OBJECTIVE: Few reliable and valid prognostic tools are available to help emergency physicians identify patients who might benefit from early palliative approaches. We sought to determine if responses to a modified version of the surprise question, “Would you be surprised if this patient died in the next 30 days” could predict in-hospital mortality and resource utilization for hospitalized emergency department patients.METHODS: For this observational study, emergency physicians responded to the modified surprise question with each admission over a five-month study period. Logistic regression analyses were completed and standard test characteristics evaluated.RESULTS: 6,122 visits were evaluated. Emergency physicians responded negatively to the modified surprise question in 918 (15.1%). Test characteristics for in-hospital mortality were: sensitivity 32%, specificity 85%, positive predictive value 6%, negative predictive value 98%. The risk of intensive care unit use (relative risk [RR], 1.87; 95% confidence interval [CI], 1.45 to 2.40), use of ‘comfort measures’ orders (RR, 3.43; 95% CI, 2.81 to 4.18), palliative-care consultation (RR, 3.06; 95% CI, 2.62 to 3.56), and in-hospital mortality (RR, 2.18; 95% CI, 1.72 to 2.76) were greater for patients with negative responses.CONCLUSION: The modified surprise question is a simple trigger for palliative care needs, accurately identifying those at greater risk for in-hospital mortality and resource utilization. With a negative predictive value of 98%, affirmative responses to the modified surprise question provide reassurance that in-hospital death is unlikely.
Emergencies ; Emergency Service, Hospital ; Hospital Mortality ; Humans ; Intensive Care Units ; Logistic Models ; Observational Study ; Palliative Care ; Palliative Medicine ; Sensitivity and Specificity ; Terminal Care

PURPOSE: Prior descriptions of the psychometric properties of validated knowledge assessment tools designed to determine Emergency medicine (EM) residents understanding of physiologic and clinical concepts related to mechanical ventilation are lacking. In this setting, we have performed this study to describe the psychometric and performance properties of a novel knowledge assessment tool that measures EM residents' knowledge of topics in mechanical ventilation. METHODS: Results from a multicenter, prospective, survey study involving 219 EM residents from 8 academic hospitals in northeastern United States were analyzed to quantify reliability, item difficulty, and item discrimination of each of the 9 questions included in the knowledge assessment tool for 3 weeks, beginning in January 2013. RESULTS: The response rate for residents completing the knowledge assessment tool was 68.6% (214 out of 312 EM residents). Reliability was assessed by both Cronbach's alpha coefficient (0.6293) and the Spearman-Brown coefficient (0.6437). Item difficulty ranged from 0.39 to 0.96, with a mean item difficulty of 0.75 for all 9 questions. Uncorrected item discrimination values ranged from 0.111 to 0.556. Corrected item-total correlations were determined by removing the question being assessed from analysis, resulting in a range of item discrimination from 0.139 to 0.498. CONCLUSION: Reliability, item difficulty and item discrimination were within satisfactory ranges in this study, demonstrating acceptable psychometric properties of this knowledge assessment tool. This assessment indicates that this knowledge assessment tool is sufficiently rigorous for use in future research studies or for assessment of EM residents for evaluative purposes.
Discrimination (Psychology) ; Emergencies* ; Emergency Medicine* ; New England* ; Prospective Studies ; Psychometrics* ; Reproducibility of Results ; Respiration, Artificial* ; United States