under the care of a medical practitioner. In cases ... cate if he or she is satisfied as to the cause of death. ... class 2 missed diagnosis, 19 (95%) were brought to.
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BRIEF REPORT A Comparison of the Antemortem Clinical Diagnosis and Autopsy Findings for Patients Who Die in the Emergency Department Alan E. O’Connor, MB, DCH, Jeremy T. Parry, MB, Drew B. Richardson, MB, BSc(Hons), Sanjiv Jain, MB, BS, Peter B. Herdson, MB Abstract Objectives: In spite of advances in medical technology, there remains a high discrepancy rate between the antemortem clinical diagnosis and postmortem examination diagnosis for patients who die in hospitals. The aim of this study was to compare the clinical and postmortem examination diagnoses of patients who died in the emergency department (ED) of a tertiary hospital, and to analyze any discrepancy between them. Methods: The study was a retrospective chart review of patients who died in the ED of a tertiary referral teaching hospital and a comparison of the antemortem diagnosis with the autopsy diagnosis. Any missed diagnosis was classified, according to the Goldman criteria, into major and minor missed diagnoses. Results: A total of 59 patients were
eligible for inclusion in the study. There was complete agreement between the antemortem diagnosis and the autopsy result in 51% of cases. The incidence of major missed diagnoses—where if the diagnosis had been known before the patient died, treatment may have been altered or survival may have been prolonged—was 7%. Conclusions: There is a significant discrepancy rate between the antemortem diagnosis and the autopsy diagnosis. However, in this study, serious missed diagnoses in which outcome may have been significantly altered are unusual among those who die in the ED of a tertiary referral hospital. Key words: autopsy; postmortem examination; emergency medicine; diagnosis. ACADEMIC EMERGENCY MEDICINE 2002; 9:957–959.
Postmortem examinations, although suffering a decline in usage during the past few decades, remain a valuable contributor to our medical education and toward the understanding of medicine’s limitations.1,2 Moreover, they serve as important quality assurance indicators of clinical acumen and diagnostic tools, and as a measure of the efficacy and appropriateness of any therapy administered.3,4 In spite of advances in medical technology, there is still a high discrepancy rate between the clinical and postmortem diagnoses of deceased patients.5,6 The aim of this study was to compare the clinical and postmortem examination diagnoses of patients who died in the emergency department (ED) of a tertiary hospital, and to analyze any discrepancies.
METHODS
From the Departments of Emergency Medicine (AEO, JTP, DBR) and Pathology (SJ, PBH), The Canberra Hospital, ACT, Australia. Dr. O’Connor is currently in the Department of Emergency Medicine, Latrobe Regional Hospital, Victoria, Australia; and Dr. Parry is currently in the Department of Pathology, Peter MacCallum Cancer Institute, Melbourne, Australia. Received February 21, 2002; revision received May 9, 2002; accepted May 10, 2002. Address correspondence and reprint requests to: Alan O’Connor, 噦 Emergency Department, Latrobe Regional Hospital, Traralgon, Vic 3844, Australia. e-mail: alan.oconnor@ bigpond.com.
Study Design. This was a retrospective study, analyzing the patient notes and autopsy results of all patients who died in the ED of the Canberra Hospital during the period January 1, 1999, through June 30, 2001, who underwent a postmortem examination. This study was granted exemption from ethics committee approval by the ACT Health and Community Care Ethics Committee. Study Setting and Population. The Canberra Hospital is a tertiary referral hospital in the Australian Capital Territory (ACT), with 450 beds. The ED sees 48,000 new presentations per year, 30% of whom are pediatric patients. In Australia, autopsies are required by law on all deaths involving trauma, including homicides, suicides, and incidents considered to be ‘‘accidents.’’ They are also required by law when death is unexpected or when the patient has not recently been under the care of a medical practitioner. In cases where referral to the coroner is not mandatory as detailed above, a doctor can write a death certificate if he or she is satisfied as to the cause of death. In this instance, the family can request a hospital autopsy not under the auspices of the coroner. This is carried out by the department of anatomical pathology in our institution.
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O’Connor et al. • CLINICAL VS AUTOPSY DIAGNOSES
TABLE 1. Errors in Goldman Classification versus Autopsy Findings Type of Error
Goldman Class
Major
1
Major
2
Minor
3
Minor
4 (i)
Minor
4 (ii)
No error
5
Definition
Example: Death due to:
Directly related to death; if recognized, may have altered treatment or survival Directly related to death; if recognized, would not have altered treatment or survival Incidental autopsy finding not directly related to death but related to terminal disease process Incidental autopsy finding unrelated to cause of death Incidental autopsy finding contributing to death in an already terminally ill patient Clinical and autopsy diagnoses in complete agreement
Unsuspected myocardial infarction presenting with chest pain Unsuspected myocardial infarction presenting with cardiac arrest Known myocardial infarction with unsuspected left ventricular mural thrombus Known myocardial infarction with unsuspected lung cancer Unsuspected aspiration pneumonia in an already terminally ill patient
Study Protocol. The ED patient database was examined to identify all patients who died in the ED during the review period. The medical records of all these patients were then examined to identify those patients on whom a postmortem examination was carried out. These data were then cross-referenced with the data of the ACT coroner’s office and the hospital department of anatomical pathology to ensure that no patients were missed. The autopsy reports of all these cases were obtained from either the ACT coroner’s office, hospital medical records, or the department of anatomical pathology. The clinical diagnosis reached by the attending clinician was taken from the clinical notes made by the primary doctor attending the patient. Depending on the time from admission to the death of the patient, this diagnosis may have been made with the benefit of a collateral history only (as in the case of patients arriving in cardiac arrest) or with the help of the full spectrum of investigative procedures available to the emergency physician in a tertiary ED. Any discrepancies between the clinical diagnosis and the postmortem examination findings were categorized, using the Goldman criteria,7 into major and minor classes (Table 1).
examination: all of these cases were coroner’s autopsies. This represents an autopsy rate of 67%. In all 59 cases, the hospital medical records and autopsy results were reviewed. In the study group, the most common cause of death as determined by postmortem examination was myocardial ischemia/infarction (37% of cases). This was followed by multiple traumatic injuries (13.5%) and pulmonary embolism (7%). During the review process, the fourth reviewer was necessary in two cases (3.3%) where agreement could not be reached by the initial reviewers. The results are tabulated in Table 2. Three patients had a diagnosis in more than one Goldman category—as a result, the number of cases in this table adds up to 64 rather that 59. The four Goldman class 1 diagnoses were a pulmonary embolus, a myocardial infarction, dissection of the thoracic aorta, and a traumatic rupture of the diaphragm. Of the 20 patients who are classified as Goldman class 2 missed diagnosis, 19 (95%) were brought to the ED in cardiac arrest, and were subsequently declared dead in the ED. This is a common scenario in EDs, and making a definitive diagnosis in these patients is often virtually impossible.
Review Process. Two specialist (board-certified) emergency physicians and a registrar in emergency medicine independently reviewed all the patients hospital records. These three physicians then met and discussed any areas of disagreement between the antemortem and postmortem diagnoses. Where all three physicians reached consensus, the review process was complete. In cases where there was residual disagreement, a further review was undertaken by an experienced pathologist following which agreement was reached in all cases.
DISCUSSION
RESULTS There were 88 patients who died in the ED during the review period, of whom 59 had a postmortem
Deaths in the ED are relatively rare. Since many of these deaths are unexpected, a high proportion of TABLE 2. Goldman Categorization of the Study Patients Goldman Classification 1 2 3 4 5
Total Number (%) of Cases 4 20 4 6 30
(7%) (34%) (14%) (10%) (51%)
Note: three patients had diagnoses in more than one Goldman category.
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patients are referred for a postmortem examination.8 Few studies have analyzed the results of autopsy examinations in ED patients. One study, which looked at this issue in pediatric cases, showed that there were more Goldman class 1 through 4 unexpected findings in pediatric intensive care unit patients than in ED or ward patients.8 Another study suggested that patients referred for postmortem examination from the ED had a high rate of discrepancies between the diagnosis made during resuscitation and the cause of death found at autopsy, especially in those dying from noncardiac causes.9 In our study, there is a significant discrepancy between the antemortem and autopsy diagnoses, but most missed diagnoses are minor and in patients where outcome is not altered. The total of four (7%) missed major diagnoses (Goldman class 1) in our study falls in the midrange of similar studies, and these are all conditions that are notoriously difficult to diagnose in the ED. Our results show a higher preponderance of Goldman class 2 diagnoses than in other studies. This is due to the high incidence of patients who present to the ED having had a cardiac arrest in the community. In this group of patients, the cause of the cardiac arrest is often very difficult to determine in the ED. These patients have a very poor survival rate and are usually declared dead soon after arrival in the ED. As the management of these patients follows standard Advanced Cardiac Life Support (ACLS) protocols in the first instance, and is often unsuccessful, the determination of the cause of the arrest is often academic in these situations. There are a small number of Goldman class 3 and 4 diagnoses in the study (14% and 10%, respectively)—these by definition do not directly impact on emergency treatment, but may impact on decisions involving continuation or withdrawal of treatment, and thus are important to recognize.
LIMITATIONS There are several limitations to our study. It is a retrospective review, necessitating review and interpretation of clinical notes not written in standard form. There was of necessity a certain amount of subjectivity in the classification of missed diagnoses, but this was overcome to some extent by having at least three and up to four reviewers for each
set of medical records. There is a selection bias in that not all deaths in the ED during the study period had a postmortem examination performed. All autopsies were due to coroner’s inquiries’ being mandated by law. If the study had included those patients in whom death was expected and no autopsy was required by law, it is likely that the incidence of missed diagnoses would have been lower. In the future, a prospective study comparing clinical and postmortem diagnoses, using standardized forms completed at the time of death, might provide more accuracy in estimating discrepancies.
CONCLUSIONS In spite of the nature of ED work, which results in working with often a limited history and investigations, the number of major missed diagnoses by ED doctors is minimal. The nature of these missed diagnoses is in line with expectations and should serve as another reminder to ED staff to have a high index of suspicion for these conditions. This in turn will improve the future care of ED patients who present with symptoms of these conditions. This study confirms the value of the postmortem examination as an educational and audit tool in the ED environment. References 1. 2. 3.
4.
5.
6.
7.
8.
9.
Bottiger LE. The post-mortem: its decline—and fall? J Intern Med. 1992; 231:99–101. Galloway M. The role of the autopsy in medical education. Hosp Med. 1999; 60:756–8. Barendregt WB, de Boer HH, Kubat K. Autopsy analysis in surgical patients: a basis for clinical audit. Br J Surg. 1992; 79:1297–9. Landefeld CS, Goldman L. The autopsy in quality assurance: history, current status, and future directions. Qual Rev Bull. 1989; 15(2):42–8. Mort TC, Yeston NS. The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit. Crit Care Med. 1999; 27:299–303. Alafuzoff I, Veress B. The selection for post-mortem examination: a retrospective analysis of 74 deceased surgical cases. Qual Assur Health Care. 1993; 5:345–9. Goldman L, Sayson R, Robbins S, Cohn LH, Bettmann M, Weisberg M. The value of the autopsy in three medical eras. N Engl J Med. 1983; 308:1000–5. Goldstein B, Metlay L, Cox C, Rubenstein JS. Association of pre mortem diagnosis and autopsy findings in pediatric intensive care unit versus emergency department versus ward patients. Crit Care Med. 1996; 24:683–6. Kendall IG, Wynn SM, Quinton DN. A study of patients referred from A&E for coroners post-mortem. Arch Emerg Med. 1993; 10:86–90.
