not surprised" group (odds ratio 4.85, 95% CI 2.34-9.98, P < 0.0001). The sensitivity, specificity, positive predictive value, and negative predictive value of the SQ were 78.6%, 56.9%, 42.7%, and 86.7%, respectively, with c-statistic = 0.68.
The SQ screening tool can assist ED providers in identifying HF patients that would benefit from early palliative care involvement.
心力衰竭（HF）与急诊科（ED）就诊后症状恶化和死亡风险相关。尽管急诊医师（EP）治疗 HF 的症状，但常常错过与姑息治疗联系的机会。“意外问题”（SQ）“如果这位患者在接下来的 12 个月内死亡，您会感到惊讶吗？”是一种简单的工具，可以识别 12 个月内死亡风险的患者。
本研究旨在评估 EP 使用 SQ 评估 HF 患者的准确性。
我们进行了一项前瞻性队列研究，其中临床医生将 SQ 应用于因 HF 症状就诊于 ED 的患者。完成了图表审查和死亡记录审查。主要结局是 SQ 预测 12 个月死亡率的准确性。对 12 个月死亡率的潜在预测因素进行了单变量分析。
在研究期间，确定了 199 名患者，其中 97%的观察结果（n=193）都有完整的数据。一年死亡率为 29%。EP 报告说，如果患者在接下来的 12 个月内死亡，他们将“不会感到惊讶”，在 53%的情况下。在“不会感到惊讶”组中，有 42.7%的患者在 12 个月内死亡，而在“会感到惊讶”组中，这一比例为 13.3%。在“不惊讶”组中与死亡有很强的关联（比值比 4.85，95%CI 2.34-9.98，P<0.0001）。SQ 的灵敏度、特异性、阳性预测值和阴性预测值分别为 78.6%、56.9%、42.7%和 86.7%，C 统计量为 0.68。
SQ 筛选工具可以帮助 ED 提供者识别 HF 患者，这些患者将受益于早期姑息治疗的介入。
