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

Christina L. Cifra*, Jason W. Custer, Craig M. Smith, Kristen A. Smith, Dayanand N. Bagdure, Jodi Bloxham, Emily Goldhar, Stephen M. Gorga, Elizabeth M. Hoppe, Christina D. Miller, Max Pizzo, Sonali Ramesh, Joseph Riffe, Katharine Robb, Shari L. Simone, Haley D. Stoll, Jamie Ann Tumulty, Stephanie E. Wall, Katie Knoedelseder Wolfe, Linder WendtPatrick Ten Eyck, Christopher P. Landrigan, Jeffrey D. Dawson, Heather Schacht Reisinger, Hardeep Singh, Loreen A. Herwaldt

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

Abstract

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.

Original languageEnglish (US)
Article number10.1097/CCM.0000000000006511
JournalCritical care medicine
DOIs
StateAccepted/In press - 2024

Funding

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\u2019s, K. A. Smith\u2019s, Bloxham\u2019s, Hoppe\u2019s, Miller\u2019s, Riffe\u2019s, Robb\u2019s, Simone\u2019s, Tumulty\u2019s, Dawson\u2019s, and Herwaldt\u2019s 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\u2013413), 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\u2019s 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. This work and the article\u2019s first author, Dr. Cifra, was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development through a K12 grant to the University of Iowa Stead Family Department of Pediatrics (No. HD027748-28), Agency for Healthcare Research and Quality through a K08 grant (No. HS026965), and internal start-up grants from the University of Iowa Carver College of Medicine Department of Pediatrics and the Boston Children\u2019s Hospital Division of Medical Critical Care. This work was further supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (No. UM1TR004403) through the University of Iowa\u2019s Institute for Clinical and Translational Science.

Keywords

  • critical care
  • diagnostic error
  • patient safety
  • pediatrics
  • quality improvement

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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