Diagnostic error increases mortality and length of hospital stay in patients presenting through the emergency room

Background: Diagnostic errors occur frequently, especially in the emergency room. Estimates about the consequences of diagnostic error vary widely and little is known about the factors predicting error. Our objectives thus was to determine the rate of discrepancy between diagnoses at hospital admission and discharge in patients presenting through the emergency room, the discrepancies’ consequences, and factors predicting them. Methods: Prospective observational clinical study combined with a survey in a University-affiliated tertiary care hospital. Patients’ hospital discharge diagnosis was compared with the diagnosis at hospital admittance through the emergency room and classified as similar or discrepant according to a predefined scheme by two independent expert raters. Generalized linear mixed-effects models were used to estimate the effect of diagnostic discrepancy on mortality and length of hospital stay and to determine whether characteristics of patients, diagnosing physicians, and context predicted diagnostic discrepancy. Results: 755 consecutive patients (322 [42.7%] female; mean age 65.14 years) were included. The discharge diagnosis differed substantially from the admittance diagnosis in 12.3% of cases. Diagnostic discrepancy was associated with a longer hospital stay (mean 10.29 vs. 6.90 days; Cohen’s d 0.47; 95% confidence interval 0.26 to 0.70; P = 0.002) and increased patient mortality (8 (8.60%) vs. 25(3.78%); OR 2.40; 95% CI 1.05 to 5.5 P = 0.038). A factor available at admittance that predicted diagnostic discrepancy was the diagnosing physician’s assessment that the patient presented atypically for the diagnosis assigned (OR 3.04; 95% CI 1.33–6.96; P = 0.009). Conclusions: Diagnostic discrepancies are a relevant healthcare problem in patients admitted through the emergency room because they occur in every ninth patient and are associated with increased in-hospital mortality. Discrepancies are not readily predictable by fixed patient or physician characteristics; attention should focus on context

Emotionale Prozesse unter Einfluss hormoneller Schwankungen

Orale Kontrazeptiva gehören zu den am meisten verwendeten Verhütungsmitteln. In den letzten Jahren ist das Bewusstsein für ihre somatischen als auch psychischen Nebenwirkungen deutlich in den Fokus der Medizin als auch in den Fokus der Gesellschaft gerückt. Die vorliegende Arbeit untersucht den Zusammenhang zwischen der Einnahme oraler Kontrazeptiva und ihren Einfluss auf die Erkennung von Emotionen in Gesichtern und auf die aktuelle Stimmung. Gruppenunterschiede zwischen OC-Anwenderinnen und NC-Frauen konnten hinsichtlich der Leistung und Reaktionszeit der erkannten Emotionen nicht festgestellt werden. Jedoch zeigen sich bei Probandinnen in der follikulären Phase Hinweise auf eine Verzerrung der Wahrnehmung zum Negativen hin. Die Probandinnen, die sich in der follikulären Phase des Menstruationszyklus befanden, ordneten neutrale Gesichtsausdrücke signifikant öfter einer negativen Emotion zu. Auch konnte bei dieser Gruppe eine höhere negative Stimmung als bei den anderen Teilnehmerinnen festgestellt werden. Die Vermutung, dass OCs einen Einfluss auf die Emotionserkennung ausüben, konnte nicht gezeigt werden. Dennoch bietet die Studie Anhaltspunkte für die weitere Forschung zu dieser Thematik

Exploring objective measures for assessing team performance in healthcare: an interview study.

INTRODUCTION Effective teamwork plays a critical role in achieving high-performance outcomes in healthcare. Consequently, conducting a comprehensive assessment of team performance is essential for providing meaningful feedback during team trainings and enabling comparisons in scientific studies. However, traditional methods like self-reports or behavior observations have limitations such as susceptibility to bias or being resource consuming. To overcome these limitations and gain a more comprehensive understanding of team processes and performance, the assessment of objective measures, such as physiological parameters, can be valuable. These objective measures can complement traditional methods and provide a more holistic view of team performance. The aim of this study was to explore the potential of the use of objective measures for evaluating team performance for research and training purposes. For this, experts in the field of research and medical simulation training were interviewed to gather their opinions, ideas, and concerns regarding this novel approach. METHODS A total of 34 medical and research experts participated in this exploratory qualitative study, engaging in semi-structured interviews. During the interview, experts were asked for (a) their opinion on measuring team performance with objective measures, (b) their ideas concerning potential objective measures suitable for measuring team performance of healthcare teams, and (c) their concerns regarding the use of objective measures for evaluating team performance. During data analysis responses were categorized per question. RESULTS The findings from the 34 interviews revealed a predominantly positive reception of the idea of utilizing objective measures for evaluating team performance. However, the experts reported limited experience in actively incorporating objective measures into their training and research. Nevertheless, they identified various potential objective measures, including acoustical, visual, physiological, and endocrinological measures and a time layer. Concerns were raised regarding feasibility, complexity, cost, and privacy issues associated with the use of objective measures. DISCUSSION The study highlights the opportunities and challenges associated with employing objective measures to assess healthcare team performance. It particularly emphasizes the concerns expressed by medical simulation experts and team researchers, providing valuable insights for developers, trainers, researchers, and healthcare professionals involved in the design, planning or utilization of objective measures in team training or research

Virtual Reality for Pain Relief in the Emergency Room (VIPER) - a prospective, interventional feasibility study.

BACKGROUND Pain is one of the most common, yet challenging problems leading to emergency department (ED) presentation, despite the availability of a wide range of pharmacological therapies. Virtual reality (VR) simulations are well studied in a wide variety of clinical settings, including acute and chronic pain management, as well as anxiety disorders. However, studies in the busy environment of an adult ED are scarce. The aim of this study is to explore the feasibility and effectiveness of a VR simulation for pain and anxiety control in a convenience sample of adult ED patients presenting with traumatic and non-traumatic pain triaged 2-5 (i.e., urgent to non-urgent) with a pain rating of ≥ 3 on a numeric rating scale (NRS 0-10). METHODS Prospective within-subject, repeated measures interventional feasibility pilot study at a Swiss University ED. The intervention consisted of a virtual reality simulation in addition to usual care. Pain and anxiety levels were measured using a verbally administered numeric rating scale (NRS) before and after the intervention. Information on patient experience was collected using established rating scales. RESULTS Fifty-two patients were enrolled. The most common pain localisations were extremities (n = 15, 28.8%) and abdomen (n = 12, 23.1%). About one third of patients presented with trauma-associated pain (n = 16, 30.8%). Duration of pain was mainly acute ( 24 h) (n = 32, 61.5%). The majority of patients were triage category 3, i.e. semi-urgent (n = 48, 92.3%). Significant reduction in pain (NRS median pre-VR simulation 4.5 (IQR 3-7) vs. median post-VR simulation 3 (IQR 2-5), p < 0.001), and anxiety levels (NRS median pre-VR simulation 4 (IQR 2-5) vs. median post-VR simulation 2 (IQR 0-3), p < 0.001) was achieved, yielding moderate to large effect sizes (Cohen's d estimate for pain reduction = 0.59 (95% CI 0.19-0.98), for anxiety level on NRS = 0.75 (95% CI 0.34-1.15). With medium immersion and good tolerability of the VR simulation, user satisfaction was high. CONCLUSIONS Virtual reality analgesia for pain and anxiety reduction in the busy setting of an ED is feasible, effective, with high user satisfaction. Further randomized controlled studies are needed to better characterize its impact on pain perception and resource utilization

Development and usability testing of a fully immersive VR simulation for REBOA training.

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning

Frequency and predictors of unspecific medical diagnoses in the emergency department: a prospective observational study.

BACKGROUND Misdiagnosis is a major public health problem, causing increased morbidity and mortality. In the busy setting of an emergency department (ED) patients are diagnosed under difficult circumstances. As a consequence, the ED diagnosis at hospital admittance may often be a descriptive diagnosis, such as "decreased general condition". Our objective was to determine in how far patients with such an unspecific ED diagnosis differ from patients with a specific ED diagnosis and whether they experience a worse outcome. METHODS We conducted a prospective observational study in Bern university hospital in Switzerland for all adult non-trauma patients admitted to any internal medicine ward from August 15th 2015 to December 7th 2015. Unspecific ED diagnoses were defined through the clinical classification software for ICD-10 by two outcome assessors. As outcome parameters, we assessed in-hospital mortality and length of hospital stay. RESULTS Six hundred eighty six consecutive patients were included. Unspecific diagnoses were identified in 100 (14.6%) of all consultations. Patients receiving an unspecific diagnosis at ED discharge were significantly more often women (56.0% vs. 43.9%, p = 0.024), presented more often with a non-specific complaint (34% vs. 21%, p = 0.004), were less often demonstrating an abnormal heart rate (5.0% vs. 12.5%, p = 0.03), and less often on antibiotics (32.0% vs. 49.0%, p = 0.002). Apart from these, no studied drug intake, laboratory or clinical data including change in diagnosis was associated significantly with an unspecific diagnosis. Unspecific diagnoses were neither associated with in-hospital mortality in multivariable analysis (OR = 1.74, 95% CI: 0.60-5.04; p = 0.305) adjusted for relevant confounders nor with length of hospital stay (GMR = 0.87, 95% CI: 0.23-3.32; p = 0.840). CONCLUSIONS Women and patients with non-specific presenting complaints and no abnormal heart rate are at risk of receiving unspecific ED diagnoses that do not allow for targeted treatment, discharge and prognosis. This study did not find an effect of such diagnoses on length of hospital stay nor in-hospital mortality

Automated identification of diagnostic labelling errors in medicine

Objectives: Identification of diagnostic error is complex and mostly relies on expert ratings, a severely limited procedure. We developed a system that allows to automatically identify diagnostic labelling error from diagnoses coded according to the international classification of diseases (ICD), often available as routine health care data. Methods: The system developed (index test) was validated against rater based classifications taken from three previous studies of diagnostic labeling error (reference standard). The system compares pairs of diagnoses through calculation of their distance within the ICD taxonomy. Calculation is based on four different algorithms. To assess the concordance between index test and reference standard, we calculated the area under the receiver operating characteristics curve (AUROC) and corresponding confidence intervals. Analysis were conducted overall and separately per algorithm and type of available dataset. Results: Diagnoses of 1,127 cases were analyzed. Raters previously classified 24.58% of cases as diagnostic labelling errors (ranging from 12.3 to 87.2% in the three datasets). AUROC ranged between 0.821 and 0.837 overall, depending on the algorithm used to calculate the index test (95% CIs ranging from 0.8 to 0.86). Analyzed per type of dataset separately, the highest AUROC was 0.924 (95% CI 0.887-0.962). Conclusions: The trigger system to automatically identify diagnostic labeling error from routine health care data performs excellent, and is unaffected by the reference standards' limitations. It is however only applicable to cases with pairs of diagnoses, of which one must be more accurate or otherwise superior than the other, reflecting a prevalent definition of a diagnostic labeling error

What factors affect team members' evaluation of collaboration in medical teams?

INTRODUCTION Perceived teamwork quality is associated with numerous work-related outcomes, ranging from team effectiveness to job satisfaction. This study explored what situational and stable factors affect the perceived quality of teamwork during a specific team task: when a medical team comprising a senior (supervisor) and a junior (trainee) physician diagnoses a patient. METHODS During a field study in an emergency department, multisource data describing the patients, the diagnosing physicians, and the context were collected, including physicians' ratings of their teamwork. The relationships between perceived teamwork quality and situational (e.g., workload) and stable (e.g., seniority) factors were estimated in a latent regression model using the structural equation modeling (SEM) approach. RESULTS Across the N = 495 patients included, SEM analyses revealed that the patient-specific case clarity and urgency influenced the perceived teamwork quality positively, whereas the work experience of the supervisor influenced the perceived teamwork quality of both supervisor and trainee negatively, albeit to different degrees. DISCUSSION Our findings shed light on the complex underpinnings of perceived teamwork quality, a performance-relevant factor that may influence work and organizational effectiveness in healthcare settings

a prospective observational study

Introduction Emergency rooms (ERs) generally assign a preliminary diagnosis to patients, who are then hospitalised and may subsequently experience a change in their lead diagnosis (cDx). In ERs, the cDx rate varies from around 15% to more than 50%. Among the most frequent reasons for diagnostic errors are cognitive slips, which mostly result from faulty data synthesis. Furthermore, physicians have been repeatedly found to be poor self-assessors and to be overconfident in the quality of their diagnosis, which limits their ability to improve. Therefore, some of the clinically most relevant research questions concern how diagnostic decisions are made, what determines their quality and what can be done to improve them. Research that addresses these questions is, however, still rare. In particular, field studies that allow for generalising findings from controlled experimental settings are lacking. The ER, with its high throughput and its many simultaneous visits, is perfectly suited for the study of factors contributing to diagnostic error. With this study, we aim to identify factors that allow prediction of an ER's diagnostic performance. Knowledge of these factors as well as of their relative importance allows for the development of organisational, medical and educational strategies to improve the diagnostic performance of ERs. Methods and analysis We will conduct a field study by collecting diagnostic decision data, physician confidence and a number of influencing factors in a real-world setting to model real-world diagnostic decisions and investigate the adequacy, validity and informativeness of physician confidence in these decisions. We will specifically collect data on patient, physician and encounter factors as predictors of the dependent variables. Statistical methods will include analysis of variance and a linear mixed-effects model. Ethics and dissemination The Bern ethics committee approved the study under KEK Number 197/15. Results will be published in peer-reviewed scientific medical journals. Authorship will be determined according to ICMJE guidelines. Trial registration number The study protocol Version 1.0 from 17 May 2015 is registered in the Inselspital Research Database Information System (IRDIS) and with the IRB (‘Kantonale Ethikkomission’) Bern under KEK Number 197/15

Physicians’ attitudes toward, use of, and perceived barriers to clinical guidelines: a survey among Swiss physicians

BACKGROUND: Little is known about the attitudes toward, use of, and perceived barriers to clinical guidelines in Switzerland, a country with no national guideline agency. Moreover, there is no available data on the objective assessment of guideline knowledge in Switzerland. Therefore, we conducted a study at a large university's Department of General Internal Medicine in Switzerland to assess physicians' attitudes toward, use of, perceived barriers to, and knowledge of clinical guidelines. PARTICIPANTS AND METHODS: Ninety-six physicians (residents, n=78, and attendings, n=18) were invited to take part in a survey. Attitudes toward, self-reported use of, and barriers hindering adherence to the clinical guidelines were assessed using established scales and frameworks. Knowledge of the guidelines was objectively tested in a written assessment comprising of 14 multiple-choice and 3 short answer case-based questions. RESULTS: Fifty-five participants completed the survey (residents, n=42, and attendings, n=13; overall response rate 57%). Of these, 50 took part in the knowledge assessment (residents, n=37, and attendings, n=13; overall response rate 52%). Attitudes toward guidelines were favorable. They were considered to be a convenient source of advice (94% agreement), good educational tools (89% agreement), and likely to improve patient quality of care (91% agreement). Self-reported use of guidelines was limited, with only one-third reporting using guidelines often or very often. The main barriers to guideline adherence were identified as lack of guideline awareness and familiarity, applicability of existing guidelines to multimorbid patients, unfavorable guideline factors, and lack of time as well as inertia toward changing previous practice. In the assessment of guideline knowledge, the scores were rather modest (mean ± standard deviation: 60.5%±12.7% correct answers). CONCLUSION: In general, this study found favorable physician attitudes toward clinical guidelines. However, several barriers hindering guideline implementation were identified. The importance of improving guideline implementation was supported by modest results in a guideline knowledge test