Who Makes the Diagnosis? A Retrospective Observational Study Comparing the Emergency Department Initial Diagnosis and the Internal Medicine Discharge Diagnosis

Abstract

Background: Despite the central role of Internal Medicine (IM) in emergency admission management, both users and health planners do not seem to recognize the distinct features of the activities relative to IM. According to the Literature, the role of IM is characterized by: (1) Acute, critical, multiple pathology and complex patient management; (2) Difficult clinical diagnosis; (3) Individuation of priorities; (4). Hospitalterritory pathways promoting integration of diverse specialist activities. Objective: To determine the proportion of correct and missed emergency department (ED) diagnoses compared to IM discharge diagnoses. Methods: ED diagnoses and hospital IM discharge diagnoses were compared. By using the consensus among experts method a diagnosis evaluation grid was formed. Diagnosis was defined as follows: (1) The “gold standard” diagnosis (correct diagnosis), according to ICD10 (10th International Classification of Diseases and Related Health Problems), independently made by two experienced IM specialists and reported in the discharge letter. (2) ED diagnosis made by the Emergency Physician and reported in the patient acceptance or transfer record to the Internal Medicine Unit; (3) Priority Error: the correct diagnosis appears as a secondary diagnosis in the ED diagnosis; (4) Incomplete diagnosis: diagnostic orientation without a precise diagnosis; (5) Diagnosis Error: the correct diagnosis was not made in the ED. The first 13 diagnoses made in ED are defined as the most frequent in number within the sample being examined. Results: 317 non trauma patients presenting to the ED from June to September 2016 and admitted to the INI (Italian Neurotraumatology Institute) IM department were included for final analysis. The final diagnosis at IM discharge was taken to be the correct “gold standard” diagnosis. In 180 patients (56,7%) this corresponded with the primary ED diagnosis, in 104 patients (32,8%) the diagnosis was missed and in the remaining 10.5%, the diagnosis (33 patients) was incomplete or a priority error occurred. The most frequent final diagnoses were cardiac failure (n =53), pneumonia (n= 43), TIA (Transient Ischemic Attack) (n=31); respiratory failure (n=28); COPD (Chronic Obstructive Pulmonary Disease) (n=21), correctly diagnosed in the ED in 37, 26, 19, 20, and 11 patients, respectively. Conclusion: Patients presenting to ED with acute symptoms represent a diagnostic challenge that in 43.3% of cases is explained by the clinical activity carried out by the Internal Medicine specialist during hospitalization. The study confirms the central role of Internal Medicine in defining the correct diagnosis in acute and complex patients. It is likely time to instigate awareness campaigns for patients and policy makers promoting the central role of Internal Medicine in hospital organization and hospital-territory integration and to duly recognize the complexity of IM activity through the endorsement of appropriate DRGs (Diagnosis Related Groups) in the Medical Area.