Clinical Scorecard: Recognizing Emergency Department Patients Prone to Diagnostic Discrepancies Between Initial and Final Discharge Diagnoses: The Distinct Influence of Frailty

At a Glance

Key Highlights

• Diagnostic discordance has been reported in 8% to 43% of patients with suspected infection; in this cohort, discordance occurred in 25% of patients.

• Frail patients had more frequent diagnostic discordance than nonfrail patients (31.3% vs 21.8%; P = 0.007).

• Frailty remained independently associated with diagnostic discordance after adjustment for age, comorbidity, and other factors.

• Higher age-adjusted comorbidity burden was also independently associated with diagnostic discordance, whereas age alone was not independently associated after adjustment.

• Frailty was assessed retrospectively using the Clinical Frailty Scale, with CFS <5 categorized as nonfrail and CFS ≥5 as frail.

Guideline-Based Recommendations

Diagnosis

• This study does not establish a formal diagnostic guideline. The findings support careful diagnostic evaluation and repeated reassessment in frail ED patients with suspected infection.

Management

• Recognition of frailty should prompt careful consideration of alternative diagnoses and continued reassessment as additional clinical information becomes available.

Monitoring & Follow-up

• Reassess the presence and focus of infection during hospitalization as new clinical, laboratory, microbiological, and outcome information becomes available.

Risks

• Diagnostic discordance may contribute to both overtreatment and undertreatment. Overtreatment can increase adverse effects and antimicrobial resistance, whereas undertreatment can increase the risk of complications, sepsis, and in-hospital mortality.

Patient & Prescribing Data

The analysis included 646 unique adults presenting to the ED with suspected infection. Among them, 163 patients (25%) had diagnostic discordance. The study did not evaluate a specific prescribing intervention or recommend a particular antibiotic regimen.

Clinical Best Practices

• Consider frailty, assessed with the Clinical Frailty Scale, as a marker of diagnostic complexity in adults presenting with suspected infection.

• Avoid interpreting diagnostic discordance automatically as diagnostic error, because changes between ED and discharge diagnoses may reflect the natural evolution of clinical assessment as new information emerges.

• Perform careful diagnostic evaluation, consider alternative diagnoses, and repeat assessment in frail patients as additional information becomes available.

Related Resources & Content

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2. Dregmans E, Kaal AG, Meziyerh S, Kolfschoten NE, van Aken MO, Schippers EF, et al. Analysis of variation between diagnosis at admission vs discharge and clinical outcomes among adults with possible bacteremia. JAMA Netw Open. 2022;5(6):e2218172.

3. Hooper GA, Klippel CJ, McLean SR, Stenehjem EA, Webb BJ, Murnin ER, et al. Concordance between initial presumptive and final adjudicated diagnoses of infection among patients meeting sepsis-3 criteria in the emergency department. Clin Infect Dis. 2023;76(12):2047-2055.

4. Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, et al. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015;19(1):319.

5. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-762.

6. Church S, Rogers E, Rockwood K, Theou O. A scoping review of the Clinical Frailty Scale. BMC Geriatr. 2020;20(1):393.