Acute internal medicine physicians' clinical intuition based on acute care telephone referral: A prospective study

• Published in: PloS one Vol. 19; no. 6; p. e0305566
• Main Authors: van Dam, Paul M E L, Lasso Peña, Roberto E, Mommertz, Jody A, Borggreve, Hella F, van Loon, Nicole P H, Zelis, Noortje, Westerman, Dewa, Henry, Ronald M A, Posthouwer, Dirk, Cals, Jochen W L, Stassen, Patricia M
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 14.06.2024; Public Library of Science (PLoS)
• Subjects: Adult; Aged; Aged, 80 and over; Comorbidity; Data collection; Diagnostic tests; Emergency medical care; Emergency medical services; Emergency Service, Hospital; Family physicians; Female; Gastroenterology; Hospitals; Humans; Illnesses; Internal Medicine; Intuition; Male; Medical personnel; Medical records; Medical referrals; Medical research; Medicine; Medicine and Health Sciences; Medicine, Experimental; Middle Aged; Mortality; Netherlands; Patients; People and Places; Physical Sciences; Physicians; Prospective Studies; Questionnaires; Referral and Consultation; Regression analysis; Research and Analysis Methods; ROC Curve; Telephone; Triage - methods; Netherlands
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0305566

In the Netherlands, most emergency department (ED) patients are referred by a general practitioner (GP) or a hospital specialist. Early risk stratification during telephone referral could allow the physician to assess the severity of the patients' illness in the prehospital setting. We aim to assess the discriminatory value of the acute internal medicine (AIM) physicians' clinical intuition based on telephone referral of ED patients to predict short-term adverse outcomes, and to investigate on which information their predictions are based. In this prospective study, we included adult ED patients who were referred for internal medicine by a GP or a hospital specialist. Primary outcomes were hospital admission and triage category according to the Manchester Triage System (MTS). Secondary outcome was 31-day mortality. The discriminatory performance of the clinical intuition was assessed using an area under the receiver operating characteristics curve (AUC). To identify which information is important to predict adverse outcomes, we performed univariate regression analysis. Agreement between predicted and observed MTS triage category was assessed using intraclass and Spearman's correlation. We included 333 patients, of whom 172 (51.7%) were referred by a GP, 146 (43.8%) by a hospital specialist, and 12 (3.6%) by another health professional. The AIM physician's clinical intuition showed good discriminatory performance regarding hospital admission (AUC 0.72, 95% CI: 0.66-0.78) and 31-day mortality (AUC 0.73, 95% CI: 0.64-0.81). Univariate regression analysis showed that age ≥65 years and a sense of alarm were significant predictors. The predicted and observed triage category were similar in 45.2%, but in 92.5% the prediction did not deviate by more than one category. Intraclass and Spearman's correlation showed fair agreement between predicted and observed triage category (ICC 0.48, Spearman's 0.29). Clinical intuition based on relevant information during a telephone referral can be used to accurately predict short-term outcomes, allowing for early risk stratification in the prehospital setting and managing ED patient flow more effectively.