大辛辛那提/北肯塔基卒中研究中急诊科对缺血性卒中的潜在漏诊情况
Potentially Missed Diagnosis of Ischemic Stroke in the Emergency Department in the Greater Cincinnati/Northern Kentucky Stroke Study.
作者信息
Madsen Tracy E, Khoury Jane, Cadena Rhonda, Adeoye Opeolu, Alwell Kathleen A, Moomaw Charles J, McDonough Erin, Flaherty Matthew L, Ferioli Simona, Woo Daniel, Khatri Pooja, Broderick Joseph P, Kissela Brett M, Kleindorfer Dawn
机构信息
Division of Sex and Gender in Emergency Medicine, Department of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI.
Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
出版信息
Acad Emerg Med. 2016 Oct;23(10):1128-1135. doi: 10.1111/acem.13029. Epub 2016 Sep 27.
OBJECTIVE
Missed diagnoses of acute ischemic stroke (AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen (tPA) eligibility among those with missed strokes.
METHODS
Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis.
RESULTS
Of 2,027 AIS cases, 14.0% (n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [aOR] = 0.94, 95% confidence interval [CI] = 0.89 to 0.98) and decreased level of consciousness (LOC) (aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA.
CONCLUSION
In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients.
目的
急诊科对急性缺血性卒中（AIS）的漏诊可能导致错失治疗AIS的机会。我们的目标是描述急诊科AIS漏诊的发生率及临床特征，确定AIS漏诊的临床预测因素，并报告漏诊卒中患者的组织型纤溶酶原（tPA）治疗 eligibility。
方法
在俄亥俄州西南部和肯塔基州北部五县地区的130万人口中，使用ICD - 9编码识别2010年期间在16家急诊科就诊的AIS病例，随后由医生对病例进行核实。急诊科漏诊是指经医生核实的卒中病例在急诊科未得到提示卒中的诊断。采用双变量分析比较有和没有急诊科AIS诊断的患者的临床特征。使用逻辑回归评估AIS漏诊的预测因素。对AIS漏诊患者给出的其他诊断进行编码。报告有和没有漏诊卒中诊断的患者的tPA治疗 eligibility。
结果
在2027例AIS病例中，14.0%（n = 283）在急诊科被漏诊。AIS漏诊患者与在急诊科确诊的患者在种族、性别和卒中亚型方面相似。漏诊患者的住院时间更长（5天对3天，p < 0.0001）。年龄较小（调整优势比[aOR] = 0.94，95%置信区间[CI] = 0.89至0.98）和意识水平（LOC）降低（aOR = 3.58，95%CI = 2.63至4.87）与AIS漏诊的较高几率相关。意识状态改变是AIS漏诊患者中最常见的诊断。漏诊卒中诊断的患者中只有1.1%符合tPA治疗条件。
结论
在一个基于大样本人群的AIS病例样本中，七分之一的病例在急诊科未被诊断为AIS，但对急性治疗率的影响可能较小。在LOC降低的患者中漏诊更为常见，这表明需要改进这些患者的诊断方法。
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