Najlla Nassery1,2, Michael A Horberg3,4, Kevin B Rubenstein3, Julia M Certa3, Eric Watson3, Brinda Somasundaram3, Ejaz Shamim3,5, Jennifer L Townsend6, Panagis Galiatsatos7, Samantha I Pitts1, Ahmed Hassoon2,8,9, David E Newman-Toker2,8,9,10. 1. Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 2. Center for Diagnostic Excellence, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA. 3. Mid-Atlantic Permanente Medical Group, Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA. 4. Mid-Atlantic Permanente Medical Group, Department of Infectious Diseases, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA. 5. Mid-Atlantic Permanente Medical Group, Department of Neurology, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA. 6. Division of Infectious Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 7. Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 8. Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. 9. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. 10. Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Abstract
OBJECTIVES: The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach. METHODS: SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared. RESULTS: There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits. CONCLUSIONS: Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.
OBJECTIVES: The aim of this study was to identify delays in early pre-sepsis diagnosis in emergency departments (ED) using the Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach. METHODS: SPADE methodology was employed using electronic health record and claims data from Kaiser Permanente Mid-Atlantic States (KPMAS). Study cohort included KPMAS members ≥18 years with ≥1 sepsis hospitalization 1/1/2013-12/31/2018. A look-back analysis identified treat-and-release ED visits in the month prior to sepsis hospitalizations. Top 20 diagnoses associated with these ED visits were identified; two diagnosis categories were distinguished as being linked to downstream sepsis hospitalizations. Observed-to-expected (O:E) and temporal analyses were performed to validate the symptom selection; results were contrasted to a comparison group. Demographics of patients that did and did not experience sepsis misdiagnosis were compared. RESULTS: There were 3,468 sepsis hospitalizations during the study period and 766 treat-and-release ED visits in the month prior to hospitalization. Patients discharged from the ED with fluid and electrolyte disorders (FED) and altered mental status (AMS) were most likely to have downstream sepsis hospitalizations (O:E ratios of 2.66 and 2.82, respectively). Temporal analyses revealed that these symptoms were overrepresented and temporally clustered close to the hospitalization date. Approximately 2% of sepsis hospitalizations were associated with prior FED or AMS ED visits. CONCLUSIONS: Treat-and-release ED encounters for FED and AMS may represent harbingers for downstream sepsis hospitalizations. The SPADE approach can be used to develop performance measures that identify pre-sepsis.
Authors: Michael A Horberg; Eric Watson; Mamta Bhatia; Celeena Jefferson; Julia M Certa; Seohyun Kim; Lily Fathi; Keri N Althoff; Carolyn Williams; Richard Moore Journal: Nat Commun Date: 2022-10-12 Impact factor: 17.694