Mann F A, Danz P L
Mallinckrodt Institute of Radiology, St. Louis, MO.
Invest Radiol. 1993 Jan;28(1):92-6. doi: 10.1097/00004424-199301000-00032.
The authors assessed whether a non-sleep-deprived, second-year diagnostic radiology resident assigned to an after-hours "night stalker" emergency radiology (ER) rotation in an urban university hospital has a measurable impact on the number and clinical significance of "missed" radiologic findings.
After-hours Emergency Department (ED) radiographs interpreted by radiology residents between January and December 1991 were reviewed daily by ER faculty. Faculty-modified final interpretations were recorded on a worksheet and given to the attending ED physician (EDP). The EDP reviewed and, if indicated, modified clinical dispositions, and categorized missed diagnoses as requiring recall into the following categories: 1 = immediately, 2 = in 24 to 48 hours, 3 = no recall necessary, or 4 = recognized during patient visit by clinicians. Morbidity attributable to "misses" was graded A to C (A, definite; B, possible; C, none). All cases requiring patient recall were evaluated monthly with follow-up information and classified as false-positive, false-negative, or indeterminant. The relative performance of control (traditional "call") and night stalker groups were compared.
Of 26,421 on-call examinations in 1991, there were 489 (1.1%) misses, of which 202 (1.4%) were from the June-to-December study group. The control group residents averaged 2.75 hours of sleep per call night. On night stalker days, on-call residents and the night stalker averaged 5.75 and 7.25 hours of sleep daily, respectively. The fractions (and number) of recall assignments of discordant cases for the control and night stalker groups, respectively, were: 1) immediate 48% (23) and 26% (32); 2) within 48 hours 31% (15) and 26% (31); 3) no recall 79% (38) and 36% (43); and, 4) abnormality not missed by EDPs 10% (5) and 12% (15). Morbidity for the control and night stalker groups, respectively, were: 1) 4% and 0%; 2) 31% and 30%; and 3) 65% and 70%. The amount of rework between July and December 1991 spent by the EDPs to re-evaluate cases because of discordant opinions was more than 68 hours, with no significant difference noted between the study groups. Errors were false-negative, 84.9% (415); false-positive, 7% (34); and indeterminant, 8.2% (40). Radiology faculty errors contributed 5.8% (13) of patient recalls (false-positive, 11; false-negative, 2). Finally, 58/78 questionnaire respondents believed that service quality had improved. No one believed that the standard of service had been lowered.
A dedicated night-shift ER coverage of a busy urban ED improves quality, appropriateness, and timeliness of patient care.
作者评估了在一所城市大学医院，一名未被剥夺睡眠的二年级诊断放射科住院医师被安排参与非工作时间的“夜间追踪者”急诊放射学（ER）轮转，是否会对“漏诊”放射学检查结果的数量及临床意义产生可测量的影响。
1991年1月至12月期间，放射科住院医师在非工作时间解读的急诊科（ED）X光片，由急诊放射科教员每日进行复查。教员修改后的最终解读结果记录在工作表上，并交给急诊主治医师（EDP）。EDP进行复查，并在必要时修改临床处置方案，将漏诊诊断按照需要召回的情况分为以下几类：1 = 立即召回，2 = 在24至48小时内召回，3 = 无需召回，或4 = 临床医生在患者就诊期间发现。将“漏诊”导致的发病率分为A至C级（A，明确；B，可能；C，无）。所有需要召回患者的病例每月进行随访评估，并分类为假阳性、假阴性或不确定。比较了对照组（传统“值班”）和夜间追踪者组的相对表现。
1991年的26421次值班检查中，有489例（1.1%）漏诊，其中202例（1.4%）来自6月至12月的研究组。对照组住院医师每次值班夜间平均睡眠时间为2.75小时。在夜间追踪者日，值班住院医师和夜间追踪者平均每日睡眠时间分别为5.75小时和7.25小时。对照组和夜间追踪者组不一致病例的召回分配比例（及数量）分别为：1）立即召回48%（23例）和26%（32例）；2）48小时内召回31%（15例）和26%（31例）；3）无需召回79%（38例）和36%（43例）；4）EDP未漏诊异常10%（5例）和12%（15例）。对照组和夜间追踪者组的发病率分别为：1）4%和0%；2）31%和30%；3）65%和70%。1991年7月至12月期间，由于意见不一致，EDP重新评估病例所花费的返工时间超过68小时，研究组之间未发现显著差异。错误类型为假阴性，84.9%（415例）；假阳性，7%（34例）；不确定，8.2%（40例）。放射科教员的错误导致5.8%（13例）的患者被召回（假阳性11例，假阴性2例）。最后，78名问卷受访者中有58人认为服务质量有所提高。没有人认为服务标准降低了。
在繁忙的城市急诊科安排专门的夜间急诊放射科值班，可提高患者护理的质量、适宜性和及时性。
