Misdiagnosis of cellulitis in the emergency department and potential impact of clinical decision support interventions

Abstract

Background

Cellulitis is misdiagnosed in 19 % to 34 % of emergency department (ED) cases resulting in excess healthcare spending and threatening patient safety. The objectives of this planned secondary analysis was to report the proportion of cellulitis misdiagnosis in the ED. Secondarily, we evaluated the potential impact of diagnostic adjuncts on misdiagnosis rates.

Methods

We prospectively enrolled ED patients presenting with acute lower extremity dermatologic complaints involving visible erythema (potential cellulitis). We abstracted the treating physician's diagnosis from the medical chart. Consensus diagnosis was determined by a group of six independent, multidisciplinary physicians. The treating ED physician's diagnosis was compared to the consensus panel diagnosis to identify errors. We evaluated the potential impact of two individual diagnostic adjuncts, skin surface temperature measurement and the ALT-70 score, plus a combination of both, on reducing cellulitis diagnostic errors

Results

The final sample included 201 patients. The diagnosis assigned by the treating physician and consensus panel was discordant in 50 of 201 cases (24.9 %). Among patients with an ED physician diagnosis of cellulitis, 35.6 % were overdiagnosed (48/135). In cases diagnosed as cellulitis, utilization of skin surface temperature, the two-level ALT-70 and the combination measure would have yielded an absolute reduction in cellulitis overdiagnosis by 8.9 %, 5.7 % and 13.0 % of cases respectively

Conclusion

Consistent with other reports, we observed a high rate of cellulitis overdiagnosis, highlighting the need for diagnostic support interventions. Proposed diagnostic adjuncts had an overall positive theoretical impact on overdiagnosis and should be evaluated in prospective interventional trials