The surprise question: predictive accuracy in an unselected emergency department population - a prospective study in...

The 'surprise question' (SQ) asks care professionals to assess the patient's mortality risk. In this prospective study, we investigated 1) the prognostic accuracy of the SQ regarding 3- and 12-month mortality (SQ³/SQ¹²) answered by nurses and physicians in unselected adult emergency department (ED) patients, and in high risk subgroups (age ≥ 50 y; medical patients), 2) the agreement between these care professionals.

In this prospective study, the SQ³ and SQ¹² were scored by nurses and physicians. AU-ROC, sensitivity, specificity, and negative predictive value (NPV) were calculated.Kappa values and absolute agreement were calculated.

In total, 1958 patients were assessed. Mortality within 12 months was 13.9% in all patients (8.3% within 3 months), 22.9% in older and 20.1% in medical patients. The AU-ROC of the SQ³ was 0.639 and 0.698 for nurses and physicians, resp., and that of the SQ¹² was 0.722 and 0.847, resp. For SQ³, sensitivity was 46.8-48.0%, and specificity 93.9-95.1%, with high NPV (95.6-97.0%). For SQ¹², sensitivity was higher (54.1-60.8%), with specificity of 83.4-96.4%, and high NPV. AU-ROCs for the two high risk subgroups were comparable. Agreement was fair (kappa 0.255) for SQ³, and moderate (kappa 0.461) for SQ¹², while absolute agreement was 91.4% and 80.5%, resp.

The study supports the SQ as a simple prognostic tool in the ED, with 12-month prognostic accuracy being especially reliable in high-risk patients. The agreement between nurses and physicians was fair-moderate. The SQ could play an important role in guiding ED care, especially in high-risk patients.