Are two (inexperienced) heads better than one (experienced) head? Averaging house officers' prognostic judgments for critically ill patients.

Inexperienced physicians may make prognostic judgments and management decisions about acutely ill patients in the absence of supervision. We hypothesized that mathematically combining judgments of junior and senior house officers might yield aggregate judgments as good as those made by experienced critical care attending physicians. We obtained independent quantitative assessments of the likelihood of in-hospital survival for 269 sequential intensive care unit admissions from the patient's intern or resident and the critical care fellow and attending physician on duty within 24 hours of admission, and compared these judgements with mortality data. By logistic regression, the residents' and fellows' judgments added independent prognostic information to each other (likelihood ratio chi 2, 7.6; df = 1). The junior house officers' and fellows' assessments were significantly less reliable than the attending physicians' by calibration curves, and by Brier scores, 0.126 and 0.127 vs 0.119. All physicians had good discriminating ability (receiver operating characteristic areas [SE] were 0.83 [0.03], 0.85 [0.03], 0.86 [0.03], respectively). A simple average of the residents' and fellows' judgments was slightly but significantly more reliable by calibration curve and by Brier score, 0.117, and as discriminating (ROC area = 0.85, SE = 0.03) as the attending physicians' judgments. Nonmedical studies have shown that averaging independent judgments may compensate for people's tendency to make extreme estimates, and may take advantage of their complementary abilities. This first medical application of this technique suggests that this form of voting by secret ballot may prove useful for health care teams making other judgments and decisions.

Prediction of survival of critically ill patients by admission comorbidity.

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

ARDS following acute lithium carbonate intoxication.

Lithium is a two-edged sword; it is on the one hand a unique drug with invaluable psychoactive potential and on the other a drug which can cause multisystem toxicity and even death. We present a case of severe lithium intoxication with multiple organ involvement. Our patient developed the adult respiratory distress syndrome (ARDS), nephrogenic diabetes insipidus (DI), distinctive neurological abnormalities, and hyperglycemia. We believe that this is a case of ARDS due to lithium toxicity in which elevated left atrial pressures were excluded by right heart catheterization and suggest a causal relationship between lithium and ARDS.

What difference do two days make? The inertia of physicians' sequential prognostic judgments for critically ill patients.

Medical authorities have asserted the importance of observing a patient's clinical course over time. Distinguished committees have suggested that changes over time in physicians' prognostic estimates should influence decisions to transfer patients out of intensive care units (ICUs). This study evaluated how the opportunity to observe patients over time affected physicians' prognostic estimates for a cohort of 269 critically ill patients sequentially admitted to a medical-surgical ICU in a teaching hospital. As soon as possible after admission and again 48 hours later, the authors obtained a quantitative estimate of the probability of survival through hospital discharge from each patient's house officer and primary attending physician, and the critical care attending physician on duty. They independently determined each patient's survival. From this population they analyzed 181 pairs of judgments made by the same house officers, 211 pairs by the same primary attendings, and 172 pairs by the same critical care attendings. The physicians' 48-hour estimates were little changed from their previous estimates for the same patients. The correlation coefficient for the house officers' paired estimates was 0.84 (p less than 0.0001); for the critical care attendings' estimates 0.84 (p less than 0.0001), and for the primary attendings' estimates, 0.90 (p less than 0.0001). Forty-eight hours did not substantially reduce the disagreements present between estimates made by different physicians for the same patient. No group of physicians substantially improved the reliability or the discriminating power of its later estimates. The physicians in the study could not take advantage of sequential clinical information over time. These results point out the need to teach physicians how to better integrate and process sequential clinical data.

Peritoneal catheterization.

Procedures involving invasion of the peritoneal cavity are often performed on critically ill or injured patients. Like any invasive procedure, they require a thorough understanding not only of their techniques and indications, but also of their contraindications and complications. Used appropriately, these procedures may serve as invaluable diagnostic or therapeutic tools in the care of acutely ill patients.

Long-term follow-up of ICU patients.

Critical care medicine programs must provide outpatient experience for their fellowship trainees. We have developed an unusual follow-up plan allowing critical care fellows to contact their patients months after their intensive care unit stay. We evaluated responses of 46 patients after a mean interval of 8.6 months since their initial intensive care unit stay. Patients were stratified by severity of disease by using the APACHE scoring system. Diagnostically, the patients represented the typical medical-surgical intensive care unit population. Patients were asked 11 questions concerning their health and socio-emotional status as it related to their hospitalization and intensive care unit stay. Our results established a practical method of providing outpatient follow-up that may fulfill residency review requirements for critical care fellowships, confirmed previously speculative ideas about ICU experiences, and suggested future research opportunities to study intensive care unit patients following discharge.

Occult metoprolol overdose.

A patient with an apparent dilantin and phenobarbital overdose displayed hypotension and oliguria resistant to usual cardiotonic drugs and volume loading. In addition, she required an unusually high dose of epinephrine for resuscitation. Metoprolol, a beta-blocker not included on the drug screen, was subsequently implicated. An overdose of this drug should be suspected in patients whose hypotension is resistant to usually effective doses of inotropic and chronotropic agents.

Reimbursement for intensive care services under diagnosis-related groups.

Current governmental policy, in an effort to reduce the federal deficit, has switched to a prospective payment system for hospital care of Medicare patients based on Diagnosis-Related Groups (DRGs). In New Jersey, all hospital care is reimbursed using a DRG system. This study examines the relationship between charges and reimbursement in a university hospital ICU under a DRG system for the care of patients who consume a large amount of the ICU resources. For patients who were classified Class IV under the Therapeutic Intervention Scoring System, with the possible exception of open heart patients, the charges for care delivered exceeded income received, with a net revenue of -$24,098 and an adjusted net revenue of -$5,057 for ICU Class IV patients (excluding open hearts). Thus, it appears that the care given to these patients may have resulted in a financial loss to the institution. If this were to continue, the financial impact might have a negative effect upon attempts to regionalize intensive care services.

Ego bias, reverse ego bias, and physicians' prognostic.

OBJECTIVE: To evaluate the effects of "ego bias" on physicians' prognostic judgments. Ego bias is defined as systematic overestimation of the prognosis of one's own patients compared with the expected outcome of a population of similar patients. DESIGN: A prospective study of an inception cohort of critically ill patients followed until death or discharge from the hospital. PATIENTS: Consecutive patients admitted to either an ICU or an intermediate ICU at a teaching hospital during January and February 1987, excluding patients admitted after coronary artery bypass grafting, for elective dialysis, or transferred to the intermediate ICU from another critical care unit. MAIN OUTCOME MEASURES AND COMPARISONS: House officers' and critical care attending physicians' assessments of the likelihood of inhospital survival for each patient, and their assessments of the overall survival rate of ICU and intermediate ICU patients were compared with each other and with actual survival rates. RESULTS: The attending physicians' predictions for individual patients were significantly lower than their judgments of the overall survival rate, 79.8% vs. 88.0%, p = .0067, suggesting the presence of a "reverse ego bias." The house officers' predictions for individual patients were significantly higher than their judgments of the overall survival rate, 73.5% vs. 68.9%, p = .018, suggesting the presence of ego bias. The magnitude and directions of these differences varied significantly among the attending physicians (F = 4.3, degrees of freedom = 3, p = .0062 by repeated-measures analysis of variance) and the house officers (F = 6.3, degrees of freedom = 5, p = .0001). CONCLUSIONS: The critical care attending physicians exhibited reverse ego bias that was mainly a function of their optimism about the overall survival rate for critically ill patients. The house officers exhibited ego bias that was mainly a function of their pessimism about the overall survival rate for critically ill patients.