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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.
Critical Care Medicine
|November 25, 2024
Summary
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.
