Use of autopsy results in the emergency department quality assurance plan

Discrepancies Between Clinical and Autopsy Diagnoses in Rapid Response Team-Assisted Patients: What Are We Missing?

OBJECTIVES

The rapid response team (RRT) assists hospitalized patients with sudden clinical deterioration. There is scarce evidence of diagnostic accuracy in this scenario, but it is possible that a considerable rate of misdiagnosis exists. Autopsy remains a valuable tool for assessing such question. This study aimed to compare clinical (premortem) and autopsy (postmortem) diagnoses in patients assisted by the RRT and describe major discrepancies.

METHODS

We reviewed 104 clinical data and autopsies from patients assisted by the RRT during a cardiac arrest event in a tertiary care hospital in Brazil. Clinical and autopsy diagnostic discrepancies were classified using the Goldman criteria. Other clinical and pathological data were described, and the group with major diagnostic discrepancies was further analyzed.

RESULTS

We found 39 (37.5%) patients with major diagnostic discrepancies. Most frequent immediate causes of death in this group determined by autopsy were sepsis (36%), pulmonary embolism (23%) and hemorrhagic shock (21%). Pulmonary embolism was the cause of death significantly more frequent in the major discrepancy group than in the minor discrepancy group (23% versus 3%, P = 0.002). We individually described all major diagnostic discrepancies.

CONCLUSIONS

We found a high rate (37.5%) of major misdiagnosis in autopsies from patients assisted by the RRT in a tertiary teaching hospital. Pulmonary embolism was the most inaccurate fatal diagnosis detected by autopsy.

Optimal treatment for blunt trauma patients with cardiopulmonary arrest: An account of a successful case and review of the literature

Introduction:

Prognosis of cardiopulmonary arrest occurring in patients with blunt trauma is very poor; patients rarely recover from this condition. We either do not attempt cardiopulmonary resuscitation or terminate it after some time in blunt trauma–cardiopulmonary arrest cases. We presented a rare case of successful resuscitation of a patient with blunt trauma–cardiopulmonary arrest.

Case presentation:

A 54-year-old man was admitted to our emergency department after being injured in a traffic accident. The patient suffered from ventricular fibrillation, and spontaneous circulation was restored by a defibrillator. The estimated arrest time was 20 min.

Discussion:

On arrival of our emergency department, the patient showed intra-abdominal hemorrhage and we performed emergency surgery; 10 days after admission, the patient suffered from pulseless ventricular tachycardia—coronary angiography was performed, which revealed that the patient had coronary artery stenosis.

Conclusion:

We experienced trauma patients concealed with coronary artery stenosis. In traumatic arrest with ventricular fibrillation, it may be due to a medical reason, and more prolonged and intensive resuscitation may be considered.

Autopsy in Islam and current practice in Arab Muslim countries

Autopsy, or post-mortem examination, is the dissection of a dead body. It is performed for many reasons. Attitudes toward dead bodies vary with religious beliefs and cultural and geographical backgrounds. We have carried out an extensive literature review to determine the Islamic view and current practice of Autopsy, in at least four Arab countries which published their experiences. Several research articles have studied the history of Islamic Autopsy as well as the current situation and legal debates about it. The overwhelming conclusion is that data is lacking. More must be published from Arabic Muslim countries and more research done to correct misconceptions. We also recommend more application of non-invasive Autopsy.

Death Within 48 Hours of Admission to the Emergency Department: The Value of Autopsy

OBJECTIVE

To identify factors that contribute to patient death within 48 hours of admission to the emergency department.

MATERIALS AND METHODS

A retrospective study of the patients who died within 48 hours of admission to the emergency department, from the years 2000 to 2003. The antemortem diagnosis and postmortem diagnosis were compared.

RESULTS

A total of 189 autopsies were performed. The mean age at death for men (41.4 years) was lower than that for women (48.6) (p = 0.02). In both men and women, cardiac system involvement was the leading cause of death (27.5%), with myocardial infarction at 21.2%. The other common causes of death for both genders were blunt trauma (20.1%), intoxication with alcohol and/or other drugs (13.8%), penetrating trauma (gunshot or stab injuries) (13.2%), pulmonary thromboembolism (7.9%), and death caused by other respiratory causes (7.4%). Death caused by pulmonary thromboembolism was more common in women, whereas death caused by strokes, burns, and penetrating trauma were seen almost exclusively in men.

CONCLUSIONS

Our study found a considerable concordance between the presumed antemortem cause of death and the postmortem findings. Although the mean age of death caused by myocardial infarction in our study was 52.45 years, MI caused a significant number of deaths among adults younger than 40 years of age.

Aetiology of unsuccessful prehospital witnessed cardiac arrest of unclear origin

OBJECTIVES

To determine, by means of autopsy, the cause of death following unsuccessful cardiopulmonary resuscitation of patients with a witnessed prehospital cardiac arrest of unclear origin.

METHOD

Observational study of all prehospital-witnessed cardiac arrest of unclear origin over a period of 19 months in the emergency medical service region of a tertiary care hospital.

RESULTS

During the study period, 211 prehospital cardiopulmonary resuscitation attempts were recorded. In 144 study participants, cardiopulmonary resuscitation was not successful: there was no return of spontaneous circulation. Cardiac arrest of traumatic or other clear origin was not considered, nor were paediatric cases. Thirty out of the 114 remaining patients underwent an autopsy (26.3%). The main aetiology of cardiac arrest in this selected population was ischaemic heart disease in 16 out of 30 patients (53.3%) followed by pulmonary embolism in four patients (13.3%) and vascular disease other than coronary disease in two patients (6.7%). Other causes consisted of hypertrophic obstructive cardiomyopathy (one patient) (3.3%) and poisoning (one patient) (3.3%). The cause of death could not be identified in six cardiac arrest victims (20%).

CONCLUSIONS

Ischaemic heart disease and pulmonary embolism account for 66.6% of all witnessed cardiac arrest with no return of spontaneous circulation.

Overestimation of clinical diagnostic performance caused by low necropsy rates

BACKGROUND

Diagnostic sensitivity is calculated as the number of correct diagnoses divided by the sum of correct diagnoses plus the number of missed or false negative diagnoses. Because missed diagnoses are generally detected during clinical follow up or at necropsy, the low necropsy rates seen in current practice may result in overestimates of diagnostic performance. Using three target conditions (aortic dissection, pulmonary embolism, and active tuberculosis), the prevalence of clinically missed cases among necropsied and non-necropsied deaths was estimated and the impact of low necropsy rates on the apparent sensitivity of antemortem diagnosis determined.

METHODS

After reviewing case series for each target condition, the most recent study that included cases first detected at necropsy was selected and the reported sensitivity of clinical diagnosis adjusted by estimating the total number of cases that would have been detected had all decedents undergone necropsy. These estimates were based on available data for necropsy rates, time period, country (US v non-US), and case mix.

RESULTS

For all three target diagnoses, adjusting for the estimated prevalence of clinically missed cases among non-necropsied deaths produced sensitivity values outside the 95% confidence interval for the originally reported values, and well below sensitivities reported for the diagnostic tests that are usually used to detect these conditions. For active tuberculosis the sensitivity of antemortem diagnosis decreased from an apparent value of 96% to a corrected value of 83%, with a plausible range of 42-91%; for aortic dissection the sensitivity decreased from 86% to 74%; and for pulmonary embolism the reduction fell only modestly from 97% to 91% but was still lower than generally reported values of 98% or more.

CONCLUSIONS

Failure to adjust for the prevalence of missed cases among non-necropsied deaths may substantially overstate the performance of diagnostic tests and antemortem diagnosis in general, especially for conditions with high early case fatality.

What do we know about patients dying in the emergency department?

OBJECTIVE

To determine our knowledge in terms of cause of death and quality of death certification about patients who die in the emergency department. To establish the role of autopsy in this matter.

METHODS

Retrospective chart review of all patients dying in an academic emergency department (ED) of a tertiary hospital over a period of 1 year.

RESULTS

One hundred and ninety-six patients died in the ED in 1998. In 141/196 patients the cause of death could be determined on clinical grounds. In 53/196 patients, the antemortem clinical diagnosis was unknown. Twenty-nine out of 53 patients underwent autopsy. In all but one patient autopsy revealed the cause of death. After retrospective analysis of all patient data (notes, biology, radiology and pathological investigation), the major causes of death were cardiac (19.4%), cerebral (non-traumatic) (16.8%), trauma (15.3%) and unknown (13.3%). In the patient group with sudden cardiac arrest of unclear origin, the postmortem cause of death was identified as cardiac (51.7%), non-traumatic bleeding (10.3%), infectious (10.3%) and pulmonary embolism (3.4%). In the group of patients with a clinically clear cause of death, who underwent autopsy, 14 class II findings according to the Goldman's classification of autopsy diagnoses (i.e. major diagnosis whose detection would not have altered therapy nor outcome) were found in 16 patients. No class I findings (i.e. major diagnosis whose detection would have altered therapy or outcome) were noted. Altogether, major discrepancies between the antemortem presumed cause of death according to the notes and the real cause of death was found in 15.3%.

CONCLUSIONS

Autopsy remains a very important tool to establish the cause of death in patients dying in ED. The concordance between the antemortem presumed cause of death recorded in the patient notes and the real cause (all patient data) is poor.

Infectious diseases detected at autopsy at an urban public hospital, 1996-2001

Previous studies have demonstrated significant discrepancy rates between clinical and autopsy diagnoses. However, infectious diseases have not received emphasis in these studies. We conducted a study to determine whether the clinical and autopsy diagnoses of infectious diseases are concordant or discrepant and to determine discrepancy rates. Retrospective reviews of the records of 276 patients (adults, 182; fetuses and neonates, 94) who underwent autopsy during the years 1996 through 2001 were performed. Comparison of clinical and autopsy diagnoses was performed using the Goldman classification scheme. Of 182 adult patients, 137 (75.3%) had an infectious disease at autopsy. In 59 (43.1%) of 137 patients, the infectious disease diagnoses were unknown clinically. Of 94 fetuses and neonates, 45 (48%) had an infectious disease at autopsy. In 26 (58%) of 45 patients, the infectious disease diagnoses were unknown before death. There are substantial discrepancies between clinical and autopsy diagnoses of infectious diseases. In adults, acute bronchopneumonia is the infectious disease most often missed clinically; in fetuses and neonates, it is acute chorioamnionitis.

Promoting patient safety and preventing medical error in emergency departments

An estimated 108,000 people die each year from potentially preventable iatrogenic injury. One in 50 hospitalized patients experiences a preventable adverse event. Up to 3% of these injuries and events take place in emergency departments. With long and detailed training, morbidity and mortality conferences, and an emphasis on practitioner responsibility, medicine has traditionally faced the challenges of medical error and patient safety through an approach focused almost exclusively on individual practitioners. Yet no matter how well trained and how careful health care providers are, individuals will make mistakes because they are human. In general medicine, the study of adverse drug events has led the way to new methods of error detection and error prevention. A combination of chart reviews, incident logs, observation, and peer solicitation has provided a quantitative tool to demonstrate the effectiveness of interventions such as computer order entry and pharmacist order review. In emergency medicine (EM), error detection has focused on subjects of high liability: missed myocardial infarctions, missed appendicitis, and misreading of radiographs. Some system-level efforts in error prevention have focused on teamwork, on strengthening communication between pharmacists and emergency physicians, on automating drug dosing and distribution, and on rationalizing shifts. This article reviews the definitions, detection, and presentation of error in medicine and EM. Based on review of the current literature, recommendations are offered to enhance the likelihood of reduction of error in EM practice.

The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit

OBJECTIVE

To evaluate pre- and post mortem diagnoses and determine their relationship and the discrepancy rate.

DESIGN

Retrospective, descriptive chart review.

SETTING

A 36-bed surgical intensive care unit (ICU) of an academic, tertiary care center.

PATIENTS

149 adults who died in the ICU and had an post mortem examination.

INTERVENTIONS

Review of the medical record for the ICU course, hospital discharge/death summary, major and minor clinical diagnoses, and the cause of death were directly compared with the major and minor diagnoses and cause(s) of death determined by post mortem examination.

MEASUREMENTS AND MAIN RESULTS

Major and minor clinical diagnoses were categorized by the Goldman method and compared with post mortem findings to determine the discrepancy rate. Patients were categorized by the primary surgical service that provided medical and surgical care. Sixty-one (41%) patients had discrepancies uncovered at post mortem examination, of which 20 had two discrepancies. Twenty-three percent of the 149 patients had errors categorized as major and 18% as minor. Overall, 85% of the major errors were undiagnosed infectious processes. Complete agreement between the pre and post mortem diagnoses was present in 58% and varied with the surgical population: trauma group (86%) and cardiac surgery (69%) vs. the transplantation group (17%). Those with longer lengths of stay in the ICU were more likely to develop and, subsequently, have a major error discovered post mortem. Conversely, those who died early (<48 hrs), were less likely to have an undiagnosed disease at post mortem examination and, thus, more likely to have complete agreement between pre and post mortem findings.

CONCLUSIONS

The overall discrepancy rate as well as the infectious discrepancy rate between pre mortem clinical diagnoses and post mortem findings were substantially higher in a surgical ICU compared with a hospital-wide population. The majority of these discrepancies were undiagnosed infections. The length of time spent in the ICU before death appeared to influence the rate of errors uncovered at the post mortem examination, suggesting that a longer ICU course, as well as the particular type of surgical patient population, may increase the chance of developing an infectious process, only to be uncovered at post mortem examination.

Factors predicting cases with unexpected clinical findings at necropsy

AIMS/BACKGROUND

A major medical role for postmortem examinations is the detection of clinically unexpected disease processes contributing to death. The aim of the present study was to determine whether simple clinical parameters can predict the presence of important unanticipated findings at necropsy.

METHODS

Prospective audit of adult necropsies carried out in a single year to assess the extent of unexpected findings at necropsy, to compare these cases with non-necropsied deaths to confirm they are a similar population and to seek features that predict which cases have unexpected necropsy findings.

RESULTS

No correlation was found between age, sex, duration of in-hospital treatment, surgical intervention, clinical specialty, or necropsy request rates and incidence of unexpected findings in 187 adult necropsies.

CONCLUSIONS

No parameters have been identified for patient selection to permit an increase in the yield of clinically unexpected findings. Until there is clear evidence that the current practice of patient selection is anything more than random, an increase in postmortem examination rates, as proposed by the Joint Working Party of the Royal College of Pathologists, the Royal College of Physicians of London and the Royal College of Surgeons of England in their report The Autospy and Audit, will increase the workload without necessarily producing a commensurate gain in knowledge.

Quality assurance in Canadian emergency departments: a national survey

This survey provides a description of quality assurance (QA) in emergency departments of Canadian hospitals, looking at QA structure, processes, outcome measurements, and applications. With survey questions addressing the existence of a written QA plan, chart audits, mortality review, data collection and reporting, the frequency of comprehensive QA programs was measured. All Canadian hospitals with 200 or more beds were surveyed by mail; 66% responded (134 of 204). Teaching and larger hospitals were more likely to respond. QA structure was reported by 81% of respondents, with 59% of these having a written plan. The majority collected data (74%), issued reports (75%), and had QA committees (50%), but only 34% were computerized. QA processes included chart audits (78%), review of laboratory, radiology, or ECG reports (73%, 46%, 54%, respectively), and mortality review (91%). Comprehensive QA existed in only 12% of responding hospitals.

Autopsies and the pediatric intensive care unit

The pediatric autopsy can provide great benefits to families at a time when their world is falling apart. It can be invaluable in the processing of grief that families endure, helping them to plan their future. Autopsy results not only provide information but may also provide consolation by giving the family the opportunity to discuss the disease process that resulted in death. Autopsy results also provide information regarding the future and reassurance that appropriate care was given. Failure to perform a postmortem examination denies the family and the clinician knowledge regarding mechanisms of disease, confirmation or inclusion of unsuspected diagnoses, and the presence of iatrogenic complications. This missed information can be both informative to the current family's situation and potentially therapeutic in future cases. If death is the final chapter of life, then the physician's responsible relationship with the parents of the deceased patient should not end until a conference takes place several weeks or months after the child's death. The results of the postmortem examination provide a beginning point for discussion regarding the child's illness and death, the parents responses and coping, and the opportunity to help the family make sense of and bring closure to one of life's greatest crises.