Missed diagnosis of subarachnoid hemorrhage in the emergency department.

Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
Stroke (Impact Factor: 6.02). 05/2007; 38(4):1216-21. DOI: 10.1161/01.STR.0000259661.05525.9a
Source: PubMed

ABSTRACT Subarachnoid hemorrhage (SAH) can be devastating, yet its initial presentation may be limited to common symptoms and subtle signs, potentially leading to misdiagnosis. Little is known about population rates of misdiagnosis of SAH, or hospital factors that may contribute to it. We estimated the population-based rate of missed SAH among emergency department (ED) patients and examined its relationship with hospital characteristics.
We studied persons admitted with a nontraumatic SAH to all Ontario hospitals over 3 years (April 2002 to March 2005). SAH was defined as missed if the patient had an ED visit related to the SAH (based on a prespecified definition) in the 14 days before admission. We examined the association between hospital teaching status and missed SAH and explored whether annual ED volume of SAH or CT availability explained this association.
Of 1507 patients diagnosed with SAH, 5.4% (95% CI, 4.3 to 6.6) had a missed diagnosis. The risk was significantly higher among patients triaged as low acuity (odds ratio 2.65; 95% CI, 1.46 to 4.80), as well as in nonteaching hospitals (adjusted odds ratio 2.12; 95% CI, 1.02, 4.44). Neither ED SAH volume nor on-site CT availability explained the effect of teaching status.
About 1 in 20 SAH patients are missed during an ED visit. Lower acuity patients are at higher risk of misdiagnosis, suggesting the need for heightened suspicion among patients with minimal clinical findings. The risk is also greater in nonteaching hospitals, but this is not explained by the annual volume of SAHs seen in the ED or access to CT.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective This study aims to establish current practice among Australasian emergency physicians and trainees on several aspects of the investigation of suspected subarachnoid haemorrhage (SAH).Methods An electronic questionnaire (SurveyMonkeyTM) was distributed to emergency physicians and trainees by email through the ACEM. Survey recipients were asked about demographics, followed by a series of questions relating to the investigation of SAH.ResultsThere were 878 survey respondents (response rate 24%). Our data showed that 47.3% of respondents agreed or strongly agreed that a CT brain within 6 h of headache onset is sufficient to exclude a diagnosis of SAH. For a CT performed within 12 h of ictus, 14.4% were satisfied that SAH could be excluded. After a negative CT scan, for further investigation of SAH, 88% of respondents preferred lumbar puncture to CT angiography. For detection of xanthochromia in the cerebrospinal fluid, 57.7% of respondents felt that spectrophotometry (vs visual inspection) is necessary to accurately diagnose SAH.ConclusionsA range of information was collected regarding the investigation of suspected SAH. We report significant differences in the diagnostic approach of Australasian emergency physicians and trainees to this condition, in particular the utility of CT within 6 h for exclusion of SAH.
    Emergency medicine Australasia: EMA 10/2014; · 0.99 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Early diagnosis of children with meningitis or septicemia remains a significant challenge in emergency medicine. We seek to describe the frequency of repeated emergency department (ED) visits among children admitted with meningitis or septicemia in Ontario, Canada. In this retrospective cohort study, using health administrative data, we included all children aged 30 days to 5 years who were hospitalized with a final diagnosis of meningitis or septicemia in Ontario between 2005 and 2010. ED visits at any hospital in the preceding 5 days were identified as potential repeated ED visits. We used generalized estimating equations to model the association of sex, age, triage score, immunocompromised state, visit timing, type of ED, and annual patient volume on the risk of repeated ED visits. Of 521 children, 114 (21.9%) had repeated ED visits before admission. Children admitted on initial visit and those with repeated visits had similar median lengths of stay (13 versus 12 days), critical care use (21.1% versus 16.7%), and mortality (mean 2.9%). One in 3 children repeating visits returned to a different hospital. Repeated visits were associated with older age, a less acute triage score, and initial visit to a community hospital without available pediatric consultation. In this cohort, repeated ED visits among children with meningitis or septicemia were common, yet they had health outcomes similar to those of children admitted on initial visit. One in 3 returned to a different ED, making it unlikely that EDs and clinicians can learn from these critical events without a regionalized reporting system. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Annals of Emergency Medicine 11/2014; · 4.33 Impact Factor
  • Emergency Medicine Journal 12/2012; 30(1):84-84. · 1.78 Impact Factor

Full-text (2 Sources)

Available from
Jun 4, 2014