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Diagnostic Uncertainty Among Critically Ill Children Admitted to the PICU: A Multicenter Study
Christina L Cifra1,2, Jason W Custer3, Craig M Smith4
1Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Insights
Diagnostic uncertainty is common in critically ill children admitted to the pediatric intensive care unit (PICU). Factors like off-hours admission and clinician disagreement increase this uncertainty, impacting diagnosis.
Area of Science:
- Pediatric Critical Care Medicine
- Diagnostic Error Research
- Clinical Informatics
Background:
- Diagnostic uncertainty is a significant challenge in pediatric intensive care units (PICUs).
- Understanding factors contributing to diagnostic uncertainty is crucial for developing strategies to reduce diagnostic errors in critically ill children.
- This study investigates the prevalence and associated factors of diagnostic uncertainty upon PICU admission.
Purpose of the Study:
- To determine the prevalence of diagnostic uncertainty in critically ill children admitted to the PICU.
- To identify patient, clinician, and encounter characteristics associated with diagnostic uncertainty at PICU admission.
- To inform interventions aimed at improving diagnostic accuracy in the PICU.
Main Methods:
- A multicenter retrospective cohort study was conducted across four academic tertiary-referral PICUs.
- Trained clinicians reviewed structured medical records of 882 randomly selected pediatric patients (0-18 years) using a standardized instrument to identify diagnostic uncertainty.
- Generalized linear mixed models were employed to analyze factors associated with diagnostic uncertainty at PICU admission.
Main Results:
- Diagnostic uncertainty was identified in 25.9% (228/882) of PICU admissions, decreasing over time but persisting in 6.6% at discharge.
- Factors significantly associated with diagnostic uncertainty included off-hours admission (OR, 1.52), greater severity of illness (OR, 1.04), atypical presentation (OR, 2.14), and diagnostic discordance between clinicians (OR, 3.62).
- Neurologic primary diagnoses were associated with uncertainty (OR, 1.87), while older patients and those with respiratory or trauma diagnoses were less likely to experience it.
Conclusions:
- Diagnostic uncertainty is prevalent upon PICU admission and linked to specific clinical and encounter factors.
- Off-hours admission, severe illness, atypical presentations, and clinician diagnostic discordance are key contributors.
- Further research into recognizing and managing diagnostic uncertainty is essential for improving diagnostic outcomes in critically ill children.
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.
