Tag Archives: delayed diagnosis

Are There Really More Missed Injuries After Hours?

Yesterday, I wrote about the usual reasons for delayed diagnosis: insufficient diagnostic technique or insufficient recognition. What about time of day? A recent paper looked at the correlation between admission time and rate of missed injuries.

The work was done at a large teaching hospital and Level I trauma center in Australia. A large number of patients were reviewed over an 11 year period. The study was complicated slightly by the implementation of a dedicated trauma unit in the middle of the study period, but the authors stratified their groups to account for this. 

Results were stratified by time of admission: office hours vs after-hours vs weekends. Missed injuries were defined as those found after completion of the primary and secondary surveys. The overall statistical treatment appeared to be robust.

Here are the factoids:

  • A huge number of patients (53,000) were reviewed. This is a busy place!
  • There were 2519 missed injuries in 1262 patients (2.4%) [low!]
  • Missed injuries occurred during office hour admissions in 2.2%, after-hours in 2.6%, and on weekends 2.5% of the time
  • The increased incidence of delayed diagnosis in after-hours admits was marginally significant (p = 0.048)
  • Missed injuries appeared to have increased over time, and were 1.34 times more likely at the end of the study period vs the beginning
  • Thoracic spine and abdominal injuries were most the commonly missed

Bottom line: Hmm, time of day was not in my list of reasons for missing diagnoses. What gives? If you read the article closely, the trauma service at this hospital was staffed with a higher number of trainees after hours and on weekends than during office hours. It was also noted that incomplete physical examination was thought to be a factor in many of the delays. Most likely, both of my listed reasons were in play here. Inexperienced clinicians and insufficient examination are both major factors. And what about the increase in missed injuries over time? Midway through the study, the hospital implemented a dedicated trauma unit, and a tertiary exam became routine. This identified more injuries after the primary and secondary surveys were complete. 

Tomorrow I’ll talk about strategies to drop the incidence of missed injury.

Reference: Office hours vs after-hours: do presentation times affect the rate of missed injuries in trauma patients? Injury 2015, in press.

Missed Injury / Delayed Diagnosis

Missed injuries (or delayed diagnosis in polite conversation) are the bane of any trauma program.Trauma professionals want to know that they’ve identified all significant injuries in their patients so no future harm will occur due to them.

But what exactly is a missed injury? The definitions tend to vary a bit, which is why their incidence varies so widely in the literature (1 – 39%). The simplest way to describe one is any injury that is identified after a set amount of time. But what is a reasonable time frame? Some define it as the time spent in the emergency department (highest incidence). Others count any injury found after a predetermined period of time (typically 24-48 hours). Some use even longer time intervals, so they obviously look the best and have the lowest incidence.

And what are the factors that contribute to us “missing” these injuries? As you can imagine, there are quite a few, but they boil down to two major categories:

  • Inadequate diagnostic technique (physical exam and/or technology) – I can’t see it
  • Inadequate recognition – I didn’t think of it

A good physical exam with the focused use of appropriate imaging is paramount. Sure, you could use a shotgun approach and just scan everything. The problem is that CT scans have limitations, but we tend to forget that. So we believe that if we don’t see anything on scan, it must not exist. Wrong! The physical exam may pick up suspicious findings that tell the clinician that a specialized study is necessary to rule a potential injury out.

The failure to recognize that an injury is present can occur with everyone that “touches” the patient. The EMT or physician may not appreciate a subtle injury. The radiologist may miss a problem on the images they read. The surgeon might even fail to notice another injury separate from the one she is operating for. Obviously, experience plays a large part in this factor. Students will fail to appreciate a potential injury that a senior clinician will detect rapidly. 

What to do about it? Tomorrow, I’ll review a recent paper that tries to correlate missed injuries with time of admission. And on Friday, I’ll discuss some strategies to try to help keep it from happening to you.