An estimate of missed pediatric sepsis in the emergency department

Christina L. Cifra; Erik Westlund; Patrick Ten Eyck; Marcia M. Ward; Nicholas M. Mohr; David A. Katz

doi:10.1515/dx-2020-0023

Article

An estimate of missed pediatric sepsis in the emergency department

Christina L. Cifra , Erik Westlund , Patrick Ten Eyck , Marcia M. Ward , Nicholas M. Mohr and David A. Katz

Published/Copyright: March 19, 2020

Published by

Become an author with De Gruyter Brill

Submit Manuscript Author Information Explore this Subject

From the journal Diagnosis Volume 8 Issue 2

Abstract

Background

Timely diagnosis of pediatric sepsis remains elusive. We estimated the risk of potentially missed pediatric sepsis in US emergency departments (EDs) and determined factors associated with its occurrence.

Methods

In a retrospective study of linked inpatient and ED records from four states using administrative data (excluding 40% with missing identifiers), we identified children admitted with severe sepsis and/or septic shock who had at least one ED treat-and-release visit in the 7 days prior to sepsis admission. An expert panel rated the likelihood of each ED visit being related to subsequent sepsis admission. We used multivariable regression to identify associations with potentially missed sepsis.

Results

Of 1945 patients admitted with severe sepsis/septic shock, 158 [8.1%; 95% confidence interval (CI), 6.9%–9.4%] had potentially missed sepsis during an antecedent treat-and-release ED visit. The odds of potentially missed sepsis were lower for each additional comorbid chronic condition [odds ratio (OR), 0.86; 95% CI, 0.80–0.92] and higher in California (OR, 2.26; 95% CI, 1.34–3.82), Florida (OR, 3.33; 95% CI, 1.95–5.70), and Massachusetts (OR, 2.87; 95% CI, 1.35–6.09), compared to New York.

Conclusions

Administrative data can be used to screen large populations for potentially missed sepsis and identify cases that warrant detailed record review.

Keywords: diagnostic error; emergency department; misdiagnosis; pediatrics; sepsis

Corresponding author: Christina L. Cifra, MD, MS, Clinical Associate Professor, University of Iowa Carver College of Medicine, 200 Hawkins Drive, 8600-M JCP, Iowa City, IA 52242, USA, Phone: +(319)-384-8659

Acknowledgments

The authors thank the University of Iowa Institute for Clinical and Translational Science Bioinformatics Core (Heather Davis, James Schappet, and Nicholas Smith) for their assistance in downloading, preparing, and organizing data for this study. The authors also thank the members of their expert panel, Dr. Susan Feigelman, Dr. Charles Jennissen, and Dr. Veerajalandhar Allareddy, for lending their time and expertise. Finally, they thank Dr. David Newman-Toker for his valuable input into the overall design of this study.

Author contributions: CLC conceptualized and designed the study; acquired the databases used, collected, organized, analyzed, and interpreted the data; drafted the initial manuscript; and reviewed and revised the manuscript. EW and PTE contributed to the conception and design of the study; organized, analyzed, and interpreted the data; and reviewed the manuscript. MMW, NMM, and DAK contributed to the conception and design of the study, supervised data collection and organization, interpreted the data, and critically reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Research funding: All phases of this study were supported by the Children’s Miracle Network-University of Iowa Department of Pediatrics Research Grant. Support for informatics and statistical analysis was provided through a National Institutes of Health (NIH) Clinical and Translational Science Award Funder Id: http://dx.doi.org/10.13039/100006108, #UL1TR002537. Additionally, CLC is supported by an NIH Institutional K12 Funder Id: http://dx.doi.org/10.13039/100009633, grant #HD027748, and NMM is supported by an Agency for Healthcare Research and Quality K08 grant #HS025753, Funder Id: http://dx.doi.org/10.13039/100000133. The content of this work is solely the responsibility of the authors and does not necessarily represent the official views of these funding agencies.
Employment or leadership: None declared.
Honorarium: None declared.
Competing interests: None declared.
Competing interests: The funding organization(s) played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the report for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

References

1. Murphy SL, Mathews TJ, Martin JA, Minkovitz CS, Strobino DM. Annual summary of vital statistics: 2013–2014. Pediatrics 2017;139:e20163229.10.1542/peds.2016-3239Search in Google Scholar PubMed

2. Hartman ME, Linde-Zwirble WT, Angus DC, Watson RS. Trends in the epidemiology of pediatric severe sepsis. Pediatr Crit Care Med. 2013;14:686–93.10.1097/PCC.0b013e3182917fadSearch in Google Scholar PubMed

3. Seymour CW, Gesten F, Prescott HC, Friedrich ME, Iwashyna TJ, Phillips GS, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med 2017;376:2235–44.10.1056/NEJMoa1703058Search in Google Scholar PubMed PubMed Central

4. Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, et al. Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PLoS One 2015;10:e0125827.10.1371/journal.pone.0125827Search in Google Scholar PubMed PubMed Central

5. Liberman AL, Newman-Toker DE. Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 2018;27:557–66.10.1136/bmjqs-2017-007032Search in Google Scholar PubMed PubMed Central

6. Healthcare Cost and Utilization Project (HCUP) [Internet] [cited 2015 Aug 10]. Available from: http://www.ahrq.gov/research/data/hcup/.Search in Google Scholar

7. Access comprehensive hospital data with AHA Annual Survey Database [Internet]. AHA Data [cited 2019 Feb 14]. Available from: http://www.ahadata.com/aha-annual-survey-database-asdb/.Search in Google Scholar

8. Balamuth F, Weiss SL, Hall M, Neuman MI, Scott H, Brady PW, et al. Identifying pediatric severe sepsis and septic shock: accuracy of diagnosis codes. J Pediatr 2015;167:1295–1300.e4.10.1016/j.jpeds.2015.09.027Search in Google Scholar PubMed PubMed Central

9. Bamber AR, Mifsud W, Wolfe I, Cass H, Pryce J, Malone M, et al. Potentially preventable infant and child deaths identified at autopsy; findings and implications. Forensic Sci Med Pathol 2015;11:358–64.10.1007/s12024-015-9681-9Search in Google Scholar PubMed

10. Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. Br Med J 2009;338:b2393.10.1136/bmj.b2393Search in Google Scholar PubMed PubMed Central

11. Scott HF, Greenwald EE, Bajaj L, Deakyne Davies SJ, Brou L, Kempe A. The sensitivity of clinician diagnosis of sepsis in tertiary and community-based emergency settings. J Pediatr 2018;195:220–7.e1.10.1016/j.jpeds.2017.11.030Search in Google Scholar PubMed

12. Balamuth F, Alpern ER, Grundmeier RW, Chilutti M, Weiss SL, Fitzgerald JC, et al. Comparison of two sepsis recognition methods in a pediatric emergency department. Acad Emerg Med 2015;22:1298–306.10.1111/acem.12814Search in Google Scholar PubMed PubMed Central

13. Vaillancourt S, Guttmann A, Li Q, Chan IY, Vermeulen MJ, Schull MJ. Repeated emergency department visits among children admitted with meningitis or septicemia: a population-based study. Ann Emerg Med 2015;65:625–32.e3.10.1016/j.annemergmed.2014.10.022Search in Google Scholar PubMed

14. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis 2014;1:155–66.10.1515/dx-2013-0038Search in Google Scholar PubMed PubMed Central

15. Moy E, Barrette M, Coffey R, Hines AL, Newman-Toker DE. Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics. Diagnosis 2015;2:29–40.10.1515/dx-2014-0053Search in Google Scholar PubMed

Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/dx-2020-0023).

Received: 2020-02-07

Accepted: 2020-02-19

Published Online: 2020-03-19

Published in Print: 2021-05-26

You are currently not able to access this content.

Supplementary material

Articles in the same Issue

https://doi.org/10.1515/dx-2020-0023

Keywords for this article

diagnostic error; emergency department; misdiagnosis; pediatrics; sepsis