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Neal J Thomas,
Padmanabhan Ramnarayan,
Michael J Bell,
Prabhat Maheshwari,
Shaun Wilson,
Emily B Nazarian,
Lorri M Phipps,
David C Stockwell,
Michael Engel,
Frank A Maffei,
Harish G Vyas, Joseph Britto
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ABSTRACT: Improving diagnostic accuracy is essential. The extent of diagnostic uncertainty at patient admission is not well described in critically ill children. Therefore, we studied the extent that pediatric trainee diagnostic performance could be improved with the aid of a computerized diagnostic tool. Data regarding patient admissions to five Pediatric Intensive Care Units were collected. Information included patients' clinical details, admitting team's diagnostic workup and discharge diagnosis. An attending physician assessed each case independently and suggested additional diagnostic possibilities. Diagnostic accuracy was calculated using the discharge diagnosis as the gold standard. 206 out of 927 patients (22.2%) admitted to the PICUs did not have an established diagnosis at admission. The trainee teams considered a median of three diagnoses in their workup (IQR 3-5) and made an accurate diagnosis in 89.4% cases (95% CI 84.6%-94.2%). Diagnostic accuracy improved to 92.5% with use of the diagnostic tool alone, and to 95% with the addition of attending physicians' diagnostic suggestions. We conclude that a modest proportion of admissions to these PICUs were characterized by diagnostic uncertainty during initial assessment. Although there was a relatively high accuracy rate of initial assessment in our clinical setting, it was further improved by both the diagnostic tool and the physicians' diagnostic suggestions. It is plausible that the tool's utility would be even greater in clinical settings with less expertise in critical illness assessment, such as community hospitals, or emergency departments of non-training institutions. The role of diagnostic aids in the care of critically ill children merits further study.further study.
Technology and health care: official journal of the European Society for Engineering and Medicine 02/2008; 16(2):103-10.
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ABSTRACT: Diagnostic error is a significant problem in emergency medicine, where initial clinical assessment and decision making is often based on incomplete clinical information. Traditional computerised diagnostic systems have been of limited use in the acute setting, mainly due to the need for lengthy system consultation. We evaluated a novel web-based reminder system, which provides rapid diagnostic advice to users based on free text search terms.
Clinical data collected from patients presenting to three emergency departments with acute medical problems were entered into the diagnostic system. The displayed results were assessed against the final discharge diagnoses for patients who were admitted to hospital (diagnostic accuracy) and against a set of "appropriate" diagnoses for each case provided by an expert panel (potential utility).
Data were collected from 594 patients (53.4% of screened attendances). Mean age was 49.4 years (95% CI 47.7 to 51.1) and the majority had significant past illnesses. Most were assessed first by junior doctors (70%) and 266/594 (44.6%) were admitted to hospital. Overall, the diagnostic system displayed the final discharge diagnosis in 95% of inpatients and 90% of "must-not-miss" diagnoses suggested by the expert panel. The discharge diagnosis appeared within the first 10 suggestions in 78% of cases.
The Isabel diagnostic aid has been shown to be of potential use in reminding junior doctors of key diagnoses in the emergency department. The effects of its widespread use on decision making and diagnostic error can be clarified by evaluating its impact on routine clinical decision making.
Emergency Medicine Journal 10/2007; 24(9):619-24. · 1.44 Impact Factor
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ABSTRACT: Diarrhea is frequently observed among critically ill children (CIC) admitted for intensive care. There is increasing evidence that probiotics decrease the incidence of acute infectious and nosocomial and antibiotic induced diarrhea amongst children hospitalized in nonintensive care settings. Despite theoretic advantages for the use of probiotics in CIC, safety has remained a concern in this vulnerable group. The objective of this study was to establish clinical safety (invasive infection/colonization) of Lactobacillus casei shirota (LCS) used as a probiotic in CIC.
Prospective, descriptive pilot study on children admitted to a pediatric intensive care unit. Data regarding safety were collected on the initial recruits to a randomized controlled trial aimed to study the effects of LCS on stool frequency and consistency in CIC. Safety was assessed by bacteriologic surveillance for LCS in surface swabs and endotracheal aspirates (colonization) as well as blood, urine, and sterile body fluid cultures (invasive infection/bacteremia).
Safety data were available on 28 patients. LCS was cultured from the feces of five of the six study subjects who opened bowels during their stay on the pediatric intensive care unit. There was no evidence of either colonization or bacteremia with LCS in bacteriologic cultures obtained from study subjects. The preparation was well tolerated with no apparent side effects.
Our pilot safety study suggests that the use of LCS as a probiotic in enterally fed CIC is safe.
Journal of Pediatric Gastroenterology and Nutrition 03/2006; 42(2):171-3. · 2.30 Impact Factor
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ABSTRACT: Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty.
Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined.
Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec-3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance.
We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.
BMC Medical Informatics and Decision Making 02/2006; 6:37. · 1.48 Impact Factor
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ABSTRACT: Abstract
Background
Diagnostic error is a significant problem in specialities characterised by diagnostic uncertainty such as primary care, emergency medicine and paediatrics. Despite wide-spread availability, computerised aids have not been shown to significantly improve diagnostic decision-making in a real world environment, mainly due to the need for prolonged system consultation. In this study performed in the clinical environment, we used a Web-based diagnostic reminder system that provided rapid advice with free text data entry to examine its impact on clinicians' decisions in an acute paediatric setting during assessments characterised by diagnostic uncertainty.
Methods
Junior doctors working over a 5-month period at four paediatric ambulatory units consulted the Web-based diagnostic aid when they felt the need for diagnostic assistance. Subjects recorded their clinical decisions for patients (differential diagnosis, test-ordering and treatment) before and after system consultation. An expert panel of four paediatric consultants independently suggested clinically significant decisions indicating an appropriate and 'safe' assessment. The primary outcome measure was change in the proportion of 'unsafe' workups by subjects during patient assessment. A more sensitive evaluation of impact was performed using specific validated quality scores. Adverse effects of consultation on decision-making, as well as the additional time spent on system use were examined.
Results
Subjects attempted to access the diagnostic aid on 595 occasions during the study period (8.6% of all medical assessments); subjects examined diagnostic advice only in 177 episodes (30%). Senior House Officers at hospitals with greater number of available computer workstations in the clinical area were most likely to consult the system, especially out of working hours. Diagnostic workups construed as 'unsafe' occurred in 47/104 cases (45.2%); this reduced to 32.7% following system consultation (McNemar test, p < 0.001). Subjects' mean 'unsafe' workups per case decreased from 0.49 to 0.32 (p < 0.001). System advice prompted the clinician to consider the 'correct' diagnosis (established at discharge) during initial assessment in 3/104 patients. Median usage time was 1 min 38 sec (IQR 50 sec – 3 min 21 sec). Despite a modest increase in the number of diagnostic possibilities entertained by the clinician, no adverse effects were demonstrable on patient management following system use. Numerous technical barriers prevented subjects from accessing the diagnostic aid in the majority of eligible patients in whom they sought diagnostic assistance.
Conclusion
We have shown that junior doctors used a Web-based diagnostic reminder system during acute paediatric assessments to significantly improve the quality of their diagnostic workup and reduce diagnostic omission errors. These benefits were achieved without any adverse effects on patient management following a quick consultation.
BMC Medical Informatics and Decision Making. 01/2006;
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ABSTRACT: Abstract
Background
Computerized decision support systems (DSS) have mainly focused on improving clinicians' diagnostic accuracy in unusual and challenging cases. However, since diagnostic omission errors may predominantly result from incomplete workup in routine clinical practice, the provision of appropriate patient- and context-specific reminders may result in greater impact on patient safety. In this experimental study, a mix of easy and difficult simulated cases were used to assess the impact of a novel diagnostic reminder system (ISABEL) on the quality of clinical decisions made by various grades of clinicians during acute assessment.
Methods
Subjects of different grades (consultants, registrars, senior house officers and medical students), assessed a balanced set of 24 simulated cases on a trial website. Subjects recorded their clinical decisions for the cases (differential diagnosis, test-ordering and treatment), before and after system consultation. A panel of two pediatric consultants independently provided gold standard responses for each case, against which subjects' quality of decisions was measured. The primary outcome measure was change in the count of diagnostic errors of omission (DEO). A more sensitive assessment of the system's impact was achieved using specific quality scores; additional consultation time resulting from DSS use was also calculated.
Results
76 subjects (18 consultants, 24 registrars, 19 senior house officers and 15 students) completed a total of 751 case episodes. The mean count of DEO fell from 5.5 to 5.0 across all subjects (repeated measures ANOVA, p < 0.001); no significant interaction was seen with subject grade. Mean diagnostic quality score increased after system consultation (0.044; 95% confidence interval 0.032, 0.054). ISABEL reminded subjects to consider at least one clinically important diagnosis in 1 in 8 case episodes, and prompted them to order an important test in 1 in 10 case episodes. Median extra time taken for DSS consultation was 1 min (IQR: 30 sec to 2 min).
Conclusion
The provision of patient- and context-specific reminders has the potential to reduce diagnostic omissions across all subject grades for a range of cases. This study suggests a promising role for the use of future reminder-based DSS in the reduction of diagnostic error.
BMC Medical Informatics and Decision Making. 01/2006;
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Nelly Ninis,
Claire Phillips,
Linda Bailey,
Jon I Pollock,
Simon Nadel, Joseph Britto,
Ian Maconochie,
Andrew Winrow,
Pietro G Coen,
Robert Booy,
Michael Levin
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ABSTRACT: To determine whether suboptimal management in hospital could contribute to poor outcome in children admitted with meningococcal disease.
Case-control study of childhood deaths from meningococcal disease, comparing hospital care in fatal and non-fatal cases.
National statistics and hospital records.
All children under 17 years who died from meningococcal disease (cases) matched by age with three survivors (controls) from the same region of the country.
Predefined criteria defined optimal management. A panel of paediatricians blinded to the outcome assessed case records using a standardised form and scored patients for suboptimal management.
We identified 143 cases and 355 controls. Departures from optimal (per protocol) management occurred more frequently in the fatal cases than in the survivors. Multivariate analysis identified three factors independently associated with an increased risk of death: failure to be looked after by a paediatrician, failure of sufficient supervision of junior staff, and failure of staff to administer adequate inotropes. Failure to recognise complications of the disease was a significant risk factor for death, although not independently of absence of paediatric care (P = 0.002). The odds ratio for death was 8.7 (95% confidence interval 2.3 to 33) with two failures, increasing with multiple failures.
Suboptimal healthcare delivery significantly reduces the likelihood of survival in children with meningococcal disease. Improved training of medical and nursing staff, adherence to published protocols, and increased supervision by consultants may improve the outcome for these children and also those with other life threatening illnesses.
BMJ (Clinical research ed.). 07/2005; 330(7506):1475.
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ABSTRACT: Clinical diagnostic aids are relatively scarce, and are seldom used in routine clinical practice, even though the burden of diagnostic error may have serious adverse consequences. This may be due to difficulties in creating, maintaining and even using such expert systems. The current article describes a novel approach to the problem, where established medical content is used as the knowledge base for a pediatric diagnostic reminder tool called ISABEL. The inference engine utilizes advanced textual pattern-recognition algorithms to extract key concepts from textual description of diagnoses, and generates a list of diagnostic suggestions in response to clinical features entered in free text. Development was an iterative process, relying on sequential evaluation of clinical performance to provide the basis for improvement. The usage of the system over the past 2 years, as well as results of preliminary clinical performance evaluation are presented. These results are encouraging. The ISABEL model may be extended to cover other domains, including adult medicine.
Studies in health technology and informatics 02/2004; 107(Pt 2):1091-5.
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ABSTRACT: There is little published experience regarding the outcome of children with human immunodeficiency virus (HIV) infection treated on a paediatric intensive care unit (PICU). We describe the outcome of children with HIV infection in our hospital over a 10-year period.
We performed a retrospective analysis of all children with HIV infection admitted to our PICU between August 1992 and July 2002. Their ages ranged from 2 months to 11 years (median 4 months). Information collected included demographic data, clinical presentation, investigations, treatment and outcome.
There were 42 children with HIV infection admitted to PICU during the study period, with 66 admission episodes. Sixteen (38%) children died in PICU, and 26 (62%) survived their last PICU admission. Of these, 5 died at a later date (between 1 and 32 months after discharge from PICU) and 21 survived to the time of reporting. The most frequent reason for PICU admission was respiratory failure, due either to Pneumocystis carinii pneumonia (45% of admissions) or to other respiratory pathogens (32%). Over 80% of current survivors had good outcomes in terms of growth and development; 6 children had evidence of spastic diplegia.
Although there is significant mortality among children with HIV infection admitted to PICU, many of them survive their admission, and over 80% of the survivors have good outcomes with the currently available highly active anti-retroviral therapy. This provides evidence that intensive care treatment is appropriate for this group of patients in the United Kingdom.
Intensive Care Medicine 02/2004; 30(1):113-8. · 5.40 Impact Factor
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BMJ (Clinical research ed.). 10/2003; 327(7415):623.
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Paediatric nursing 10/2003; 15(7):34-5.
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BMJ (Clinical research ed.). 07/2002; 324(7353):1537-8.
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