title: Physician's first clinical impression of emergency department patients with nonspecific complaints is associated with morbidity and mortality.
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.
authors.affiliation: From the Department of Emergency Medicine, University Hospital Basel, Switzerland (BB, MR, SA, JI, SB, CN, RB); Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany (RH); and Department of Emergency Medicine, Hospital of Liestal, Switzerland (NG).
authors.forename: Bettina
authors.initials: B
authors.lastname: Beglinger
authors.forename: Martin
authors.initials: M
authors.lastname: Rohacek
authors.forename: Selina
authors.initials: S
authors.lastname: Ackermann
authors.forename: Ralph
authors.initials: R
authors.lastname: Hertwig
authors.forename: Julia
authors.initials: J
authors.lastname: Karakoumis-Ilsemann
authors.forename: Susanne
authors.initials: S
authors.lastname: Boutellier
authors.forename: Nicolas
authors.initials: N
authors.lastname: Geigy
authors.forename: Christian
authors.initials: C
authors.lastname: Nickel
authors.forename: Roland
authors.initials: R
authors.lastname: Bingisser
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D009017:Morbidity; D010820:Physicians / Q000523:psychology* / Q000706:statistics & numerical data*; D011379:Prognosis; D011446:Prospective Studies; D012720:Severity of Illness Index; D012737:Sex Factors