Division of Pediatric Emergency Medicine, Department of Pediatrics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
Acad Emerg Med. 2020 Feb;27(2):128-138. doi: 10.1111/acem.13884. Epub 2019 Dec 15.
We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome.
This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow-up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation.
We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician's pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient's pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7).
Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.
我们确定了急诊医师对儿科肌肉骨骼（MSK）射线照相解释与放射科医师不一致的频率，以及导致不良事件（AE）的原因。我们还确定了与这种结果独立相关的变量。
这项前瞻性队列研究在城市三级儿童急诊部（ED）进行。我们招募了因四肢受伤而到 ED 就诊并接受射线照相的儿童。ED 医生记录了他们的射线照相解释，并与放射学参考标准进行了比较。患者在 3 周内接受电话随访并对机构病历进行了回顾。如果由于射线照相解释不正确而导致临床后遗症和/或重复就诊，则发生 AE。
我们共招募了 2302 名儿童（平均[±SD]年龄为 9.0[4.4]岁；1288 名[56.0%]男性）。其中，180 名（7.8%；95%置信区间为 6.8 至 9.0）ED 医师不一致的解释导致了 AE。具体来说，没有发生负面的临床后果；然而，与在 ED 指数期正确诊断的病例相比，骨折最初未被识别的患者后续就诊 ED 的次数增加了 77.2%，而那些错误诊断为骨折的患者额外增加了 41.5%的矫形诊所就诊次数。如果医生骨折的术前概率≤20%与>20%（调整比值比[aOR]为 1.6）、患者疼痛评分≤2 与>2（aOR 为 1.6）以及损伤位于关节与其他部位（aOR 为 1.7），则 ED 出现不一致解释的可能性显著更高。
在儿科 ED 环境中，急诊医师对儿科 MSK 射线照相解释不一致，导致 AE 时有发生。AE 主要是随后增加了医疗保健就诊次数。重要的是，对骨折或位于关节的损伤的临床怀疑程度低是 ED 医师解释不一致的危险因素。
