303 Can Nursing Staff and Junior Physicians Accurately Predict the Risk of In-Hospital Mortality of Acutely Admitted Medical Patients: An Observational Cohort Study

Abstract

Most acutely admitted medical patients are initially assessed and treated by junior staff, both nursing staff and as well as physicians. However, at presentation, many decisions have to be made and in order to make the right decisions, the staff will have to decide how ill they think the patient really is. We therefore performed the present study to assess the ability of the staff to accurately estimate the in-hospital mortality of acutely admitted medical patients. Design: A prospective observational cohort study. Upon contact with the patient, the first member of the nursing staff to assess the patient was asked to complete a form. This form included their initial estimation of the risk of in-hospital mortality (based solely on the information available to them at the present time). The first doctor to treat the patient was asked to complete a similar form. The discriminatory power (ability to discriminate between survivors and non-survivors) of the estimations of the staff was estimated using the area under the receiver-operating characteristics curve (AUROC). Values above 0.8 represent good discriminatory power. The discriminatory power of the nursing staff and physicians were compared using χ2 test. Calibration (accuracy of the prediction) was assessed using Hosmer-Lemeshow χ2 goodness of fit test with a p-value above 0.05 indicating acceptable calibration. Setting: The general internal medical and cardiology admission units at a regional teaching hospital.Type of participants: 2,855 consecutively admitted acute medical patients. Median age of the patients was 62 years. Sixty-five patients died while admitted (2.3 % in-hospital mortality). The nursing staff estimated the risk of in-hospital mortality for 1,822 patients (63.8 %). We found a good discriminatory power with an AUROC 0.838. Calculating the goodness of fit, we found a χ2 (8 degrees of freedom) of 61.6, p < 0.001.The physicians estimated the risk of in-hospital mortality for 733 patients (25.7 %). We found a good discriminatory power with an AUROC of 0.811. Calculating the goodness of fit, we found a χ2 (8 degrees of freedom) of 32.6, p < 0.001. We were only able to include 507 (17.8 %) patients where comparing the discriminatory power of the nursing staff and the physicians. We were not able to show a statistical significant difference as χ2 was 1.76, p = 0.18. Both nursing staff and physicians were able to distinguish between survivors and non-survivors with an acceptable discriminatory power. However, both groups were unable to show an acceptable calibration.