Autopsy: quality assurance in the ICU

Objective: To examine the correlation between the clinical diagnosis and autopsy findings in adult patients who died in an intensive care unit (ICU). To determine the rate of agreement of the basic and terminal causes of death and the types of errors in order to improve quality control of future care,Design, Retrospective study.Setting: Adult ICU in a university hospital.Patients: 30 adult patients who died in the ICU. with the exclusion of medicolegal cases.Methods and main results: Anatomo-clinical meetings were held to analyze the pre- and postmortem correlations in 30 consecutive autopsies at the ICU of the University Hospital, School of Medicine of Botucatu/ UNESP, from January 1994 to January 1997. The rate of correct clinical diagnoses of the basic cause was 66.7 %; in 23.3 % of cases, if the correct diagnosis was made, management would have been different, as would have been the evolution of the patient's course (Class I error): in 10 % of the cases the error would not have led to a change in management (Class II error). The rate of correct clinical diagnoses of terminal cause was 80 %.Conclusions: the rate of recognition of the basic cause was 66.7 %, which is consistent with the literature, but the Class I error rate was higher than that reported in the literature.

Discrepancies between clinical diagnoses and autopsy findings

Autopsy examination is considered to be an essential element for medical auditing and teaching. Despite the significant progress in diagnostic procedures, autopsy has not always confirmed the clinical diagnosis. In the present study, we compared the diagnosis recorded on medical charts with reports of 96 autopsies performed at the University Teaching Hospital of the Faculdade de Medicina de Botucatu, Botucatu, SP, Brazil, between 1975 and 1982, and of 156 autopsies performed at the same institution between 1992 and 1996. The clinical diagnosis of the basic cause of death was confirmed at autopsy in 77% of cases. The percent confirmation fell to 60% when the immediate terminal cause of death was considered, and in 25% of cases, the terminal cause was only diagnosed at autopsy. The discrepancies between clinical and autopsy diagnosis were even larger for secondary diagnoses: 50% of them were not suspected upon clinical diagnosis. Among them, we emphasize the diagnosis of venous thromboses (83%), pulmonary embolisms (80%), bronchopneumonias (46%) and neoplasias (38%). Iatrogenic injuries were very frequent, and approximately 90% of them were not described in clinical reports. Our results suggest that highly sensitive and specific diagnostic tests are necessary but cannot substitute the clinical practice for the elaboration of correct diagnoses.

Clinical and pathological assessment of 82 patients with cardiovascular diseases undergoing autopsy at the Hospital das Clínicas of the Faculdade de Medicina de Botucatu from 1988 to 1993

OBJECTIVE: To evaluated the clinical diagnostic, efficiency for basic death causes in patients dying of circulatory disease and de relative frequency of those diseases. METHODS: Analysis of medical record data of 82 patients, ages from 16 to 84 years old (68 over 40 years old), whose died of circulatory disease and had undergone necropsy in the period from 1988 to 1993 years in the University Hospital of Medicine Faculty of Botucatu-UNESP, Br. RESULTS: The functional class of patients were III or IV, in 78%, and 81.7% needed urgent hospitalization. By the clinical judgment the death were by ischemic heart disease in 32 (21 acute myocardial infarction), Chagas'disease in 12, valvopathy in 11, cardiomyopathy in 7, heart failure with no specification of cardiopathy in 11 and other causes in 9. At the necropsy the death cause was ischemic heart disease in 34 patients, valvopathy in 10, Chagas'disease in 10, cardiomyopathy in 5, and heart failure with no specification of cardiopathy in 2.The concordance taxes were in thhe same order: 94,6%, 90,0%, 83.3%, 71.4% and 28.5%. CONCLUSION: There was a great efficiency of clinical diagnosis for death cause in a general university hospital. The ischemic heart disease were the main causes of death.