Information Factors Impacting Diagnostic Decisions Across Sign-outs: Experimental Study (Preprint)
Authors: Matin Roni , King Brent  L , Mehta Amit , Fenton Susan H , Hoot Nathan R , Robinson David J , Maddow Charles L , Franklin Amy 
Published: October 2023

BACKGROUND

Transitions of care have been associated with breakdowns in communication and medical errors. In emergency departments (ED), sign-outs provide this continuity of care for patients at the physician’s change of shift. Sign-outs are short, typically verbal interactions, where pertinent information and responsibility for the patient is transferred to the physician assuming care for them. However, these exchanges may be vulnerable to the transfer or introduction of cognitive biases, leading to erroneous decision-making and incorrect diagnoses. Yet, little is known of the information factors that increase the risk of diagnostic error during sign-outs.

OBJECTIVE

This study aimed to determine the impact of information factors in the sign-out narrative on clinicians’ diagnostic accuracy and confidence.

METHODS

A within-subjects experiment with blocking design for chief complaint type was conducted to assess the influence of the amount of information included in a sign-out might have on the receiving clinician’s diagnostic decision-making. The Qualtrics survey-based experiment contained control and stimuli patient case vignettes presented in a narrative format simulating sign-out communication. The study involved randomized assignment to emergency medicine clinician participants (N= 69) across two academic ED sites; one using sign-out protocols, the other not. The amount of information was represented by two test conditions: the explicitness of the sign-out information, and the stage in the diagnostic process the case was at the time of sign-out. Each participant was required to provide a primary working diagnosis, differential and indicate their confidence in their diagnosis and differential, for each case.

RESULTS

The results indicated that the site (χ2 =0.491, df=1 P=.48) and clinician role (χ2 =0.024, df=2 P=.99) did not affect diagnostic accuracy. Diagnostic accuracy was significantly influenced by the volume of information related to the stage in the diagnostic process of stimuli cases (χ2 =19.945, df=1 P<.01). Earlier stage cases i.e. middle stage stimuli cases had lower diagnostic accuracy (33%) and lower confidence in the diagnosis (48.9%) compared to cases later in the process at the time of sign-out (t=5.404, df=273, P<.01) for both diagnostic accuracy (60%) and confidence in diagnosis (64.1%). However, the explicitness of sign-out information did not significantly influence either clinicians’ diagnostic accuracy (χ2 =0.364, df=1 P=.55) or their confidence in the diagnosis. (t=0.514, df=273, P=.61)

CONCLUSIONS

The test condition of explicitness of the information did not affect either clinician’s diagnostic accuracy or their confidence in their diagnosis, whereas the stage of the case was highly influential and earlier cases were associated with significantly lower diagnostic accuracy. This suggests additional support during sign-out for the oncoming ED team may be required for cases that are at an earlier stage in the diagnostic process at the time of sign-out, as they pose a significantly higher risk for diagnostic error.