Diagnosis of pneumonia in the ED has poor accuracy despite diagnostic uncertainty

Sikka, Rishi; Tommaso, Laura; Kaucky, Carleen; Kulstad, Erik

doi:10.1016/j.ajem.2011.06.006

Cited by 16 publications

(10 citation statements)

References 12 publications

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“…Welker et al also found that inpatient physicians’ diagnosis of pneumonia was generally in agreement with the guideline definition, although they did make the diagnosis in about 10% more patients than met the guideline criteria 31 . Similar results have been noted by other authors 35,36 . The reasons for this overdiagnosis have not been studied directly.…”

Section: Discussionmentioning

confidence: 60%

Disagreement Between Emergency Physician and Inpatient Physician Diagnosis of Infection in Older Adults Admitted From the Emergency Department

Caterino

Stevenson

2012

Academic Emergency Medicine

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Objectives: Older adults with infection are at increased risk of misdiagnosis while they are patients in the emergency department (ED) due to the common presence of nonspecific signs and symptoms. The primary objective was to determine the proportion of admitted older adult patients thought by the emergency physician (EP) to be infected, as compared with the diagnostic impression of inpatient physicians. The secondary objective was to determine the agreement between EP and inpatient physician diagnosis of specific infection types. Methods:The authors conducted a prospective, observational, convenience sampling of a cohort of ED patients ‡65 years old admitted to the hospital with diagnoses of acute infection. EPs noted at least one suspected source of infection. Inpatient diagnosis of infection was determined by chart review of the inpatient chart. Outcomes included the presence of any infection and of specific infectious sources diagnosed within 48 hours of admission. EP and inpatient diagnoses were compared using proportions, positive and negative likelihood ratios (LR+ and LR)), and the phi coefficient.Results: The study included 103 patients diagnosed with a suspected infection by the EP. Nineteen patients (18.4%, 95% confidence interval [CI] = 11.5% to 27.3%) were not diagnosed with any infection by the inpatient physician. For specific infection sources, ED diagnosis of bloodstream infection often did not agree with the inpatient diagnosis. Sensitivity was 40.0% and specificity 78.4% with an LR+ of 1.85 and LR) of 0.76. The phi coefficient was 0.15. EPs overdiagnosed pulmonary infection, with 72.1% specificity and an LR+ of 3.24. EP diagnosis had good accuracy for skin and soft tissue infection (sensitivity = 78.6% and specificity = 96.6%), with adequate LRs (LR+ of 23.3 and LR) of 0.22). Urinary tract infection (UTI) was underdiagnosed in the ED (sensitivity = 58.3%), but it is unclear if this is due to true ED underdiagnosis or due to overdiagnosis of UTI in the inpatient setting. Conclusions:In older patients admitted from the ED, the provisional ED diagnosis and the inpatient diagnosis of an acute infection often disagree. In this sample, 18% of older ED patients diagnosed with infection during an ED stay were not diagnosed as infected by the inpatient physician. Regarding infection types, EPs were poor at diagnosing bacteremia and overdiagnosed pulmonary infections. EP diagnosis of skin and soft tissue infection generally agreed with the inpatient physician.

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Section: Discussionmentioning

confidence: 60%

Disagreement Between Emergency Physician and Inpatient Physician Diagnosis of Infection in Older Adults Admitted From the Emergency Department

Caterino

Stevenson

2012

Academic Emergency Medicine

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“…28,29,32 Our study found approximately twice as much (47%) diagnostic discordance. Signifi cantly greater discordance for adult patients, ranging from 33% to 41%, has been demonstrated directly after implementation of guidelines recommending early antibiotic administration in the ED.…”

Section: Discussionmentioning

confidence: 85%

“…[28][29][30][31][32] Antibiotic discordance between ED and hospitalist physicians for respiratory illness at admission has not been measured in any age group. Our study sought to quantify the diagnostic and antibiotic discordance between ED physicians and pediatric hospitalists for children admitted to the hospital for respiratory illness.…”

mentioning

confidence: 99%

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness

Coon

Maloney

Shen

2015

Hospital Pediatrics

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“…Unfortunately, flawed diagnostic reason ing is an under recognized cause of preventable patient harm, especially in common syndromic conditions such as CAP. In two studies that evaluated diagnostic correla tion between an ED admitting diagnosis of pneumonia and discharge diagnosis, 26%-27% of cases were mis diagnosed at admission (over diagnosis) [2,3]. In another study, autopsy data demonstrated that pneumonia is one of the 3 most common missed diagnosis (under diagnosis) [4].…”

Section: A Missed Opportunity -A Near Disastermentioning

confidence: 99%

A missed opportunity – a near disaster

Rubenstein

2014

Diagnosis

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Diagnosis of pneumonia in the ED has poor accuracy despite diagnostic uncertainty

Cited by 16 publications

References 12 publications

Disagreement Between Emergency Physician and Inpatient Physician Diagnosis of Infection in Older Adults Admitted From the Emergency Department

Disagreement Between Emergency Physician and Inpatient Physician Diagnosis of Infection in Older Adults Admitted From the Emergency Department

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness

A missed opportunity – a near disaster

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