The surprise question: predictive accuracy in an unselected emergency department population – a prospective study in nurses and physicians

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.