Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA.
Division of Orthopedic Surgery, Boston Children's Hospital, Boston, MA, USA.
Diagnosis (Berl). 2020 Jun 26;8(2):219-225. doi: 10.1515/dx-2020-0035. Print 2021 May 26.
Using case review to determine whether a patient experienced a delayed diagnosis is challenging. Measurement would be more accurate if case reviewers had access to multi-expert consensus on grading the likelihood of delayed diagnosis. Our objective was to use expert consensus to create a guide for objectively grading the likelihood of delayed diagnosis of appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis.
Case vignettes were constructed for each condition. In each vignette, a patient has the condition and had a previous emergency department (ED) visit within 7 days. Condition-specific multi-specialty expert Delphi panels reviewed the case vignettes and graded the likelihood of a delayed diagnosis on a five-point scale. Delayed diagnosis was defined as the condition being present during the previous ED visit. Consensus was defined as ≥75% agreement. In each Delphi round, panelists were given the scores from the previous round and asked to rescore. A case scoring guide was created from the consensus scores.
Eighteen expert panelists participated. Consensus was achieved within three Delphi rounds for all appendicitis and sepsis vignettes. We reached consensus on 23/30 (77%) DKA vignettes. A case review guide was created from the consensus scores.
Multi-specialty expert reviewers can agree on the likelihood of a delayed diagnosis for cases of appendicitis and sepsis, and for most cases of DKA. We created a guide that can be used by researchers and quality improvement specialists to allow for objective case review to determine when delayed diagnoses have occurred for appendicitis, DKA, and sepsis.
通过病例回顾来确定患者是否存在延迟诊断具有一定的挑战性。如果病例审查员能够获得关于延迟诊断可能性分级的多专家共识，那么评估结果会更加准确。我们的目标是使用专家共识为阑尾炎、新发糖尿病酮症酸中毒（DKA）和脓毒症的延迟诊断可能性制定客观评分指南。
为每种疾病构建病例描述。在每个病例中，患者都患有相应疾病，且在 7 天内曾到急诊就诊。针对特定疾病的多学科专家德尔菲小组审查了病例描述，并对延迟诊断的可能性进行了五分制评分。延迟诊断定义为疾病在之前的急诊就诊时已存在。一致性定义为≥75%的同意率。在每个德尔菲回合中，小组成员会收到上一轮的评分，并被要求重新评分。从共识评分中创建了病例评分指南。
18 名专家小组成员参与了研究。所有阑尾炎和脓毒症病例在三轮德尔菲回合中达成了共识。我们就 30 个 DKA 病例中的 23 个（77%）达成了共识。从共识评分中创建了病例回顾指南。
多学科专家审查员可以就阑尾炎和脓毒症病例以及大多数 DKA 病例的延迟诊断可能性达成一致意见。我们创建了一个指南，可用于研究人员和质量改进专家，以允许进行客观的病例回顾，从而确定阑尾炎、DKA 和脓毒症的延迟诊断是否发生。
