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A diagnostic time-out to improve differential diagnosis in pediatric abdominal pain

Authors
  • Kasick, Rena T.1
  • Melvin, Jennifer E.1
  • Perera, Sajithya T.1
  • Perry, Michael F.1
  • Black, Joshua D.1
  • Bode, Ryan S.1
  • Groner, Jonathan I.1
  • Kersey, Kelly E.1
  • Klamer, Brett G.1, 2
  • Bai, Shasha1, 2
  • McClead, Richard E.1
  • 1 Nationwide Children’s Hospital, USA , (United States)
  • 2 The Ohio State University, USA , (United States)
Type
Published Article
Journal
Diagnosis
Publisher
De Gruyter
Publication Date
Nov 02, 2019
Volume
8
Issue
2
Pages
209–217
Identifiers
DOI: 10.1515/dx-2019-0054
Source
De Gruyter
Keywords
License
Yellow

Abstract

BackgroundPediatric abdominal pain is challenging to diagnose and often results in unscheduled return visits to the emergency department. External pressures and diagnostic momentum can impair physicians from thoughtful reflection on the differential diagnosis (DDx). We implemented a diagnostic time-out intervention and created a scoring tool to improve the quality and documentation rates of DDx. The specific aim of this quality improvement (QI) project was to increase the frequency of resident and attending physician documentation of DDx in pediatric patients admitted with abdominal pain by 25% over 6 months.MethodsWe reviewed a total of 165 patients admitted to the general pediatrics service at one institution. Sixty-four history and physical (H&P) notes were reviewed during the baseline period, July–December 2017; 101 charts were reviewed post-intervention, January–June 2018. Medical teams were tasked to perform a diagnostic time-out on all patients during the study period. Metrics tracked monthly included percentage of H&Ps with a ‘complete’ DDx and quality scores (Qs) using our Differential Diagnosis Scoring Rubric.ResultsAt baseline, 43 (67%) resident notes and 49 (77%) attending notes documented a ‘complete’ DDx. Post-intervention, 59 (58%) resident notes and 69 (68%) attending notes met this criteria. Mean Qs, pre- to post-intervention, for resident-documented differential diagnoses increased slightly (2.41–2.47, p = 0.73), but attending-documented DDx did not improve (2.85–2.82, p = 0.88).ConclusionsWe demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

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