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

BACKGROUND

Pediatric 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.

METHODS

We 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.

RESULTS

At 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).

CONCLUSIONS

We demonstrated a marginal improvement in the quality of resident-documented DDx. Expansion of diagnoses considered within a DDx may contribute to higher diagnostic accuracy.

The key role of differential diagnosis in diagnosis

Differential diagnosis, that is, the creation of a list of suspected diseases, is important as it guides us in looking for these diseases in a patient during diagnosis. If a disease is not included in differential diagnosis, it is not likely to be diagnosed. It is important to include uncommon as well as common diseases in differential diagnosis.

The scientific nature of diagnosis

The method of diagnosis is essentially similar to the scientific method in which a cause is suspected from clues in a situation and formulated as a hypothesis that is proven correct by the observation of its consequences. An awareness of scientific nature of diagnosis emphasizes search for clues rather than evidence for a disease when we encounter a patient with symptoms.

Why is diagnosis not probabilistic in clinical-pathological conference (CPCs): Point

The main reason a probabilistic approach is not employed for diagnosis in clinical-pathological conferences (CPCs) is the notion of prior probability as prior evidence in it which encourages failure to suspect diseases with atypical presentations thus increasing diagnostic errors. In addition, errors in some individual persons are a necessary consequence of employing a probabilistic approach for inference as is seen in its use in the life insurance business. This consequence is in conflict with the aim in diagnosis of determining a disease correctly in every individual patient which also leads to a probabilistic approach not being employed in CPCs.