Background: The diagnostic process, inherently fraught with uncertainty and susceptible to errors, has been associated with adverse outcomes when physicians exhibit lower tolerance for uncertainty (1,2). The Diagnostic Time-Out (DTO) serves as a structured tool to outline a problem representation, prioritize the differential diagnosis, and communicate diagnostic uncertainty in high-risk situations for diagnostic errors. In a pilot study, we found that residents who took an adapted (3) analog version of the DTO were more likely to communicate diagnostic uncertainty to their patients and to reach out to their supervising physicians when feeling uncertain about the diagnosis (4). However, the analog version of the DTO exhibited limitations: it lacked interactivity and accessibility, was incapable of data collection for research or quality improvement purposes, and did not facilitate documentation within the Electronic Medical Record (EMR). The broader usability of a diagnostic time-out digital application and its impact on perceptions of diagnostic uncertainty among house staff remain unknown.
Purpose: To develop, disseminate, implement, and evaluate the usability of a digital diagnostic time-out application to optimize clinical reasoning and assess its impact on addressing diagnostic uncertainty among internal medicine (IM) residents at a major academic hospital.
Description: • Design: We developed an online application using iterative, human-centered design principles structured through the REDCap® electronic data survey interface. The digital tool, accessible via mobile and online platforms, guides users through the five steps of the DTO, visually prioritizes the differential diagnosis, generates a summary paragraph for EMR documentation, and collects process measures and clinical data for research and quality improvement.• Pre-implementation period: Following IRB approval, we enrolled a total of 31 residents from 01/08/23 to 10/31/23. Participants responded to the PRU scale, a 23-item measure of physicians’ affective reactions to uncertainty (5). Using animated videos and live demonstrations, we provided synchronous and asynchronous training to residents on criteria for selecting high-risk cases for diagnostic error and the use of the DTO.• Implementation: Each participant was asked to select 8 patients at high risk for diagnostic error and to take one diagnostic time-out per patient from 9/1/23 to 12/31/23, while rotating through general and subspecialty IM inpatient clinical services. We sent bi-weekly newsletters to reinforce training and engagement. • Post-implementation: Upon completion of 8 DTOs, participants will retake the PRU scale and provide perceptions on usability and intention to change practice using a Likert scale survey.• Evaluation: PRU scores between the pre- and post-implementation periods will be compared. Clinical outcomes of patients who underwent a DTO will be extracted from the EMR and described, including discharge diagnosis, 7-day readmission, 30-day mortality, ICU transfers, and length of stay.
Conclusions: Most DTOs have resulted in team discussions and communication of diagnostic uncertainty with patients. The primary triggers for initiating a DTO were a high perceived level of diagnostic uncertainty (47%) and clinical deterioration (19%). Notably, 27% of DTOs have resulted in a change in management, with the most frequent changes involving the acquisition of new imaging and laboratory tests, and obtaining collateral information.
