On behalf of the Fellows from the Division of Emergency Medicine at Cincinnati Children’s I am delighted to bring you a new series that will highlight what we are learning during our ongoing didactic conferences. The main goal of the Pediatric Emergency Digest series will be to provide concise teaching points to reinforce in-person learning and to further the conversation. As always, feedback is welcome.
The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them
With Dr. Andy Krack
Background – Initial work starts with “To Err is Human” which starts the process of recognizing and attempting to mitigate cognitive bias. Time pressures, heavy cognitive loads, lack of experience, missed diagnosis play heavily in how cognitive errors occur in the ED. As your cognitive load increases, more likely to rely on biases to make quicker decisions.
- Remove the stigma of “bias” – Instead use “CDRs”: “Cognitive Disposition to Respond” should be the term, and we should understand our own CDRs
- Take our cognitive pills for our cognitive ills: Apply the cognitive debiasing strategies to attempt to overcome CDRs.
Take away – we’ll always have bias, normalize cognitive debiasing amongst students and peers. It will be worse when we are react fast. So be aware you are bringing this to the table. Slow down. Talk out loud.
The top three biases we should work on defending ourselves against
Availability Bias the disposition to judge things as being more likely if they readily come to mind. Recent experience with a disease may inflate the likelihood of its being diagnosed
Confirmation Bias Tendency to look for confirming evidence to support a diagnosis rather than look for disconfirming evidence to refute it
Anchoring Bias Tendency to perceptually lock onto salient features in the patient’s initial presentation too early in the diagnostic process and failing to adjust this initial impression in the light of later information
And finally, keep in Mind Dynamic Skepticism: Is your perception of reality really what is going on? Ask yourself this often!
PEM Journal Review
Prior reported prevalence of UTI in patients <3months with bronchiolitis was 3.3%, as defined by a positive urine culture. 2011 AAP guidelines pretest probability thresholds reference a testing range of 1-3% (does include abnormal UA of pyuria/bacteruria and positive UCx)
However, increasing recognition that positive urinalysis WITHOUT pyuria may be asymptomatic bacteriuria or contaminate.
Hypothesis: Adding a positive UA result (pyuria or nitrites) along with positive urine culture will decrease the prevalence of concomitant UTI in bronchiolitis below the current testing thresholds.
Screened 477 articles, 30 full text review, 18 with UTI prevalence in bronchiolitis and 7 with UA data.
Overall UTI prevalence was 3.1 (95% CI, 1.8-4.6) in the 18 studies and 2.2% in the 7 studies with UA data (if don’t account for UA0
- If added UA characteristics of pyuria (positive LE or >5WBC) or nitrites as diagnostic criteria, prevalence in those 7 studies 0.8% (95% CI 0.3%-1.4%)
- Proportion of E.Coli UTIs in bronchiolitis 63.9%, when applying UA diagnostic criteria weighted prevalence was 80.3%
Overall prevalence of UA positive UTI was less than pretest probability threshold of AAP UTI guidelines
Suggest most urine cultures positive for non E.Coli organisms without pyuria either do not reflect true UTI or represent UTI that spontaneously resolve.
Findings of 0.8% prevalence translates to 125 infants tested to detect 1 UTI.
Defined UTI based on individual studies (rather than standard for all studies included in the meta-analysis)
The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease
STI’s are a significant problem in women between the ages of 15-24. Many of those patients present to the pediatric emergency department with a history of symptoms concern for an STI. The CDC recommends the use of a focused history and physical exam to determine if empiric therapy is needed and a key component of the physical exam is a pelvic exam. With improved nucleic acid amplification testing available, the utilization of the pelvic exam has come into question.
Goal of the study: Determine the test characteristics and the additive value of pelvic exam performed in the pediatric emergency department in predicting STI’s in young female patients.
A prospective observational study in a single urban pediatric emergency department.
They had providers of all levels perform a focused history based on the CDC recommendations and then asked the provider to record their likelihood of cervicitis or PID in that patient on a 100 point VAS scale. A score >50 meant that the provider believed treatment for STI’s was needed. They then performed a pelvic exam and, based on those results, recorded a 2nd score on the 100 point scale. A change that crossed the 50 mark was determined to be a change in therapy (not planning on treating → treating after pelvic exam or planning on treating → not treating after pelvic exam)
Urine testing was sent on all patients for chlamydia and gonorrhea and a wet prep was sent for trichomonas
Of the 288 patients enrolled:
- 79/288 tested positive for an STI on urine testing [STI(+) on the chart]
- 123/288 received treatment for STI’s
- Of the 127 patients who had a score >50 after history, 38 had a score <50 after the pelvic exam and thought to be negative for STI. However, 15 of those patients still tested positive for STI on urine testing
- Of the 161 patients who had a score <50 after history, 33 had a score >50 after the pelvic exam and thought to be positive for STI. However, 21 of those patients still tested negative for STI on urine testing
Overall they found that history plus the pelvic exam has similar poor test characteristics as the history alone. They also found that sensitivity and specificity did not improve with the level of experience. The authors state that the pelvic exam does NOT improve the sensitivity or specificity in diagnosing gonorrhea, chlamydia, or trichomonas infection compared to a history alone. However, that does not mean it isn’t a useful exam. It just isn’t a good exam for PID or cervicitis but can help determine if there are lesions, foreign body, or traumatic injuries.
This study was done at a single center with a high prevalence of symptomatic STI’s so generalizability may be difficult if the patient population is different at other settings.
Farrukh et al. The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease.Annals of Emergency Medicine, 2018