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Objectives This study aimed to explore clinicians’ perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU). Methods A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record. Results A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002). Conclusions Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.

Background: A transbronchial forceps lung biopsy performed in mechanically ventilated patients with respiratory failure of unknown etiology has significant uncertainty of diagnostic yield and safety along with sparse literature. This study investigated the complication rate of transbronchial biopsies in mechanically ventilated patients in the intensive care unit and its ability to obtain a diagnosis and change current therapy. Methods: PubMed, Ovid MEDLINE, and Ovid Cochrane Central Register of Controlled Trials databases were systematically searched for all publications of transbronchial lung biopsies in mechanically ventilated patients. We pooled the results of individual studies using random-effects meta-analysis models to achieve the summary proportions. Results: Of the identified 9 observational studies with a total of 232 patients undergoing a transbronchial biopsy, complications occurred in 67 patients [25.2%; 95% confidence interval (CI), 11.5%-42.0%; I 2=70.0%]. Pneumothorax occurred in 24 patients (9.5%; 95% CI, 4.5%-16.2%; I 2=15.9%) and bleeding in 18 patients (8.9%; 95% CI, 4.1%-15.3%; I 2=0%). A diagnosis was given in 146 patients (62.9%; 95% CI, 56.0%-69.1%; I 2=74.6%), with 103 of 210 patients (49.0%; 95% CI, 44.6%-55.1%; I 2=74.9%) having a change in treatment. Conclusion: The results of this meta-analysis suggest that a transbronchial forceps biopsy when performed in mechanically ventilated patients with respiratory failure of unclear etiology had a moderate complication rate. These biopsies resulted in varied diagnoses with a high rate of management change. Randomized controlled trials are necessary to identify the ideal patients to perform a transbronchial forceps biopsy on in the intensive care unit.

AbstractRationaleThe use of endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) is currently recommended for staging non‐small cell lung cancer (NSCLC) in centrally located tumors, tumors >3 cm, or with radiologic evidence of lymph node (LN) metastasis. Current guidelines do not recommend staging EBUS‐TBNA in patients with stage I NSCLC who do not have any of the aforementioned conditions.ObjectiveWe hypothesize that using EBUS‐TBNA is useful for detecting occult metastasis in radiologic stage I NSCLC.MethodsIn this single‐center, retrospective study, charts of patients ≥18 years old who underwent staging EBUS‐TBNA from January 2005 to May 2019 were reviewed. Only patients with combined positron‐emission tomography and computed tomography (PET/CT) scans consistent with radiologic stage I NSCLC were included. Identified variables included: age, gender, personal history of any cancer, smoking history, tumor location, tumor centrality, tumor size, tumor PET activity, histopathologic type of NSCLC, and LN biopsy results. Patients whose LN samples showed a diagnosis other than NSCLC were excluded. The association between LN positivity, and each of the variables was assessed using Pearson's correlation for categorical variables, and logistic regression analysis for continuous variables.ResultsFrom the 2,892 initially screened patients, 188 were included. Of those, 13 (6.9%; 95% CI, 4%–11%) had a malignancy‐positive LN biopsy. The number needed to test (NNT) in order to detect one case of any occult metastasis was 15. Among the included variables, a significant association was found between LN positivity and tumor centrality, with central tumors found in 61.5% of patients with positive LN (n = 8) (p < 0.01). This association stayed significant after adjusting for age, gender, smoking history, tumor size, tumor location, and PET activity (p = 0.015). Among patients with malignancy‐positive LN biopsies, five (38.5%; 95% CI, 17.6%–64.6%) were upstaged to N1, and eight (61.5%; 95% CI, 35.4%–82.4%) were upstaged to N2, with NNT of 23 to detect one case of occult N2 metastasis. Subgroup analysis comparing LN‐positive patients based on their N stage did not show statistically significant association with any of the variables.ConclusionBased on our results and along with the existing evidence, EBUS‐TBNA should be recommended as part of the routine staging in all patients with radiologic stage I NSCLC.