Startseite Medizin Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
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Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system

  • Michael A. Horberg EMAIL logo , Najlla Nassery , Kevin B. Rubenstein , Julia M. Certa ORCID logo , Ejaz A. Shamim , Richard Rothman , Zheyu Wang , Ahmed Hassoon , Jennifer L. Townsend , Panagis Galiatsatos , Samantha I. Pitts und David E. Newman-Toker
Veröffentlicht/Copyright: 26. April 2021
Diagnosis
Aus der Zeitschrift Diagnosis Band 8 Heft 4

Abstract

Objectives

Delays in sepsis diagnosis can increase morbidity and mortality. Previously, we performed a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-back” analysis to identify symptoms at risk for delayed sepsis diagnosis. We found treat-and-release emergency department (ED) encounters for fluid and electrolyte disorders (FED) and altered mental status (AMS) were associated with downstream sepsis hospitalizations. In this “look-forward” analysis, we measure the potential misdiagnosis-related harm rate for sepsis among patients with these symptoms.

Methods

Retrospective cohort study using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (2013–2018). Patients ≥18 years with ≥1 treat-and-release ED encounter for FED or AMS were included. Observed greater than expected sepsis hospitalizations within 30 days of ED treat-and-release encounters were considered potential misdiagnosis-related harms. Temporal analyses were employed to differentiate case and comparison (superficial injury/contusion ED encounters) cohorts.

Results

There were 4,549 treat-and-release ED encounters for FED or AMS, 26 associated with a sepsis hospitalization in the next 30 days. The observed (0.57%) minus expected (0.13%) harm rate was 0.44% (absolute) and 4.5-fold increased over expected (relative). There was a spike in sepsis hospitalizations in the week following FED/AMS ED visits. There were fewer sepsis hospitalizations and no spike in admissions in the week following superficial injury/contusion ED visits. Potentially misdiagnosed patients were older and more medically complex.

Conclusions

Potential misdiagnosis-related harms from sepsis are infrequent but measurable using SPADE. This look-forward analysis validated our previous look-back study, demonstrating the SPADE approach can be used to study infectious disease syndromes.

Keywords: delirium; diagnostic error; emergency medical services; health services research; sepsis; water-electrolyte balance
Corresponding author: Michael A. Horberg, MD, MAS, Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 East Jefferson St., 3-East, Rockville, MD 20852, USA; and Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA, Phone: +1 301 852 9307, E-mail:
Michael A. Horberg and Najlla Nassery contributed equally to the work and wish to be listed as co-first authors.

Funding source: Gordon and Betty Moore Foundation

Award Identifier / Grant number: GBMF5756

Acknowledgments

We would like to thank Carla V. Rodriguez-Watson, PhD (formerly of KPMAS) and Yuxin Zhu, PhD (Johns Hopkins) for their contributions to this project, and the patients of Kaiser Permanente for helping us improve care using information collected via the electronic health record system.

  1. Research funding: This journal article was supported by a sub-agreement from the Johns Hopkins University with funds provided by Grant No. #GBMF5756 from the Gordon and Betty Moore Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Gordon and Betty Moore Foundation or the Johns Hopkins University. Dr. Newman-Toker’s effort was supported partly by the Armstrong Institute Center for Diagnostic Excellence at the Johns Hopkins University School of Medicine.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Dr. Newman-Toker conducts research related to diagnostic error, including serving as the principal investigator for grants on this topic. He serves as an unpaid member of the Board of Directors of the Society to Improve Diagnosis in Medicine and as its President (2018–2020). He serves as a medico-legal consultant for both plaintiff and defense in cases related to diagnostic error. There are no other conflicts of interest. None of the authors have any financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work.

  4. Informed consent: Informed consent requirement was waived by the KPMAS Institutional Review Board.

  5. Ethical approval: This study was approved with waived informed consent by the KP Mid-Atlantic States (KPMAS) Institutional Review Board.

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Supplementary Material

The online version of this article offers supplementary material (https://doi.org/10.1515/dx-2020-0145).

Received: 2020-10-29
Accepted: 2021-03-16
Published Online: 2021-04-26
Published in Print: 2021-11-25

© 2021 Walter de Gruyter GmbH, Berlin/Boston

Artikel in diesem Heft

  1. Frontmatter
  2. Reviews
  3. An overview of mental health during the COVID-19 pandemic
  4. Potential mechanisms of action of convalescent plasma in COVID-19
  5. Mini Review
  6. Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education
  7. Opinion Papers
  8. Learning clinical reasoning from the fictional detectives
  9. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal
  10. (F)utility of urine Bence Jones proteins for “routine” screening for plasma cell dyscrasia
  11. COVID-19 and the Le Chatelier’s principle
  12. Original Articles
  13. Are sniffer dogs a reliable approach for diagnosing SARS-CoV-2 infection?
  14. Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients
  15. Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool
  16. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology
  17. Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
  18. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study
  19. Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
  20. Postnatal ultrasound follow-up in neonates with prenatal hydronephrosis
  21. Clinical performance of amperometry compared with enzymatic ultra violet method for lactate quantification in cerebrospinal fluid
  22. Case Report – Lessons in Clinical Reasoning
  23. Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error
  24. Case Report
  25. The COVID trap: pediatric diagnostic errors in a pandemic world
  26. Letters to the Editor
  27. Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis
  28. Serious game training in medical education: potential to mitigate cognitive biases of healthcare professionals
  29. Revisiting handoffs: an opportunity to prevent error
https://doi.org/10.1515/dx-2020-0145
Schlagwörter für diesen Artikel
delirium; diagnostic error; emergency medical services; health services research; sepsis; water-electrolyte balance

Artikel in diesem Heft

  1. Frontmatter
  2. Reviews
  3. An overview of mental health during the COVID-19 pandemic
  4. Potential mechanisms of action of convalescent plasma in COVID-19
  5. Mini Review
  6. Gap of knowledge in diagnosis of pyoderma gangrenosum in clinical specialties education
  7. Opinion Papers
  8. Learning clinical reasoning from the fictional detectives
  9. Integrating infection and sepsis management through holistic early warning systems and heuristic approaches: a concept proposal
  10. (F)utility of urine Bence Jones proteins for “routine” screening for plasma cell dyscrasia
  11. COVID-19 and the Le Chatelier’s principle
  12. Original Articles
  13. Are sniffer dogs a reliable approach for diagnosing SARS-CoV-2 infection?
  14. Using body temperature and variables commonly available in the EHR to predict acute infection: a proof-of-concept study showing improved pretest probability estimates for acute COVID-19 infection among discharged emergency department patients
  15. Identifying children at high risk for infection-related decompensation using a predictive emergency department-based electronic assessment tool
  16. Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology
  17. Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology in an integrated health system
  18. Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study
  19. Overutilization and underutilization of autoantibody tests in patients with suspected autoimmune disorders
  20. Postnatal ultrasound follow-up in neonates with prenatal hydronephrosis
  21. Clinical performance of amperometry compared with enzymatic ultra violet method for lactate quantification in cerebrospinal fluid
  22. Case Report – Lessons in Clinical Reasoning
  23. Lessons in clinical reasoning – pitfalls, myths, and pearls: the contribution of faulty data gathering and synthesis to diagnostic error
  24. Case Report
  25. The COVID trap: pediatric diagnostic errors in a pandemic world
  26. Letters to the Editor
  27. Atrial arrhythmia and its association with COVID-19 outcome: a pooled analysis
  28. Serious game training in medical education: potential to mitigate cognitive biases of healthcare professionals
  29. Revisiting handoffs: an opportunity to prevent error
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