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Objective Missed diagnoses of acute ischemic stroke (AIS) in the ED may result in lost opportunities to treat AIS. Our objectives were to describe the rate and clinical characteristics of missed AIS in the ED, to determine clinical predictors of missed AIS, and to report tissue plasminogen (tPA) eligibility among those with missed strokes. Methods Among a population of 1.3 million in a five-county region of southwest Ohio and northern Kentucky, cases of AIS that presented to 16 EDs during 2010 were identified using ICD-9 codes followed by physician verification of cases. Missed ED diagnoses were physician-verified strokes that did not receive a diagnosis indicative of stroke in the ED. Bivariate analyses were used to compare clinical characteristics between patients with and without an ED diagnosis of AIS. Logistic regression was used to evaluate predictors of missed AIS diagnoses. Alternative diagnoses given to those with missed AIS were codified. Eligibility for tPA was reported between those with and without a missed stroke diagnosis. Results Of 2,027 AIS cases, 14.0% (n = 283) were missed in the ED. Race, sex, and stroke subtypes were similar between those with missed AIS diagnoses and those identified in the ED. Hospital length of stay was longer in those with a missed diagnosis (5 days vs. 3 days, p < 0.0001). Younger age (adjusted odds ratio [aOR] = 0.94, 95% confidence interval [CI] = 0.89 to 0.98) and decreased level of consciousness (LOC) (aOR = 3.58, 95% CI = 2.63 to 4.87) were associated with higher odds of missed AIS. Altered mental status was the most common diagnosis among those with missed AIS. Only 1.1% of those with a missed stroke diagnosis were eligible for tPA. Conclusion In a large population-based sample of AIS cases, one in seven cases were not diagnosed as AIS in the ED, but the impact on acute treatment rates is likely small. Missed diagnosis was more common among those with decreased LOC, suggesting the need for improved diagnostic approaches in these patients.

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Objectives: Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine. Methods: Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.Results: Twenty-five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.Conclusions: Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.