1315: Diagnostic Timeouts to Communicate Diagnostic Uncertainty Across the Pediatric Icu Team

Introduction: Diagnostic uncertainty is associated with a higher risk of diagnostic error among critically ill children. To effectively address diagnostic uncertainty, it must be communicated clearly across the pediatric intensive care unit (PICU) team. However, perceptions of uncertainty at patient admission are often discordant among team members. Our objective was to evaluate the utility and feasibility of diagnostic timeouts (DTOs) for structured communication of diagnostic uncertainty across the PICU team. Methods: A multidisciplinary PICU stakeholder group iteratively developed a 3-question DTO tool to structure PICU teams’ discussion of: 1) the working diagnosis, 2) differential diagnoses, and 3) plans to address diagnostic uncertainty. The DTO tool was implemented over 8 weeks at a single academic PICU and was used during all admissions, morning rounds for all newly-admitted patients, and patients for whom a team member believed a DTO may be beneficial. We collected data on feasibility and relevance via direct observation of rounds and clinician surveys/interviews. Results: Over 38 days, DTOs were performed for 48 patients (28 new admissions and 20 existing patients). DTOs for existing patients were most commonly done due to poor treatment response (53%) and unexplained findings (40%). DTOs revealed diagnostic uncertainty in 30 (63%) patients. To address uncertainty, teams most commonly discussed ordering new tests (52%) and consulting subspecialties (29%). DTOs were completed at a mean of 1.8 (range 1-6) mins. Majority of PICU staff surveyed (n=14) noted that the DTO tool was easy to use (71%), integrated well with admission (54%) and rounding (55%) workflows, and helped the team create a shared mental model of diagnosis (86%). Staff interviews showed that DTOs helped to consider alternative diagnoses, were valuable learning opportunities, and engaged nurses more in the diagnostic process. Staff suggestions to improve implementation included more selective use of DTOs and refining integration into rounds/huddles. Conclusions: Diagnostic timeouts are useful, feasible, and relevant in structuring PICU team discussions about patients’ diagnoses and diagnostic uncertainty. Future work will include improving integration into workflows and evaluating impact on the diagnostic process and patient outcomes.