Factors influencing diagnostic accuracy among intensive care unit clinicians - an observational study.

OBJECTIVES: Diagnostic errors are a source of morbidity and mortality in intensive care unit (ICU) patients. However, contextual factors influencing clinicians' diagnostic performance have not been studied in authentic ICU settings. We sought to determine the accuracy of ICU clinicians' diagnostic impressions and to characterize how various contextual factors, including self-reported stress levels and perceptions about the patient's prognosis and complexity, impact diagnostic accuracy. We also explored diagnostic calibration, i.e. the balance of accuracy and confidence, among ICU clinicians. METHODS: We conducted an observational cohort study in an academic medical ICU. Between June and August 2019, we interviewed ICU clinicians during routine care about their patients' diagnoses, their confidence, and other contextual factors. Subsequently, using adjudicated final diagnoses as the reference standard, two investigators independently rated clinicians' diagnostic accuracy and on each patient on a given day ("patient-day") using 5-point Likert scales. We conducted analyses using both restrictive and conservative definitions of clinicians' accuracy based on the two reviewers' ratings of accuracy. RESULTS: We reviewed clinicians' responses for 464 unique patient-days, which included 255 total patients. Attending physicians had the greatest diagnostic accuracy (77-90 %, rated as three or higher on 5-point Likert scale) followed by the team's primary fellow (73-88 %). Attending physician and fellows were also least affected by contextual factors. Diagnostic calibration was greatest among ICU fellows. CONCLUSIONS: Additional studies are needed to better understand how contextual factors influence different clinicians' diagnostic reasoning in the ICU.

Diagnostic Yield of Combined Lumbar Puncture and Brain MRI in Critically Ill Patients With Unexplained Acute Encephalopathy: A Retrospective Cohort Study.

Critically ill patients frequently experience acute encephalopathy, often colloquially termed "altered mental status" (AMS); however, there are no consensus guidelines or criteria about performing lumbar puncture (LP) and advanced neuroimaging in medical ICU patients with unexplained encephalopathy. OBJECTIVES: We sought to characterize the yield of combined LP and brain MRI (bMRI) in such patients as determined by both the frequency of abnormal results and the therapeutic efficacy of these investigations, that is, how often results changed management. DESIGN SETTING AND PARTICIPANTS: Retrospective cohort study of medical ICU patients admitted to a tertiary academic center between 2012 and 2018 who had documented diagnoses of "AMS" and/or synonymous terms, no clear etiology of encephalopathy, and had undergone both LP and bMRI. MAIN OUTCOMES AND MEASURES: The primary outcome was the frequency of abnormal diagnostic testing results determined objectively for LP using cerebrospinal fluid (CSF) findings and subjectively for bMRI through team agreement on imaging findings deemed significant through retrospective chart review. We subjectively determined the frequency of therapeutic efficacy. Finally, we analyzed the effect of other clinical variables on the likelihood of discovering abnormal CSF and bMRI findings through chi-square tests and multivariate logistic regression. RESULTS: One hundred four patients met inclusion criteria. Fifty patients (48.1%) had an abnormal CSF profile or definitive microbiological or cytological data by LP, 44 patients (42.3%) had bMRI with significant abnormal findings, and 74 patients (71.2%) had abnormal results on at least one of these investigations. Few clinical variables were associated with the abnormal findings in either investigation. We judged 24.0% (25/104) of bMRI and 26.0% (27/104) of LPs to have therapeutic efficacy with moderate interobserver reliability. CONCLUSIONS: Determining when to perform combined LP and bMRI in ICU patients with unexplained acute encephalopathy must rely on clinical judgment. These investigations have a reasonable yield in this selected population.

Diagnostic Error in the Critically Ill: A Hidden Epidemic?

Epidemiologic studies of diagnostic error in the intensive care unit (ICU) consist mostly of descriptive autopsy series. In these studies, rates of diagnostic errors are approximately 5% to 10%. Recently validated methods for retrospectively measuring error have expanded our understanding of the scope of the problem. These alternative measurement strategies have yielded similar estimates for the frequency of diagnostic error in the ICU. Although there is a fair understanding of the frequency of errors, further research is needed to better define the risk factors for diagnostic error in the ICU.

Diagnostic Stewardship: Appropriate Testing and Judicious Treatments.

Diagnostic stewardship encompasses the entire diagnosis-to-treatment paradigm in the intensive care unit (ICU). Initially born of the antimicrobial stewardship movement, contemporary diagnostic stewardship aims to promote timely and appropriate diagnostic testing that directly links to management decisions. In the stewardship framework, excessive diagnostic testing in low probability cases is discouraged due to its tendency to generate false-positive results, which have their own downstream consequences. Though the evidence basis for diagnostic stewardship initiatives in the ICU is nascent and largely limited to retrospective analyses, available literature generally suggests that these initiatives are safe, feasible, and associated with similar patient outcomes. As diagnostic testing of critically ill patients becomes increasingly sophisticated in the ensuing decade, a stewardship mindset will aid bedside clinicians in interpreting and incorporating new diagnostic strategies in the ICU.

The Risks of Reflexive Refilling.

INTRODUCTION: The electronic health record and electronic prescribing have transformed the practice of medicine. Both have led to improved efficacy and safety in medication management. However, dangers may arise when electronic prescription requests are filled by default and when electronic health record medication lists are presumed accurate. In this case, our patient underwent 2 days of inpatient evaluation before a thorough medication reconciliation revealed that his symptoms had likely resulted from a medication that had been refilled reflexively. CASE PRESENTATION: A 69-year-old man presented with worsening weakness, weight loss, decreased appetite, and nonbloody diarrhea. Imaging revealed a large right pleural effusion and a nonspecific colitis. Lab workup revealed significant bicytopenia, hypogammaglobulinemia, and hypolipidemia. Initial evaluation and diagnoses were focused toward causes of malnutrition and malabsorption. However, on hospital day 2, a pharmacist discovered that the patient had been taking long-term oral linezolid for unclear reasons. With cessation of linezolid, the patient's myriad symptoms resolved and all lab values progressively normalized. DISCUSSION: The side effects of linezolid have been well documented and include reversible myelosuppression and gastrointestinal symptoms. However, medication reconciliation was imperative in diagnosing and treating our patient. Further, reflexive refilling of this patient's medication likely explains why he was taking linezolid for such a long period of time, as other forms of automation bias are known to introduce errors in electronic prescribing. CONCLUSION: This case calls attention to the importance of medication reconciliation, the danger of overreliance on electronic health record medication lists, and the pitfalls in not maintaining vigilance with electronic prescribing. It also highlights the necessity of patient and caregiver education regarding their medications.

Impact of Fellows-as-Teachers Workshops on Teaching Rounds: An Observational Study in an ICU.

During training, fellows serve as teachers and role models for junior colleagues. Fellows-as-teachers curricula may support these roles, but little is known about their effectiveness and durability. We sought to measure the long-term effects on ICU rounds after administering fellows-as-teachers workshops. DESIGN: Prospective pre-/postintervention observational study of ICU rounds. SETTING: Tertiary-care medical ICU with both pulmonary critical care and critical care medicine fellowships. SUBJECTS: ICU teaching teams. INTERVENTIONS: Fellows attended immersive workshops on promoting clinical reasoning, managing the learning environment, teaching bedside skills, and developing situational awareness on ICU rounds. After the workshops, faculty physicians were encouraged to have fellows routinely lead afternoon rounds. MEASUREMENTS AND MAIN RESULTS: We gathered data from direct observations of ICU rounding activities, residents' evaluations of rounds from surveys, and faculty physicians' written comments on fellows' performance in the ICU from end-of-rotation evaluations. Data were analyzed using descriptive statistics, nonparametric comparative tests, and chi-square tests for categorical data. A total of 61 ICU rounding sessions were observed with 501 discrete provider-patient interactions. Survey responses were collected from a total of 53 residents preintervention and 34 residents postintervention. We reviewed 72 open-ended faculty comments on fellows' end-of-rotation evaluations, with 22 occurring postintervention. During the postintervention period, fellows were significantly more likely to make clinical decisions, explain their reasoning, provide teaching points, and ask questions on rounds. Additionally, we observed significantly higher quality written feedback on end-of-rotation evaluations by faculty physicians. However, residents generally harbored neutral or negative perceptions about the educational value of fellow-led rounds postintervention. CONCLUSIONS: Fellows' contributions to patient care and teaching on ICU rounds increased for several months after our fellows-as-teachers workshops. Despite limitations and contamination in our design, our data suggest that similarly designed curricula may promote fellow engagement, possibly at the expense of residents' education.

Controversies in diagnosis: contemporary debates in the diagnostic safety literature.

Since the 2015 publication of the National Academy of Medicine's (NAM) Improving Diagnosis in Health Care (Improving Diagnosis in Health Care. In: Balogh EP, Miller BT, Ball JR, editors. Improving Diagnosis in Health Care. Washington (DC): National Academies Press, 2015.), literature in diagnostic safety has grown rapidly. This update was presented at the annual international meeting of the Society to Improve Diagnosis in Medicine (SIDM). We focused our literature search on articles published between 2016 and 2018 using keywords in Pubmed and the Agency for Healthcare Research and Quality (AHRQ)'s Patient Safety Network's running bibliography of diagnostic error literature (Diagnostic Errors Patient Safety Network: Agency for Healthcare Research and Quality; Available from: https://psnet.ahrq.gov/search?topic=Diagnostic-Errors&f_topicIDs=407). Three key topics emerged from our review of recent abstracts in diagnostic safety. First, definitions of diagnostic error and related concepts are evolving since the NAM's report. Second, medical educators are grappling with new approaches to teaching clinical reasoning and diagnosis. Finally, the potential of artificial intelligence (AI) to advance diagnostic excellence is coming to fruition. Here we present contemporary debates around these three topics in a pro/con format.

Frequency, Risk Factors, Causes, and Consequences of Diagnostic Errors in Critically Ill Medical Patients: A Retrospective Cohort Study.

OBJECTIVE: Diagnostic errors are a source of significant morbidity and mortality but understudied in the critically ill. We sought to characterize the frequency, causes, consequences, and risk factors of diagnostic errors among unplanned ICU admissions. DESIGN: We conducted a retrospective cohort study of randomly selected nonsurgical ICU admissions between July 2015 and June 2016. SETTING: Medical ICU at a tertiary academic medical center. SUBJECTS: Critically ill adults with unplanned admission to the medical ICU. MEASUREMENTS AND MAIN RESULTS: The primary investigator reviewed patient records using a modified version of the Safer Dx instrument, a validated instrument for detecting diagnostic error. Two intensivists performed secondary reviews of possible errors, and reviewers met periodically to adjudicate errors by consensus. For each confirmed error, we judged harm on a 1-6 rating scale. We also collected detailed demographic and clinical data for each patient. We analyzed 256 unplanned ICU admissions and identified 18 diagnostic errors (7% of admissions). All errors were associated with harm, and only six errors (33%) were recognized by the ICU team within the first 24 hours. More women than men experienced a diagnostic error (11.7% vs 2.7%; p = 0.015, χ test). On multivariable logistic regression analysis, female sex remained independently associated with risk of diagnostic error both at admission (odds ratio, 5.18; 95% CI, 1.34-20.08) and at 24 hours (odds ratio, 11.6; 95% CI, 1.37-98.6). Similarly, Quick Sequential Organ Failure Assessment score greater than or equal to 2 at admission was independently associated with diagnostic error (odds ratio, 5.73; 95% CI, 1.72-19.01). CONCLUSIONS: Diagnostic errors may be an underappreciated source of ICU-related harm. Women and higher acuity patients appear to be at increased risk for such errors. Further research is merited to define the scope of error-associated harm and to clarify risk factors for diagnostic errors among the critically ill.