Emergency department patients with weakness or fatigue: Can physicians predict their outcomes at the front door? A prospective observational study

Abstract

Background Generalized weakness and fatigue are underexplored symptoms in emergency medicine. Triage tools often underestimate patients presenting to the emergency department (ED) with these nonspecific symptoms (Nemec et al., 2010). At the same time, physicians’ disease severity rating (DSR) on a scale from 0 (not sick at all) to 10 (extremely sick) predicts key outcomes in ED patients (Beglinger et al., 2015; Rohacek et al., 2015). Our goals were (1) to characterize ED patients with weakness and/or fatigue (W|F); to explore (2) to what extent physicians’ DSR at triage can predict five key outcomes in ED patients with W|F; (3) how well DSR performs relative to two commonly used benchmark methods, the Emergency Severity Index (ESI) and the Charlson Comorbidity Index (CCI); (4) to what extent DSR provides predictive information beyond ESI, CCI, or their linear combination, i.e., whether ESI and CCI should be used alone or in combination with DSR; and (5) to what extent ESI, CCI, or their linear combination provide predictive information beyond DSR alone, i.e., whether DSR should be used alone or in combination with ESI and / or CCI. Methods Prospective observational study between 2013–2015 (analysis in 2018–2020, study team blinded to hypothesis) conducted at a single center. We study an all-comer cohort of 3,960 patients (48% female patients, median age = 51 years, 94% completed 1-year follow-up). We looked at two primary outcomes (acute morbidity (Bingisser et al., 2017; Weigel et al., 2017) and all-cause 1- year mortality) and three secondary outcomes (in-hospital mortality, hospitalization and transfer to ICU). We assessed the predictive power (i.e., resolution, measured as the Area under the ROC Curve, AUC) of the scores and, using logistic regression, their linear combinations. Findings Compared to patients without W|F (n = 3,227), patients with W|F (n = 733) showed higher prevalences for all five outcomes, reported more symptoms across both genders, and received higher DSRs (median = 4; interquartile range (IQR) = 3–6 vs. median = 3; IQR = 2–5). DSR predicted all five outcomes well above chance (i.e., AUCs > ~0.70), similarly well for both patients with and without W|F, and as good as or better than ESI and CCI in patients with and without W|F (except for 1-year mortality where CCI performs better). For acute morbidity, hospitalization, and transfer to ICU there is clear evidence that adding DSR to ESI and/or CCI improves predictions for both patient groups; for 1-year mortality and in-hospital mortality this holds for most, but not all comparisons. Adding ESI and/or CCI to DSR generally did not improve performance or even decreased it. Conclusions The use of physicians’ disease severity rating has never been investigated in patients with generalized weakness and fatigue. We show that physicians’ prediction of acute morbidity, mortality, hospitalization, and transfer to ICU through their DSR is also accurate in these patients. Across all patients, DSR is less predictive of acute morbidity for female than male patients, however. Future research should investigate how emergency physicians judge their patients’ clinical state at triage and how this can be improved and used in simple decision aids.

Mortality Prediction in Hip Fracture Patients: Physician Assessment Versus Prognostic Models

“…17 Several studies have investigated physician assessment of mortality risk in patients admitted to the ED. Herzog et al 40 reported accurate physician prediction of mortality in patients admitted with generalized weakness and fatigue. Similarly, Zelis et al 20 found that clinical intuition documented at admission could predict mortality and other adverse outcomes in older patients.…”

Fatigue in Heart Failure

“…The relationship between fatigue and hospitalization risk is also consistent in the literature for numerous disease processes. Herzog et al 92 found that weakness and/ or fatigue can predict hospitalization and transfer to intensive care units in patients assessed in the emergency department setting regardless of disease process. Thus, fatigue may be an indicator of disease severity and a predictor of patient outcomes and should therefore be addressed as a priority symptom.…”

The Undertriage of Older Adults in the Emergency Department

“…This has been concluded in other investigations. For example, Herzog, Jenny, Nickel, Nieves-Ortega, and Bingisser. (2020) found that a physician's "impression" of acute morbidity and mortality in patients presenting to the ED with generalized weakness and fatigue accurately predicted mortality, hospitalization, and transfer to the intensive care unit.…”