Emergency Physicians Should Trust Own Judgment

A new study suggests that physicians in emergency departments (EDs) should consult with other physicians against discharge when they feel strongly about a patient for whom there is no compelling data, other than their own evaluation and judgment.

Researchers at Duke University Medical Center (Duke, Durham, NC, USA) conducted a post-hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. Following the recording of patient history, a physical exam, and an electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The data were stratified by unstructured physician risk estimate as: noncardiac, low risk, high risk, or unstable angina.

The results showed that of the 10,145 patients evaluated, 6% were defined by the physicians as having unstable angina; 23.5% of the patients were classified as high risk; 44.2% as low risk; and 26.3% were classified as noncardiac cases. Adverse cardiac event rates had an inverse relationship to physician ranking, decreasing from 22% for unstable angina, 10.2% for those stratified as high risk, 2.2% for low risk, and to 1.8% for noncardiac. The researchers also evaluated data on 524 patients who were discharged home from the group which were assessed as high risk, five of whom had a major adverse outcome within 30 days. The researchers then evaluated the resulting relative risk (RR) of an adverse cardiac event and found that the RR for those for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2. The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was four. The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression. The study was published in the August 2009 issue of Academic Emergency Medicine.

"There is evidence for emergency room physicians to trust their gut instinct when they have to make a quick decision about a potential heart patient, before lab results are even returned,” said lead author Abhinav Chandra, M.D., director of acute care research and of the clinical evaluation unit in the Duke Division of Emergency Medicine. "Sometimes these patients could be better served by staying at the hospital and having more tests rather than being treated and released or discharged.”

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Duke University Medical Center