Diagnostic Uncertainty Among Critically Ill Children Admitted to the PICU: A Multicenter Study.

Autor:	Cifra CL; Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.; Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA., Custer JW; Division of Critical Care, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD., Smith CM; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL., Smith KA; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI., Bagdure DN; Department of Pediatrics, Louisiana State University Health Shreveport School of Medicine, Shreveport, LA., Bloxham J; University of Iowa College of Nursing, Iowa City, IA., Goldhar E; Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL., Gorga SM; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI., Hoppe EM; Pediatric Intensive Care Unit, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL., Miller CD; Department of Pediatrics, Section of Critical Care, University of Colorado School of Medicine, Aurora, CO., Pizzo M; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.; University of Michigan School of Nursing, Ann Arbor, MI., Ramesh S; Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, Kansas City, MO., Riffe J; Department of Pediatrics, Family First Health, York, PA., Robb K; Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA., Simone SL; University of Maryland School of Nursing, Baltimore, MD., Stoll HD; University of Iowa College of Nursing, Iowa City, IA., Tumulty JA; Pediatric Intensive Care Unit, University of Maryland Children's Hospital, Baltimore, MD., Wall SE; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.; University of Michigan School of Nursing, Ann Arbor, MI., Wolfe KK; Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO., Wendt L; Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA., Ten Eyck P; Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA.; Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA., Landrigan CP; Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.; Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA., Dawson JD; Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA., Reisinger HS; Institute for Clinical and Translational Science, University of Iowa, Iowa City, IA.; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.; Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA., Singh H; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX., Herwaldt LA; Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA.; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
Jazyk:	angličtina
Zdroj:	Critical care medicine [Crit Care Med] 2024 Nov 25. Date of Electronic Publication: 2024 Nov 25.
DOI:	10.1097/CCM.0000000000006511
Abstrakt:	Objectives: This study aimed to identify the prevalence of and factors associated with diagnostic uncertainty when critically ill children are admitted to the PICU. Understanding diagnostic uncertainty is necessary to develop effective strategies to reduce diagnostic errors in the PICU. Design: Multicenter retrospective cohort study with structured medical record review by trained clinicians using a standardized instrument to identify diagnostic uncertainty in narrative clinical notes. Diagnoses and diagnostic uncertainty were compared across time from PICU admission to hospital discharge. Generalized linear mixed models were used to determine patient, clinician, and encounter characteristics associated with diagnostic uncertainty at PICU admission. Setting: Four academic tertiary-referral PICUs. Patients: Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs. Interventions: None. Measurements and Main Results: PICU admission notes for 228 of 882 patients (25.9%) indicated diagnostic uncertainty. Patients with uncertainty decreased over time but 58 (6.6%) had remaining diagnostic uncertainty at hospital discharge. Multivariable analysis showed that diagnostic uncertainty was significantly associated with off hours admission (odds ratio [OR], 1.52; p = 0.037), greater severity of illness (OR, 1.04; p = 0.025), an atypical presentation (OR, 2.14; p = 0.046), diagnostic discordance at admission between attending intensivists and resident physicians/advanced practice providers (OR, 3.62; p < 0.001), and having a neurologic primary diagnosis (OR, 1.87; p = 0.03). Older patients (OR, 0.96; p = 0.014) and those with a respiratory (OR, 0.58; p = 0.009) or trauma primary diagnosis (OR, 0.08; p < 0.001) were less likely to have diagnostic uncertainty. There were no significant associations between diagnostic uncertainty and attending intensivists' characteristics. Conclusions: Diagnostic uncertainty at PICU admission was common and was associated with off hours admission, severe illness, atypical presentation, diagnostic discordance between clinicians, and a neurologic primary diagnosis. Further study on the recognition and management of diagnostic uncertainty is needed to inform interventions to improve diagnosis among critically ill children. Competing Interests: Dr. Landrigan has consulted with and holds equity in the I-PASS (Handoff elements mnemonic: I-illness severity, P-patient summary, A-action items, S-situation awareness, S-synthesis) Institute, which seeks to train institutions in best handoff practices and aid in their implementation. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety; he has served as an expert witness in cases regarding patient safety and sleep deprivation; and he received funding from the Agency for Healthcare Research and Quality (AHRQ). Drs. Cifra’s, K. A. Smith’s, Bloxham’s, Hoppe’s, Miller’s, Riffe’s, Robb’s, Simone’s, Tumulty’s, Dawson’s, and Herwaldt’s institutions received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the AHRQ, and the National Center for Advancing Translational Sciences. Drs. Cifra, Bloxham, Miller, and Tumulty received funding from the AHRQ, MedStar Research Institute, and De Gruyter. Drs. Cifra, C. M. Smith, K. A. Smith, Bagdure, Bloxham, Goldhar, Hoppe, Miller, Pizzo, Riffe, Robb, Tumulty, Wolfe, Wendt, Eyck, Dawson, Reisingerr, Singh, and Herwaldt received support for article research from the National Institutes of Health. Dr. Gorga disclosed institutional grant funding. Dr. Ten Eyck disclosed work for hire. Dr. Dawson received funding from Neurosurgery, the University of Nebraska Medical Center, and IotaSoft. Dr. Singh is supported in part by the AHRQ (R01HS028595 and R18HS029347), the Houston Veterans Administration (VA) Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety (CIN 13–413), and the VA National Center for Patient Safety; he disclosed government work. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of the VA or the U.S. government. Dr. Herwaldt’s institution received funding from the Centers for Disease Control and Prevention. The remaining authors have disclosed that they do not have any potential conflicts of interest. (Copyright © 2024 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)
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