PHM 2024 Session Recap
This session began with a discussion of a patient presentation pediatric hospitalists are very familiar with—a toddler with vomiting, diarrhea, and abdominal pain most consistent with a diagnosis of acute gastroenteritis. However, the presenters pushed the audience to expand their differentials, leading to a discussion of cognition and diagnostic errors.
The presenters remind us that while most of the time diagnostic hypotheses reached in less than five minutes are correct, it is important to remember that more than two-thirds of medical errors are thought to be cognitive. The presenters contrasted type 1 (“intuitive”) and type 2 (“analytical”) thinking and their use in clinical scenarios. Type 1 thinking tends to be more reflexive, automatically activated, experiential, based on pattern recognition, and heuristic. Type 2 thinking is slower and more complex, deliberate and conscious, and needed in more complex clinical scenarios. Overuse of type 1 thinking may lead to cognitive biases such as anchoring bias, premature closure on a diagnosis, and confirmation bias, leading to medical errors. The more deliberate analysis of a situation used in type 2 thinking is meant to prevent these cognitive biases and is the basis for the diagnostic timeout.
The diagnostic timeout is a structured reflection introduced by the presenters to improve diagnostic accuracy via a retrospective, deliberate examination of signs, symptoms, treatment, and test results with reflection on the leading diagnosis. This can be performed on any patient at any time, with suggested use when signs and symptoms are atypical for the presumed diagnosis, there is an unclear diagnosis, when objective data is no longer typical for the presumed diagnosis, or when any team member has a “gut feeling” that something is off. These are standardized discussion topics at regularly occurring charge nurse updates including vital sign trends, intake and output for the shift or last 24 hours, the patient’s plan for the next 24 hours, concerns escalated by the bedside nurse or patient family, discussion of what could go wrong, discussion of the patient’s status compared to the day prior, and patient progress based on the diagnosis listed. Any of these topics could result in a multidisciplinary diagnostic timeout being called if concerns arise.
A diagnostic timeout as operationalized by the presenters includes gathering the hospital medicine team including attending or fellow, residents, bedside nursing, respiratory therapy, and/or charge nurse. The medical team uses a smart phrase in Epic to guide timeout, taking approximately five minutes, with sections including subjective data, objective data, assessment, and plan. The subjective data includes the clinical concern that triggered the timeout. Objective data includes interventions that could mask symptoms of concern and important clinical data including laboratory studies, actual images from radiologic studies, intake and output, vital signs, and missing data if there are barriers to collecting vitals or intake and output. The assessment explains the leading diagnosis prior to the time out as well as supporting or conflicting evidence of that diagnosis. Importantly, the assessment section also includes can’t-miss diagnoses and a discussion of whether the current organ system or process is the only one that can produce the symptoms a patient is experiencing. The plan contains the next steps (which could include obtaining a new history and physical exam), obtaining new clinical data (including laboratory and/or imaging studies), changing the frequency of monitoring (such as more frequent vital signs), or deciding to include new people in the patient case (such as subspecialists, nurses, peer consults, or the family).
Importantly, to promote the psychological safety of the diagnostic timeout team members and to minimize family stress that may occur when openly discussing “red flag” diagnoses, the presenters recommend against including the family in the timeout. Instead, the team may update the family with the outcome of the timeout. In addition, the diagnostic timeout framework is not recommended during times of rapid deterioration, as it is meant to be a deliberate and thoughtful process. In times of rapid deterioration, it is better to shift from diagnostic reasoning to management reasoning per the hospitalist’s institutional guidelines.
Two real-life examples of timeout use were shared, with two very different outcomes. In one example, a question about new tachycardia led to a diagnostic timeout with the outcome of closer intake and output monitoring and additional fluid replacement, without delay of discharge. In the second example, when a patient with acute viral bronchiolitis did not improve as expected with time, a diagnostic timeout prompted further history and physical exam findings that led to a diagnosis of botulism with prompt treatment and a good outcome.
The presenters summarized by stating that diagnostic timeout is a tool to use when patients are not progressing as expected. They emphasized that the goal is not always to change management, but rather to avoid anchoring to a leading diagnosis that may no longer fit with clinical data, and also to improve interdisciplinary communication about patient status. This tool can be utilized by hospitalists when there are questions of diagnostic uncertainty, concerns about patient progress, or new clinical data that call the presumed diagnoses into question. Utilization of this tool can prevent cognitive errors that can lead to medical errors, improving the safety of our patients.
Key Takeaways
- Cognitive biases such as anchoring, premature closure, and confirmation bias can lead to medical errors.
- Use of type 2 thinking (slow, deliberate, and analytical) in a multidisciplinary setting can help avoid anchoring and improve communication.
- A standardized diagnostic timeout framework is a brief and effective tool to implement when patients are not progressing as expected, but not rapidly deteriorating.
Dr. Conley Hamlin is a second-year pediatric hospital medicine fellow at the University of Louisville/Norton Children’s Hospital in Louisville, Ky., and a member of SHM’s Pediatrics Special Interest Group executive council.