Reduce Risks of Atypical Appendicitis Presentation
Though myocardial infarction is often a key area of focus when it comes to ED misdiagnoses and subsequent lawsuits, appendicitis is another common and serious misdiagnosis in the ED.
A review of the Physician Insurers Association of America's Data Sharing Project identified 2,156 appendicitis claims between 1985 and 2008, of which 48.6% were misdiagnosed and resulted in an average indemnity payment of $103,391. Among these claims, 284 occurred in the ED and had an average indemnity payment of $49,451.
The ED is among the top locations named in claims in which appendicitis was allegedly misdiagnosed, second only to the practitioner's office which resulted in an average indemnity payment of $94,769 for the same allegation.
In 2005 to 2009, there were 342 appendicitis claims, and 145 were misdiagnosed, with an average indemnity payment of $226,865. The ED ranked first by location and had an average payment of $54,375.
William Sullivan, DO, JD, FACEP, director of emergency services at St. Mary's Hospital in Streator, IL, says that it is important for ED physicians to understand the magnitude of missed appendicitis cases.
"There are more than five million ED visits each year for patients with abdominal pain," says Sullivan. "The misdiagnosis of abdominal pain accounts for between 4% and 10% of all medical malpractice suits."
Abdominal pain, in general, is often a difficult complaint to evaluate, adds Sullivan. "It is not uncommon for even the most experienced clinicians to misdiagnose appendicitis," he says.
Missed appendicitis is the leading cause of litigation against emergency physicians in patients with abdominal pain, and is the sixth most commonly missed diagnosis of all patient complaints, notes Sullivan.
"The problem with appendicitis is that the cases that are missed usually aren't typical presentations," says Sullivan. "Not too many doctors would miss a case of appendicitis when the patient has fever, migrating abdominal pain, and right lower quadrant rebound tenderness."
Sullivan says that elderly patients present even more of a diagnostic dilemma. One reason is that less than 20% of elderly patients have a "classic" appendicitis presentation.1 Sullivan gives these strategies to avoid missing appendicitis:
- Rely on your clinical judgment. "If your suspicion for appendicitis is high, consider admitting the patient for observation regardless of what the testing shows," says Sullivan.
- Reconsider your use of "wastebasket" diagnoses. "Gastroenteritis and urinary tract infections are both common diagnoses. They can also be wrong diagnoses," says Sullivan. "If you aren't confident about what is causing the patient's abdominal pain, a diagnosis of 'abdominal pain– etiology undetermined' is better than labeling an early appendicitis as a urinary tract infection. Think about whether other medical problems may be causing the patient's symptoms."
- Re-evaluate the patient and document that you re-evaluated the patient. "I have reviewed more than one case in which a patient was evaluated for abdominal pain and no re-examination was performed," says Sullivan. "When bad outcomes occur, it is more difficult to justify medical treatment that does not involve re-examining the patient and documenting whether the symptoms have progressed or resolved."
- Recommend short follow up intervals. "If you decide to discharge a patient with abdominal pain, don't feel strange about requesting that the patient have another physical examination performed within 12 to 24 hours," says Sullivan. He also routinely recommends that patients seek immediate follow-up if their symptoms worsen, if they develop new symptoms, or if problems occur.
- If you aren't sure about the diagnosis, emphasize that your diagnosis is not definitive. "Don't provide patients with premature closure to their symptoms," says Sullivan. "In cases where the diagnosis is unclear, I often document that I discussed the uncertainty of the diagnosis with the patients and the need for follow up if their symptoms do not resolve. Knowing that their diagnosis is uncertain will encourage patients to follow up if problems occur."
- Have a low threshold for admitting elderly patients. "Older patients with appendicitis are more likely to have nonspecific presenting symptoms, and to have worse outcomes when compared to younger patients with appendicitis," says Sullivan.
Sources
For more information, contact:
Andrew Garlisi, MD, MPH, MBA, VAQSF, University Hospitals Geauga Medical Center, Chardon, OH. Phone: (330) 656-9304. Fax: (330) 656-5901. E-mail: [email protected].
Steven J. Davidson, MD, MBA, FACEP, FACPE, Chairman, Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY. Phone: (718) 283-6030. Fax: (718) 283-6042. E-mail: [email protected].
Gabor D. Kelen, MD, Director, Department of Emergency Medicine, The Johns Hopkins University, 1830 East Monument Street, Suite 6-100, Baltimore, MD 21287. Phone: (410) 955-8191. E-mail: [email protected].
Reference
1. Hendrickson M, Naparst TR. Abdominal surgical emergencies in the elderly. Emerg Med Clin North Am 2003;21: 937-969.
Though myocardial infarction is often a key area of focus when it comes to ED misdiagnoses and subsequent lawsuits, appendicitis is another common and serious misdiagnosis in the ED.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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