Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.
Section of Pediatric Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Children's Hospital Colorado, Aurora, Colorado.
J Emerg Med. 2023 Jul;65(1):e9-e18. doi: 10.1016/j.jemermed.2023.04.006. Epub 2023 Apr 18.
Missed diagnosis can predispose to worse condition-specific outcomes.
To determine 90-day complication rates and hospital utilization after a missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis (DKA), and sepsis.
We evaluated patients under 21 years of age visiting five pediatric emergency departments (EDs) with a study condition. Case patients had a preceding ED visit within 7 days of diagnosis and underwent case review to confirm a missed diagnosis. Control patients had no preceding ED visit. We compared complication rates and utilization between case and control patients after adjusting for age, sex, and insurance.
We analyzed 29,398 children with appendicitis, 5366 with DKA, and 3622 with sepsis, of whom 429, 33, and 46, respectively, had a missed diagnosis. Patients with missed diagnosis of appendicitis or DKA had more hospital days and readmissions; there were no significant differences for those with sepsis. Those with missed appendicitis were more likely to have abdominal abscess drainage (adjusted odds ratio [aOR] 3.0, 95% confidence interval [CI] 2.4-3.6) or perforated appendicitis (aOR 3.1, 95% CI 2.5-3.8). Those with missed DKA were more likely to have cerebral edema (aOR 4.6, 95% CI 1.5-11.3), mechanical ventilation (aOR 13.4, 95% CI 3.8-37.1), or death (aOR 28.4, 95% CI 1.4-207.5). Those with missed sepsis were less likely to have mechanical ventilation (aOR 0.5, 95% CI 0.2-0.9). Other illness complications were not significantly different by missed diagnosis.
Children with delayed diagnosis of appendicitis or new-onset DKA had a higher risk of 90-day complications and hospital utilization than those with a timely diagnosis.
漏诊可能导致特定疾病结局恶化。
确定小儿阑尾炎、新发糖尿病酮症酸中毒（DKA）和脓毒症漏诊后 90 天的并发症发生率和住院利用率。
我们评估了在 5 家儿科急诊部就诊的 21 岁以下患者，这些患者在诊断前 7 天内有一次就诊，并进行了病例回顾以确认漏诊。对照患者没有之前的急诊就诊。我们比较了调整年龄、性别和保险后，病例组和对照组患者的并发症发生率和利用率。
我们分析了 29398 例阑尾炎、5366 例 DKA 和 3622 例脓毒症患者，其中分别有 429 例、33 例和 46 例患者存在漏诊。漏诊阑尾炎或 DKA 的患者住院天数和再入院次数更多；脓毒症患者无显著差异。漏诊阑尾炎的患者更有可能进行腹部脓肿引流（调整后的优势比[aOR]3.0，95%置信区间[CI]2.4-3.6）或穿孔性阑尾炎（aOR 3.1，95% CI 2.5-3.8）。漏诊 DKA 的患者更有可能发生脑水肿（aOR 4.6，95% CI 1.5-11.3）、机械通气（aOR 13.4，95% CI 3.8-37.1）或死亡（aOR 28.4，95% CI 1.4-207.5）。漏诊脓毒症的患者机械通气的可能性较低（aOR 0.5，95% CI 0.2-0.9）。其他疾病并发症在漏诊时无显著差异。
与及时诊断相比，阑尾炎或新发 DKA 诊断延迟的儿童在 90 天内发生并发症和住院利用率的风险更高。
