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Original article

Vol. 145 No. 0910 (2015)

The proportion of correct diagnoses is low in emergency patients with nonspecific complaints presenting to the emergency department

  • Arno Peng
  • Martin Rohacek
  • Selina Ackermann
  • Julia Ilsemann-Kakaroumis
  • Leyla Ghanim
  • Anna Messmer
  • Franziska Misch
  • Christian Nickel
  • Roland Bingisser
DOI
https://doi.org/10.4414/smw.2015.14121
Cite this as:
Swiss Med Wkly. 2015;145:w14121
Published
22.02.2015

Abstract

OBJECTIVE: To determine the proportion of correct emergency department (ED) diagnoses and of hospital discharge diagnoses, in comparison with final diagnoses at the end of a 30-day follow-up, in patients presenting with nonspecific complaints (NSCs) to the ED; to determine differences between male and female patients in the proportion of missed diagnoses.

METHODS: Prospective observational study. Diagnoses made at the ED, hospital discharge diagnoses, and final diagnoses were compared.

RESULTS: Of 22,782 nontrauma patients presenting to the ED from May 2007 until May 2009, 9,926 were triaged as emergency severity index level 2 or 3, of whom 789 presented with NSCs. After exclusion of 217 patients, 572 were included for final analysis.

The final diagnosis at the end of follow-up was taken to be the correct “gold standard” diagnosis. In 263 (46.0%) patients, this corresponded to the primary ED diagnosis, and in 292 (51%) patients to the hospital discharge diagnosis. The most frequent final diagnoses were urinary tract infections (n = 49), electrolyte disorders (n = 40) and pneumonia (n = 37), and were correctly diagnosed at the ED in 23, 21 and 27 patients, respectively. Of the twelve most common diagnoses (corresponding to 354 patients), functional impairment was most frequently missed. Among these 354 patients, diagnoses were significantly more often missed in women than in men (142 of 231 [62%] women vs 57 of 123 [46%] men, p = 0.004).

CONCLUSION: Patients presenting to the ED with NSCs present a diagnostic challenge. New diagnostic tools are needed to help in the diagnosis of these patients.

 

ClinicalTrials.gov registration number: NCT00920491

References

  1. Nemec M, Koller MT, Nickel CH, Maile S, Winterhalder C, Karrer C, et al. Patients presenting to the emergency department with non-specific complaints: the Basel Non-specific Complaints (BANC) study. Acad Emerg Med. 2010;17:284–92.
  2. Vanpee D, Swine C, Vandenbossche P, Gillet JB. Epidemiological profile of geriatric patients admitted to the emergency department of a university hospital localized in a rural area. European journal of emergency medicine: official journal of the European Society for Emergency Medicine 2001;8:301–4.
  3. Chew WM, Birnbaumer DM. Evaluation of the elderly patient with weakness: an evidence based approach. Emerg Med Clin North Am. 1999;17:265–78, x.
  4. Eliastam M. Elderly patients in the emergency department. Ann Emerg Med. 1989;18:1222–9.
  5. Sanders AB, Morley JE. The older person and the emergency department. J Am Geriatr Soc. 1993;41:880–2.
  6. Jarrett PG, Rockwood K, Carver D, Stolee P, Cosway S. Illness presentation in elderly patients. Arch Intern Med. 1995;155:1060–4.
  7. Rutschmann OT, Chevalley T, Zumwald C, Luthy C, Vermeulen B, Sarasin FP. Pitfalls in the emergency department triage of frail elderly patients without specific complaints. Swiss Med Wkly. 2005;135:145–50.
  8. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28:304–9.
  9. Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169:1881–7.
  10. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165:1493–9.
  11. Grossmann FF, Zumbrunn T, Frauchiger A, Delport K, Bingisser R, Nickel CH. At risk of undertriage? Testing the performance and accuracy of the emergency severity index in older emergency department patients. Ann Emerg Med. 2012;60:317–25 e313.
  12. Nickel CH, Ruedinger J, Misch F, Blume K, Maile S, Schulte J, et al. Copeptin and peroxiredoxin-4 independently predict mortality in patients with nonspecific complaints presenting to the emergency department. Academic emergency medicine: official journal of the Society for Academic Emergency Medicine 2011;18:851–9.
  13. Aminzadeh F, Dalziel WB. Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions. Ann Emerg Med. 2002;39:238–47.
  14. Gilboy N TP, Travers DA, ed. Emergency Severity Index, Version 4: Implementation Handbook. Rockville: Agency for Healthcare Research and Quality; 2005.
  15. Grossmann FF, Nickel CH, Christ M, Schneider K, Spirig R, Bingisser R. Transporting Clinical Tools to New Settings: Cultural Adaptation and Validation of the Emergency Severity Index in German. Ann Emerg Med. 2011;57:257–64.
  16. Zhu W, (2010) Sensitivity, specificity, accuracy, associated confidence interval and ROC analysis with practical SAS implementations. [Accessed 14th November, 2010] http://www.nesug.org/Proceedings/nesug10/hl/hl07.pdf.
  17. Nickel CH, Nemec M, Bingisser R. Weakness as presenting symptom in the emergency department. Swiss Med Wkly. 2009;139:271–2.
  18. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208–12.
  19. Heuer JF, Gruschka D, Crozier TA, Bleckmann A, Plock E, Moerer O, et al. Accuracy of prehospital diagnoses by emergency physicians: comparison with discharge diagnosis. Eur J Emerg Med. 2012;19:292–6.
  20. Lewis R, Lamdan RM, Wald D, Curtis M. Gender bias in the diagnosis of a geriatric standardized patient: a potential confounding variable. Acad Psychiatry. 2006;30:392–6.
  21. Munch S. Gender-biased diagnosing of women’s medical complaints:contributions of feminist thought, 1970–1995. Women Health. 2004;40:101–21.
  22. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular Health Study Collaborative Research G. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sc. 2001;56:M146–56.
  23. Safran DG, Rogers WH, Tarlov AR, McHorney CA, Ware JE. Gender differences in medical treatment: The case of physician-prescribed activity restrictions. Soc Sci Med. 1997;45:711–22.
  24. Mody L, Juthani-Mehta M. Urinary tract infections in older women: a clinical review. JAMA. 2014;311:844–54.
  25. Khasriya R, Khan S, Lunawat R, Bishara S, Bignall J, Malone-Lee M, et al. The inadequacy of urinary dipstick and microscopy as surrogate markers of urinary tract infection in urological outpatients with lower urinary tract symptoms without acute frequency and dysuria. J Urol. 2010;183:1843–7.
  26. Webster DC. Interstitial cystitis: women at risk for psychiatric misdiagnosis. AWHONNS Clin Issues Perinat Womens Health Nurs. 1993;4:236–43.
  27. Benedict M. Wert der klinischen Erstbeurteilung. Habil.-Schr. Med. Fak. Basel, 2000, Basel. German.
  28. Arntz HR, Klatt S, Stern R, Willich SN, Beneker J. Are emergency physicians’ diagnoses accurate? Der Anaesthesist. 1996;45:163–70. German.
  29. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med. 2008;121:S2–23.
  30. Ely JW, Graber ML, Croskerry P; Checklists to reduce diagnostic errors. Acad Med. 2011;86:307–13.

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