Background: Diagnostic error leads to increased morbidity, mortality, and cost for hospitalized adults. The ADEPT collaborative, a 13-academic medical center initiative, has launched a Diagnostic Cross Check (DXC) intervention to foster diagnostic excellence in inpatient adult medicine patients requiring a rapid response. The DXC is a structured peer-to-peer discussion of diagnostic reasoning for a rapid response (RRT). Implementing this intervention requires local modifications to integrate it into existing workflows.
Methods: We have trained ten volunteer DXC physicians who opt into a voluntary day-by-day schedule each month. The DXC physician signs on to the rapid response team pager, learns in real time about each RRT, then reaches out to the patient’s lead clinician via secure messaging through the electronic health record. The DXC physician attempts to complete the DXC in person, but this is not always possible because our institution consists of two hospitals, 30 minutes apart. After completing the DXC, the cross-checker and lead clinician each complete a brief online survey.
Results: In the first seven weeks of the intervention, we completed 14 DXCs; only two hospitalist clinicians declined the invitation to participate. Most DXCs occur within 5.5 hours of the RRT and average less than 10 minutes in duration. Due to a low number of RRTs on weekdays, some DXC clinicians have reached out to the clinician caring for the patient the next day after an overnight RRT. Sixty percent of receiving clinicians at our institution stated on the post-intervention survey that they found it useful, 18% acknowledged that the DXC changed the plan of care, and 36% of recipients stated the intervention was likely to affect the diagnostic process for future patients. Of particular value to receiving clinicians were elements of teamwork (having a “second set of eyes” to review the case, feeling less alone in caring for the patient, and confirming the care plan had been correct). At the division level, there is support for compensation for participating as a DXC clinician in the next fiscal year and for including this role in work within the division of hospital medicine.
Conclusions: Local implementation of the DXC requires knowledge of local rapid response notifications, training for efficient and effective delivery, and support at the division and ultimately the health system level to be sustained. Early data show signs of efficacy in changing the plan of care and support from receiving clinicians and administration.