Good afternoon. Welcome to our 2023 SEC and Congress. I have the pleasure today to share with you my lecture, Mitigating Diagnostic Errors with Paulkus, a New Framework. My name is Jose Diaz-Gomez and I'm currently serving as the section chief for the transplant cardiovascular and MCS critical care section at Baylor College of Medicine. It is obvious to understand that Paulkus is such a tool that allows us to leverage health care equality across all practices in America and in the planet. The tool empowers the clinician at the bedside and you will be able to assess the same clinical conditions regardless you are in a rural hospital or a teaching hospital. I do not have any conflicts of interest while I'm presenting this lecture. My objectives for this lecture will be, number one, I need to describe a clinical case, a personal case that reveals a diagnostic error with Paulkus. Second, I will analyze a new framework that intends to mitigate diagnostic errors with the tool. And lastly, I will cite specific examples that can facilitate the mitigation of diagnostic errors with Paulkus. The Emergency Care Research Institute published this article back in 2020 where they were including Paulkus as a hazard number two for the 2020 top 10 health care technology hazards. And the reason why they were stating that is because the tremendous revolution with Paulkus pretty much was outpacing those safeguards that clinicians should have in place to prevent diagnostic errors. In addition, it is important to recognize that the past decade we were probably more informed about medication errors. Well, this decade there is a tremendous interest on diagnostic errors and the reason is because diagnostic errors can represent up to 10 percent of hospital inpatient death. Had you asked yourself whether you might be involved in one of those cases where you were utilizing Paulkus and the patient might end up losing his or her life and eventually we might be in a peer review case where we were utilizing the tool. So diagnostic errors are becoming an area of interest for many health care stakeholders. This slide was taken from a law firm and here they are informing the public about the difference between diagnosis that have been delayed or missed or misdiagnosed or failure to recognize complications. The bottom line is here there are different type of diagnostic errors and they are trying to frame here there will be lawyers trying to defend their patients because we failed to make the right diagnosis with whatever tool we were using. Not only that, they provide at least the most misdiagnosed diseases in America and you can see even here sepsis is one of them or pneumonia and sometimes we have been using Paulkus for these two conditions. What I pretend today is not to try to tell you how you can prevent errors, more importantly how to mitigate them because in error proofing is a very very hard field to establish and my very first step is how to mitigate those errors. So these are my three lessons for today. Number one, you have to trust your gut. I was going to show you that case. Second, that TE is part of our scope of practice and finally I will share with you the new framework to mitigate those diagnostic errors. I just was admitting a patient from the ED that was having a significant abdominal pain. The patient actually had a cabbage procedure a month earlier and then the cardiovascular and cardiology team were transferring the patient from the ED to the ICU. This patient underwent an echocardium of Paulkus at the bedside by the cardiology fellow. This was the initial report. I want to take the opportunity to read it briefly. I put two asterisks in red to highlight the fact that the clinician just informed that the patient had a left ventricle that appears hyperdynamic and under filled and there was a pleural diffusion noted. When I received the patient in the ICU, the patient remained in refractory shock. I didn't get it but with this report I said well probably I just need to give fluids. However, the patient continued deteriorating and I couldn't just have an explanation. Well, I trusted my gut. Something was wrong so I proceeded with my own Paulkus and this was the view that I obtained. As you can see, this is a succostal view and I recognizing a complex effusion that is compressing the right side of the heart. I complement this evaluation with another view which is this short axis view in succostal. Once again, the effusion is circumferential. So, I trusted my gut. However, I have really really defensive cardiothoracic surgical team. They didn't believe me. They said no, this is a TTE. We cannot make the diagnosis with TTE. You have to do a TTE. Well, I proceeded with the TTE. This is a medial sphageal view and as you can see here again, the effusion is complex. It's surrounding the heart and there is actually here compression of the right side of the heart. And I got a transgastric view and somebody can argue that perhaps the succostal view that I procured was even better quality than this transgastric view. But once again, there was a tamponade physiology there. So, the patient was taken to the operating room and we say it's his life. Now, some people will argue why you need it to the transesophageal. Well, let me tell you, point of care ultrasonography has a specific defined view which is critical care echocardiography. And the way we are defining it right now is that point of care ultrasonography that is performed and interpreted by the treating clinician, okay, regardless of the hospital setting and will allow us to do the diagnosis, managed care, and even guiding basis procedure. But I want to highlight the fact here that transesophageal echocardiography is part of critical care echocardiography and that's what I demonstrate to the surgical colleagues. So, next day I just was sleeping and I have the cardiology chair calling me, questioning me why you did this exam, who trained you, what are your qualifications, were you competent or not. So, I realized that at that moment I needed to start building bridges, that I need collaboration, I will need, you know, involvement for multiple specialties if I wanted to be using, focusing the best interest of our patients. That was my very first step and that happened to me in 2010. So, since then I started thinking how we really need to move forward and that was the very first step I did this study involving cardiothoracic anesthesia fellows, pulmonary fellows, nurse practitioners, critical care physicians, anesthesiologists, and I was able to demonstrate that doesn't matter what your background specialty is, everybody end up learning, okay, what is important is to have that discipline to continue utilizing the tool. Not only that, I'm not a neurologist, but it happens that I follow all the steps to become board certified in neurocritical care because the patient population I was taking care of and I was able even to defend the fact that in when we are taking care of neurocritical patients it is important to have a focused evaluation, although there are neurologists that didn't believe, like Dr. Vespa, that there's a good way to really collaborate with those across the aisle and I've been able to collaborate with them and certainly there is a role for focusing neurocritical patients. Lastly, this publication was very important. You can see it's a cardiology publication for the first time, big deal, they involve two of the intensivists in America in that publication, Dr. Sam Brown and myself. So now we kind of start that, well, now we need to collaborate more and more with the cardiologists. I am at this time thinking of that novel or a better framework how I can mitigate those errors. So remember that case, I needed to go back. I needed to understand why my cardiology colleague was not able to make that call of that cardiac tamponade. Let's take a look. Well, this was his parasternal non-axis view. Somebody would argue that this is the right ventricle, this is the septum, this is the left ventricle, this is the left atrium. But this parasternal non-axis view doesn't have the appropriateness criteria. Why? Well, let me tell you why. Number one, number one, this view doesn't have, shouldn't have the apex. You are seeing barely a little bit the mitral and maybe the aorta. It has a horizontal orientation, but you cannot see the descending aorta. Because you're not able to see the descending aorta, he was not able to distinguish the left flow diffusion from the pericardial diffusion. That was his mistake. So let's try to see how we can mitigate those errors. And I'm going to show you now this new framework. I have a high esteem professor at Johns Hopkins during the master I'm pursuing at this time. And his publications since 2014 enlightened me like no other. So when you want to understand diagnostic errors, I just, I'm applying a general framework. I will apply it to pulcus. You can see here for a diagnostic error to occur, okay? And you have to distinguish two components. You can have a failure in the process, the way you're making diagnosis. It means that you have the incorrect workup. You're doing the process in the wrong way. Or you are leveling, doing the label of the diagnosis incorrectly. So you are saying, even though you have a good process, you are saying that the patient have an incorrect diagnosis. Well, these are the core elements to define preventable diagnostic errors. In this slide, I want to emphasize the fact that diagnostic process failure leading to diagnostic label failure is what is called preventable diagnostic error. So we can have preventable diagnostic errors if we address the process itself. So the diagnostic label failure doesn't occur. So we need to address the process failure first. It's a new model. It's a new model when he's describing what should be optimal and suboptimal. Or what is the difference? Well, when you have suboptimal, it means that you cannot provide the best care possible. You're still under the standard, but it's not the best care possible. It might not be the best care possible because of cognitive issues, system issues. For example, cognitive issues. Well, I guess you are pretty good obtaining two out of the three views. That's a cognitive error. That's suboptimal because that's not the best care possible. Are you bringing the most experienced critical care echocardiography in your team? It's daytime. Do you have the nurses around you to have the patient without dressings? Do you have the patient that have pain under control while you're procuring the abuse so you can apply the right pressure? That's the best care possible. And this is important. See how you now are really implementing the right process to have the right diagnosis. So far what we have here is that beside that preventable diagnostic error are two new classes of error. One is reducible and the other one is unavoidable. We're going to go over that later. You can see here that you can have very good processes and you are actually probably having near misses. Why? Well, let's say you didn't apply the ultrasound to diagnose the peri-refusion, but somebody sent an x-ray or a CT scan and diagnosed the issue there. And then the patient is drained. That effusion got better, go home. That's a near misses. And you didn't produce harm. Or you can actually be using a lot the pulcus. And then what happens is you are now finding a pericardial effusion and you have a very enthusiastic fellow, let's drain it, let's drain it. You try to drain that pericardial effusion on a patient with pulmonary hypertension and then the patient at rest. You can cause harm. So because you have the right diagnostic process, doesn't mean you can cause harm. You still can cause harm to patients. And this is important. So let's go now to the other side. On the other side, you are having this situation where you have the optimal diagnostic process, but you still are not able. You cannot avoid that diagnostic level failure. Why? There are diseases, there are applications of pulcus that hasn't been described. This is the new research. This is the new era. And that is actually what keeps me really motivated. I hope that the new generation is able to describe new techniques, new sensitivity and specificity for a specific clinical conditions. We cannot do anything with an unavoidable diagnostic error. What about the reducible? Well, in the reducible, then that's the missing opportunity. The reducible errors are those that we really need to probably pay most of the attention right now. Why? Because at this time, those reducible errors are suboptimal diagnostic processes leading to diagnostic level failure. And these differ for preventable diagnostic errors because the diagnostic process leading to the incorrect diagnosis is suboptimal, but not substandard. The practice gap therefore reflects a defect in access to a new or improved diagnostic approach, technology, or system of care. Sometimes this practice gap is a transient phenomenon while diffusion of innovation occurs. For example, a new probe. And then now we can have a better diagnosis. So this is what I call the missing opportunity we have at this time. We really need to improve these reducible errors. So in summary here, when we try to see, for example, we have any diagnostic error, you can apply this fishbone diagram. And then now you can see there will be some effective factors. Were you upset because you have been working for 30 hours? Did you communicate well your findings to the attendant? And was the diagnostic was challenged because the patient was in pain and you cannot procure the views that you needed? What about the context of care? Was the patient was admitted in the middle of the night? Organizational issues, are your equipment working or not? And what about your cognitive process? Are you really proficient on the technique? This is a different analysis to specific diagnostic errors we focus. Well, there have been some intention. As you can see here, they want, in this case, these are ED physicians trying to reduce the number of diagnostic errors in the ED. And you can see here they have done is to have exemplary intervention is the creation of checklists, making sure they have checklists. And those checklists are being used in radiology. If the radiology is used, why we don't use it? Some colleagues in our country has developed these checklists and having these assessment tools. For example, here, Dr. Sonny's group has been able to demonstrate the value of having this checklist. And for example, here, this is pertinent to that misdiagnosis we have that incorrectly the cardiology fellow said that was a pleural effusion, but it was a pericardial effusion. You can see here correctly identified the descending thoracic aorta. Yes or no? That's important. So how we can have those checklists available? And there is a recent study where some authors incorporated a checklist in a daily basis assessment of patients with sepsis. And in this case, they are proposing and the daily goal for those patients with sepsis is to identify whether or not there is pleural effusion in the motor acts or there is B-line consolidations or there are issues with the deep vein thrombosis, the ventricular function or the pericardial effusion. You can see how then we can tailor depending on the clinical condition of the patient, we should have those checklists to really mitigate those errors. So in summary, I will tell you, you have to trust your gut. Continue using the tool. Remember that T is part of your scope of practice. And third, that new framework about how to analyze your diagnostic errors and how to mitigate them might be tailored to your own institution. Thank you very much for your attention. This is my handle on Twitter. And I will look forward to connect with you soon. Enjoy Congress. Thank you.

Mitigating Diagnostic Errors

Point-of-Care Ultrasound

POCUS

Healthcare Practices

Patient Harm

Collaboration