Quality control with autopsy on a medical intensive care unit

Postmortem examination is considered as the golden standard for the evaluation of clinical diagnosis. However due to several reasons (costs, permission of family members), few medical centers continue to perform autopsy as a means of quality control. From 1995 to 1996, we performed an autopsy study in a medical intensive care unit of a university hospital: 93% of the 140 deceased patients in our medical ICU underwent an autopsy, 100 consecutive patient files were studied.

The clinical diagnosis were made by internists, specialized in intensive medicine; the diagnosis on autopsy were made by a pathologist. According to the criteria of Goldman [l], the clinical and autopsy findings were categorized into major and minor diagnoses. A missed diagnosis on clinical grounds was classified as a class 1 error (if detected before death, this would probably have caused a therapeutic change with possible altered outcome) or as a class II error (if known before death, this diagnosis would not have led to a change in therapy).

In 16% of the patients, a class I missed diagnosis was detected (cardiac tamponade, myocardial infarction, fungal pneumonia); in 9%, a class II missed diagnosis was detected (most frequently tumors). Sometimes the diagnosis was missed due to a combination of severe, acute problems (e.g. development of cardiac tamponade after insertion of a venous catheter during hemorraghic shock), or due to a lack of sensitive and specific investigational methods (fungal pneumonia is frequently suspected in immuno-compromised patients, but is often difficult to confirm), or due to logistic transportation problems in the hemodynamically unstable patient (e.g. retroperitoncal hemorrhage is not always detectable on bedside echography; for diagnosis, CAT-scan is needed).

Conclusion

Even in the era of increasing diagnostic possibilities, due to improved medical technologies in the ICU postmortem examination still remains useful in detecting unexpected diagnoses, missed in the premortem clinical evaluation. Our observations suggested the need for constant alertness and an aggressive investigational planning in patients with unexplained shock or pulmonary infiltrates.