Feel free to translate these symptom checklists into your working language. Others with the same working language would benefit from having the translated checklists available on this site. E-mail Eric Dryver (email@example.com) if you would like to have the translated version uploaded onto the site.
The starting point for patient assessment in Emergency Medicine is the patient’s symptom or problem, which may be
- subjective (e.g. chest pain)
- objective (e.g. swelling)
- potential (e.g. potential post-traumatic fracture or hemorrhage).
Diagnostic mistakes can be categorized as resulting from:
- incomplete information acquisition
- faulty knowledge
- faulty information interpretation, e.g. due to premature closure, a cognitive error consisting in settling for a diagnostic hypothesis without adequately considering alternative diagnoses
The main goal of the Symptom Checklists provided below is to reduce diagnostic errors resulting from incomplete information acquisition and the failure to consciously consider potential diagnosis. Clinical decision rules are provided to assist with likelihood assessments. Other goals of theses checklists are to promote effective information acquisition and facilitate the process whereby junior physicians review cases with senior physicians.
The following abbreviations are used to structure the background information that can be obtained from the patient, relatives and/or the patient record:
- M (Medications): current medications, sometimes with specific additional issues (eg NSAID use in abdominal pain, oral contraceptives at dyspnoea)
- A (Allergies): sensitivities to drugs, contrast agents, etc.
- P (Past Medical History): previous illnesses, sometimes with specific additional issues (eg previous cancer by back pain)
- L (Life Circumstances): social circumstances, such as support at home for elderly patients, occupation for younger patients
- E (Ethanol): alcohol, amount and frequency
- S (Smoking): Tobacco, current and past use
The following abbreviations are used to structure the history of present illness:
- O (Onset): when the symptom started, activity at symptom onset, time to peak intensity
- P (Position): location, size, radiation
- Q (Quality): nature/quality of the symptom
- R (Relieving/aggravating): whether symptom intensity is altered by certain movements/actions
- S (Severity): the severity of the symptom (e.g. VAS scale for pain), how it affects daily function
- T (Trend): whether the symptom has been intermittent or constant; increasing or decreasing; if the patient has previously experienced similar symptoms.
- +: Additional questions about specific associated symptoms
The following abbreviations are used to in the section on physical examination:
- VS (vital signs): RR (respiratory rate), SpO2% (oxygen saturation through pulse oximetry), HR (heart rate), BP (blood pressure), Temp (temperature)
- JVP: jugular venous pressure
- MSK: musculoskelettal
- ABCDE: Airway (upper airway), Breathing (oxygenation and ventilation), Circulation (heart rate & rhythm, perfusion), Disability (consciousness and neurological deficit), Exposure (abnormal findings upon superficial physical examination and temperature)
DIAGNOSTIC MISTAKES & COGNITIVE PROCESSES
Emergency care is a complex and dynamic field where diagnosis plays a central role. Patients seek, are referred or transported to the emergency room because of subjective (e.g. chest pain), objective (e.g. decreased consciousness) or potential (e.g. suspected intoxication) problems caused by close to 10,000 diagnoses. The main purpose of the investigation in the emergency room is to assess, with the patient’s symptom as starting point, the probability of diagnoses where emergency treatment reduces morbidity and mortality. Diagnostic mistakes in the emergency care are common and lead to increased morbidity, mortality and healthcare costs. Diagnostic errors are caused by:
- system factors related to the working environment, such as lack of time, simultaneous tasks, constant interruptions, noise, fatigue
- ”no-fault errors”, such as an atypical presentation of a disease or a patient who is uncooperative
- cognitive factors, due in turn to:
1-faulty information acquisition
3-faulty information interpretation
The most common cause of diagnostic error is a combination of system factors and cognitive factors, and in about 40% of cases diagnostic mistakes are due to insufficient history-taking and physical examination. Our clinical assessment of patients is based on two cognitive processes called System 1 and System 2. System 1 involves using the ability to recognize patterns and use rules of thumb. This process is unconscious, fast, requires relatively little mental energy, but is influenced by emotions and fatigue. System 1 may lead the physician to prematurely settle for a diagnostic hypothesis without considering alternative hypotheses that can also account for acquired information, a cognitive error called premature closure. System 2, on the other hand, is analytical, rational, rule-based and less error-prone than System 1, but it is also slower and more strenuous. There is no proven or validated strategy to prevent diagnostic errors due to cognitive factors.
The modern approach to patient safety accepts that people are fallible. Strategies to improve care focus on developing tools and procedures to make it easier manage the patient correctly, and to detect errors before the patient has been injured. Checklists have been used in the aerospace industry since 1935 to prevent mistakes with a well-established track record. In healthcare, a five-point checklist, coupled with changes in work culture, can prevent bacteremia from central venous catheterization, with reduced mortality and health care costs as a result. Cross professional multi-step checklists can reduce morbidity and mortality in surgical procedures. Checklists have also been suggested as a tool to reduce diagnostic errors.
Checklists have the potential to prevent inadequate information gathering and reduce the risk of premature closure by enjoining the physician to consider ”don’t miss” diagnoses, those for which early treatment reduces morbidity and mortality. Checklists can also reduce the influence of system factors in helping the physician acquire the necessary clinical information and consider the relevant diagnoses despite time constraints, interruptions, multitasking and fatigue. The challenge in creating checklists is to find a balance between too few points (risk of inadequate information gathering) and too many (reduced work efficiency and ease of use). It is also important to find a format that maximizes the user friendliness and increased use in clinical practice.
Crowdsourcing is a process whereby a large group of people contribute to the implementation of a project. Wikipedia, an online, collaborative encyclopedia that includes over 30 million articles in over 280 languages, is a product of crowdsourcing. Wikipedia has been criticized for not having its entries exclusively written by experts, but several studies suggest that the quality of the entries is high. Crowdsourcing takes advantage of the collective intelligence that emerges when many individuals contribute. Collective process development may encourage the use of the process in clinical practice.
We present checklists for the most common symptoms evaluated in the emergency department (ED). These checklists itemize what information should routinely be obtained during the evaluation in the ED, focusing on information that can be obtained quickly, cheaply and in a minimally invasive manner, namely the history, physical examination, bedside blood tests, ECG, ultrasound and urinalysis. The checklists also feature ”don’t miss” diagnoses that should be consciously considered.
We invite all those who work in emergency rooms, in Sweden and abroad, to download these checklists and we welcome suggestions for improving their content and format. The checklists will then be regularly updated with the help of these suggestions and new study results. An article describing this project (Dryver E, Johannsson G, Mokhtari A, Larsson D, Khoshnood A, Ekelund U. Checklists and ”crowdsourcing” for increased patient safety in the emergency department. Läkartidningen 2014;111:CMDU) has been published in the Swedish medical journal. It is of course free for all emergency departments to modify these checklists is accordance with local circumstances and use the checklists during clinical practice. We are confident that these checklists, optimized with the help of crowdsourcing, can help to improve healthcare quality and patient safety in our emergency rooms.
The checklists are currently provided in English and Swedish. We will post translations into other languages if requested.
Please e-mail your comments and suggestions to firstname.lastname@example.org. We suggest you include:
- E-mail address
- Rational (e.g. with reference to articles, blog, FOAM )