Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality

Bettina Beglinger, Martin Rohacek, Selina Ackermann, Ralph Hertwig, Julia Karakoumis-Ilsemann, Susanne Boutellier, Nicolas Geigy, Christian Nickel, Roland Bingisser, Bettina Beglinger, Martin Rohacek, Selina Ackermann, Ralph Hertwig, Julia Karakoumis-Ilsemann, Susanne Boutellier, Nicolas Geigy, Christian Nickel, Roland Bingisser

Abstract

The association between the physician's first clinical impression of a patient with nonspecific complaints and morbidity and mortality is unknown. The aim was to evaluate the association of the physician's first clinical impression with acute morbidity and mortality. We conducted a prospective observational study with a 30-day follow-up. This study was performed at the emergency departments (EDs) of 1 secondary and 1 tertiary care hospital, from May 2007 to February 2011. The first clinical impression ("looking ill"), expressed on a numerical rating scale from 0 to 100, age, sex, and the Charlson Comorbidity Index (CCI) were evaluated. The association was determined between these variables and acute morbidity and mortality, together with receiver operating characteristics, and validity. Of 217,699 presentations to the ED, a total of 1278 adult nontrauma patients with nonspecific complaints were enrolled by a study team. No patient was lost to follow-up. A total of 84 (6.6%) patients died during follow-up, and 742 (58.0%) patients were classified as suffering from acute morbidity. The variable "looking ill" was significantly associated with mortality and morbidity (per 10 point increase, odds ratio 1.23, 95% confidence interval [CI] 1.12-1.34, P < 0.001, and odds ratio 1.19, 95% CI 1.14-1.24, P < 0.001, respectively). The combination of the variables "looking ill," "age," "male sex," and "CCI" resulted in the best prediction of these outcomes (mortality: area under the curve [AUC] 0.77, 95% CI 0.72-0.82; morbidity: AUC 0.68, 95% CI 0.65-0.71). The physician's first impression, with or without additional variables such as age, male sex, and CCI, was associated with morbidity and mortality. This might help in the decision to perform further diagnostic tests and to hospitalize ED patients.

Conflict of interest statement

The authors have no funding and conflicts of interest to disclose.

Figures

FIGURE 1
FIGURE 1
The Proportions of patients with acute morbidity and mortality dependent on the variable “looking ill” from a scale from 0 to 100. Data for the variable “looking ill” was available in 1240 of 1278 (97%) patients.
FIGURE 2
FIGURE 2
The performance of 2 single variables (looking ill and CCI) and 2 sets of predictors (looking ill, age and male sex, in combination with or without CCI) in the ROC space for the outcome variable mortality. CCI = Charlson Comorbidity Index, ROC = receiver operating characteristic.
FIGURE 3
FIGURE 3
The performance of 2 single variables (looking ill and CCI) and 2 sets of predictors (looking ill, age and male sex, in combination with or without CCI) in the ROC space for the outcome variable acute morbidity. CCI = Charlson Commorbidity Index, ROC = receiver operating characteristic.

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Source: PubMed

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