About the Nationwide Children's Hospital Pilot Site Project
Project Lead: Rena Kasick, MD
During this prototyping collaborative, the team introduced a framework for diagnostic deliberation, the “diagnostic time-out” in efforts to circumvent cognitive biases that may interfere with medical decision-making. The diagnostic time-out asks the medical team to pause and structures the discussion with two questions: 1) What are the two to three most likely diagnoses for this patient? and 2) What is at least one life-threatening/more severe diagnosis that we must consider for this patient? Ideally, the diagnostic time-out would occur during morning rounds in collaboration with patients and their families. The hypothesis is that by fostering an environment to support active discussion regarding diagnosis, there would be an improvement in the differential diagnoses. The team examined resident and attending physician documentation of differential diagnoses on initial history and physicals (H&Ps) of patients admitted to the general pediatric ward with abdominal pain, a population which lends itself to a broad differential diagnosis but often conveys a diagnostic challenge when significant evaluation, including laboratory and imaging studies, in the emergency department is inconclusive. For the baseline, they reviewed 67 charts of patients admitted with nonspecific abdominal pain between July and December 2017. The diagnostic time-out intervention was introduced in January 2018. Documentation including two or more likely diagnoses and consideration of at least one life-threatening/more severe diagnosis were counted. Post-intervention, a total of 98 patient charts were reviewed between January and June 2018. The team monitored seven-day and 30-day readmission rates in the patient population. Our project aim was to increase the percentage of well-documented differential diagnoses on initial H&Ps from a baseline of 76% to 95%. Despite several iterative PDSA cycles and interventions over the course of this collaborative, we were unable to reach our goal within 6 months. However, the dialogue around differential diagnosis and diagnostic error has been robust and we are hoping to sustain the momentum in order to innovate and drive change.