Department of Pediatrics, Division of Critical Care Medicine, University of Michigan, Ann Arbor, MI.
Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
Crit Care Med. 2020 Nov;48(11):e1012-e1019. doi: 10.1097/CCM.0000000000004555.
To determine clinician accuracy in the identification and prediction of multiple organ dysfunction syndrome.
Prospective cohort study.
University of Michigan's C.S. Mott Children's Hospital PICU.
Patients admitted to the PICU with an anticipated PICU length of stay greater than 48 hours.
None.
For each patient, the clinical team (attending, fellow, resident/nurse practitioner) was surveyed regarding existing and anticipated organ dysfunction. The primary outcomes were clinicians' accuracy at identifying multiple organ dysfunction syndrome and predicting new or progressive multiple organ dysfunction syndrome, compared to the objective assessment of multiple organ dysfunction syndrome using Proulx criteria. We also measured sensitivity, specificity, negative and positive predictive values, and negative and positive likelihood ratios of clinician assessments. We tested for differences in accuracy by clinician type using chi-square tests. Clinicians rated their confidence in prediction on a 5-point Likert scale. There were 476 eligible PICU admissions, for whom 1,218 surveys were completed. Multiple organ dysfunction syndrome was present in 89 patients (18.7%) at enrollment, and new or progressive multiple organ dysfunction syndrome occurred in 39 (8.2%). Clinicians correctly identified multiple organ dysfunction syndrome with 79.9% accuracy and predicted additional organ dysfunction with 82.6% accuracy. However, the positive and negative likelihood ratios for new or progressive multiple organ dysfunction syndrome prediction were 3.0 and 0.7, respectively, indicating a weak relationship between the clinician prediction and development of new or progressive multiple organ dysfunction syndrome. The positive predictive value of new or progressive multiple organ dysfunction syndrome prediction was just 22.1%. We found no differences in accuracy by clinician type for either identification of multiple organ dysfunction syndrome (80.2% vs 78.2% vs 81.0%; p = 0.57) or prediction of new or progressive multiple organ dysfunction syndrome (84.8% vs 82.8% vs 80.3%; p = 0.26) for attendings, fellows, and residents/nurse practitioners, respectively. There was a weak correlation between the confidence and accuracy of prediction (pairwise correlation coefficient, 0.26; p < 0.001).
PICU clinicians correctly identified multiple organ dysfunction syndrome and predicted new or progressive multiple organ dysfunction syndrome with 80% accuracy. However, only 8% of patients developed new or progressive multiple organ dysfunction syndrome, so accuracy was largely due to true negative predictions. The positive predictive value for new or progressive multiple organ dysfunction syndrome prediction was just 22%. Accuracy did not differ by clinician type, but was correlated with self-rated confidence and was higher for negative predictions.
确定临床医生在识别和预测多器官功能障碍综合征方面的准确性。
前瞻性队列研究。
密歇根大学 C.S. Mott 儿童医院 PICU。
入住 PICU 且预计 PICU 住院时间超过 48 小时的患者。
无。
对于每个患者，临床团队（主治医生、研究员、住院医师/护士从业者）接受了关于现有和预期器官功能障碍的调查。主要结果是与使用 Proulx 标准对多器官功能障碍综合征进行的客观评估相比，临床医生识别多器官功能障碍综合征和预测新的或进行性多器官功能障碍综合征的准确性。我们还测量了临床医生评估的敏感性、特异性、阴性和阳性预测值以及阴性和阳性似然比。我们使用卡方检验测试了不同临床医生类型的准确性差异。临床医生使用 5 分李克特量表对其预测的信心进行评分。共有 476 名符合条件的 PICU 入院患者，完成了 1218 份调查。89 名患者（18.7%）在入组时存在多器官功能障碍综合征，39 名患者（8.2%）发生新的或进行性多器官功能障碍综合征。临床医生正确识别多器官功能障碍综合征的准确率为 79.9%，预测其他器官功能障碍的准确率为 82.6%。然而，新的或进行性多器官功能障碍综合征预测的阳性和阴性似然比分别为 3.0 和 0.7，表明临床医生的预测与新的或进行性多器官功能障碍综合征的发展之间关系较弱。新的或进行性多器官功能障碍综合征预测的阳性预测值仅为 22.1%。我们没有发现临床医生类型在识别多器官功能障碍综合征（80.2%比 78.2%比 81.0%；p=0.57）或预测新的或进行性多器官功能障碍综合征（84.8%比 82.8%比 80.3%；p=0.26）方面的准确性存在差异，分别为主治医生、研究员和住院医师/护士从业者。预测的准确性与信心之间存在弱相关性（两两相关系数，0.26；p<0.001）。
PICU 临床医生正确识别多器官功能障碍综合征并预测新的或进行性多器官功能障碍综合征的准确率为 80%。然而，只有 8%的患者发生新的或进行性多器官功能障碍综合征，因此准确性在很大程度上归因于真正的阴性预测。新的或进行性多器官功能障碍综合征预测的阳性预测值仅为 22%。准确性不因临床医生类型而异，但与自我评估的信心相关，且阴性预测的准确性更高。
