Cifra Christina L, Custer Jason W, Smith Craig M, Smith Kristen A, Bagdure Dayanand N, Bloxham Jodi, Goldhar Emily, Gorga Stephen M, Hoppe Elizabeth M, Miller Christina D, Pizzo Max, Ramesh Sonali, Riffe Joseph, Robb Katharine, Simone Shari L, Stoll Haley D, Tumulty Jamie Ann, Wall Stephanie E, Wolfe Katie K, Wendt Linder, Ten Eyck Patrick, Landrigan Christopher P, Dawson Jeffrey D, Reisinger Heather Schacht, Singh Hardeep, Herwaldt Loreen A
Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
Division of Critical Care, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA.
Crit Care Med. 2025 Feb 1;53(2):e294-e307. doi: 10.1097/CCM.0000000000006511. Epub 2024 Nov 25.
This study aimed to identify the prevalence of and factors associated with diagnostic uncertainty when critically ill children are admitted to the PICU. Understanding diagnostic uncertainty is necessary to develop effective strategies to reduce diagnostic errors in the PICU.
Multicenter retrospective cohort study with structured medical record review by trained clinicians using a standardized instrument to identify diagnostic uncertainty in narrative clinical notes. Diagnoses and diagnostic uncertainty were compared across time from PICU admission to hospital discharge. Generalized linear mixed models were used to determine patient, clinician, and encounter characteristics associated with diagnostic uncertainty at PICU admission.
Four academic tertiary-referral PICUs.
Eight hundred eighty-two randomly selected patients 0-18 years old who were nonelectively admitted to participating PICUs.
None.
PICU admission notes for 228 of 882 patients (25.9%) indicated diagnostic uncertainty. Patients with uncertainty decreased over time but 58 (6.6%) had remaining diagnostic uncertainty at hospital discharge. Multivariable analysis showed that diagnostic uncertainty was significantly associated with off hours admission (odds ratio [OR], 1.52; p = 0.037), greater severity of illness (OR, 1.04; p = 0.025), an atypical presentation (OR, 2.14; p = 0.046), diagnostic discordance at admission between attending intensivists and resident physicians/advanced practice providers (OR, 3.62; p < 0.001), and having a neurologic primary diagnosis (OR, 1.87; p = 0.03). Older patients (OR, 0.96; p = 0.014) and those with a respiratory (OR, 0.58; p = 0.009) or trauma primary diagnosis (OR, 0.08; p < 0.001) were less likely to have diagnostic uncertainty. There were no significant associations between diagnostic uncertainty and attending intensivists' characteristics.
Diagnostic uncertainty at PICU admission was common and was associated with off hours admission, severe illness, atypical presentation, diagnostic discordance between clinicians, and a neurologic primary diagnosis. Further study on the recognition and management of diagnostic uncertainty is needed to inform interventions to improve diagnosis among critically ill children.
本研究旨在确定危重症儿童入住儿科重症监护病房（PICU）时诊断不确定性的患病率及相关因素。了解诊断不确定性对于制定有效策略以减少PICU中的诊断错误至关重要。
多中心回顾性队列研究，由经过培训的临床医生使用标准化工具对结构化病历进行审查，以在叙述性临床记录中识别诊断不确定性。比较从PICU入院到出院期间不同时间点的诊断和诊断不确定性。使用广义线性混合模型确定与PICU入院时诊断不确定性相关的患者、临床医生和诊疗特征。
四家学术性三级转诊PICU。
882名0至18岁非选择性入住参与研究的PICU的随机选择患者。
无。
882名患者中有228名（25.9%）的PICU入院记录显示存在诊断不确定性。随着时间推移，存在不确定性的患者数量减少，但58名（6.6%）患者在出院时仍存在诊断不确定性。多变量分析显示，诊断不确定性与非工作时间入院（优势比[OR]，1.52；p = 0.037）、病情严重程度更高（OR，1.04；p = 0.025）、非典型表现（OR，2.14；p = 0.046）、主治重症监护医生与住院医师/高级执业提供者在入院时的诊断不一致（OR，3.62；p < 0.001）以及以神经系统疾病作为主要诊断（OR，1.87；p = 0.03）显著相关。年龄较大的患者（OR，0.96；p = 0.014）以及以呼吸系统疾病（OR，0.58；p = 0.009）或创伤作为主要诊断的患者（OR，0.08；p < 0.001）诊断不确定性的可能性较小。诊断不确定性与主治重症监护医生的特征之间无显著关联。
PICU入院时的诊断不确定性很常见，且与非工作时间入院、病情严重、非典型表现、临床医生之间的诊断不一致以及神经系统主要诊断相关。需要对诊断不确定性的识别和管理进行进一步研究，以为改善危重症儿童诊断的干预措施提供依据。
