By Dorothy Brooks
When patients present to the ED with emergent concerns requiring imaging studies, it is not uncommon for incidental findings unrelated to the chief complaint to turn up on radiology reports. While many of these findings are harmless, in some cases they present opportunities to identify cancers or other problems at an early, highly treatable stage. In fast-paced EDs, such opportunities can go unaddressed or overlooked, potentially leading to delayed diagnoses, adverse outcomes, and legal ramifications.
Consequently, it is important to ensure that not only are patients appropriately notified of any actionable incidental findings (AIF) when they turn up on imaging studies, but also that appropriate follow-ups occur. To that end, the American College of Emergency Physicians (ACEP) and the American College of Radiology (ACR) have unveiled new recommendations designed to help health systems implement processes that will preserve patient safety. The recommendations aim to make it easy for providers to do right by their patients when AIFs are identified.1
Christopher Moore, MD, professor of emergency medicine at Yale and lead author of the new recommendations, says appropriately managing AIFs can be particularly challenging in the emergency environment. “We are typically focused on evaluating the emergent complaint and less on incidental findings, so people may get distracted,” he explains. “Even if you tell the patient there is an incidental finding when they are discharged, they may not be focused on that at the time because they are worried about what their chief complaint was.”
Further, Moore notes that in a 24/7 environment, timing can make a difference. For example, he notes that if it is 2 p.m., the emergency provider might call a patient’s primary care provider (PCP), inform him or her of the AIF, and suggest appropriate follow-up. However, that call will not be initiated promptly if it is 2 a.m., boosting the possibility the call will not be made at all.
How often are AIFs overlooked? Anywhere from 5% to 30% of imaging studies ordered in an ED will reveal an AIF that should receive follow-up, but data suggest only about 17% of these will receive that follow-up. This compares with a 63% follow-up rate for AIFs detected in non-ED outpatient settings.2
To improve performance, a 15-member expert panel that included representatives from emergency medicine, radiology, information technology (IT), quality, and patient groups, delved into four distinct areas of focus: identifying and reporting AIFs, communicating AIFs, follow-up and tracking AIFs, and cost and economic considerations.
Regarding the identification and reporting, the panel was particularly interested in how radiologists communicate AIFs to emergency providers as well as any recommendations regarding follow-up. There is variability in how radiologists construct these reports. Thus, the panel saw room for improvement on where information about AIFs is included in radiology reports and what basic information should be provided (potentially in a templated format).
“If you look at the radiology literature, there has been a lot of talk about [structured reporting], but it has been very difficult to actually implement or enforce,” Moore explains. “Ideally, if you have an incidental finding that needs follow-up, it should be included in the summary or impression of the patient rather than in the body of the report. It should include some evidence about why follow-up should occur, and it should include a definite time frame and modality [for this follow-up].”
The panel also agreed it should be the emergency provider who ordered the imaging study who communicates to the patient an AIF. Additionally, the panel noted this information should be included the patient’s discharge summary. “We emphasize that it is really key that there is something in the discharge instructions that is written out about following up [on the AIF],” Moore says.
There was not consensus on whether the emergency provider also should notify a patient’s PCP about an AIF and the need for follow-up. However, most agreed this information should be relayed to the PCP by phone call, text, or through an electronic health record message. Ideally, the panel members noted that in cases where the patient sees a PCP, that clinician should help arrange any recommended follow-up.
To ensure appropriate follow-up occurs for AIFs, the panelists strongly agreed health systems should institute a tracking system for AIFs. This way, radiologists can activate alerts that will appear on ED tracking boards. In turn, emergency providers are aware of AIFs, as well as the need to communicate the information to patients. Moore stresses improvement in this area should be a systems issue rather than something for individual providers, whether that is an emergency physician or a radiologist.
While investments likely will be required to set up IT-driven tracking processes or other systems solutions, there might be opportunities to enhance revenue, boost patient safety, and prevent litigation. Investigators at Vanderbilt Health discovered this when they implemented an electronic medical record (EMR)-driven approach aimed at ensuring AIFs are appropriately identified, reported, and followed up.
Tyler Barrett, MD, MSCI, an emergency physician at Vanderbilt University Medical Center (VUMC), says many patients who present to the ED there undergo imaging studies. “This is the only level I trauma center [in the region],” Barrett explains. “Because a higher percentage of our patients are trauma patients who get CT scans and cross-sectional imaging, we get more of these incidental findings.”
Further, Barrett says he and colleagues noticed it was too easy for patients to forget about following up on an AIF after a hectic ED visit. “They would go home and not recall exactly what was said,” he notes.
Investigators worked with the hospital’s IT department to establish alerts that could be deployed by a radiologist using the EMR. If the radiologist sees an AIF, he or she sends a critical alert via the EMR, which shows up as a red exclamation point.
Typically, the alert message will describe the AIF and what kind of additional surveillance or follow-up is needed. The ED clinician will acknowledge the information. If the ED clinician does not acknowledge receiving the alert within one hour, the hospital operator will be notified automatically. This will prompt the operator to call the clinician personally to let him or her know about the critical alert. This is ensures emergency providers note the alert and act.
This system also includes a follow-up request form that offers the ED clinician two options. For in-network patients, clinicians will put the AIF in a work queue. Navigators contact the patient to arrange follow-up.
For out-of-network patients, the AIF alert message is sent to an ED nurse case manager, who works with the patient to arrange follow-up wherever that patient receives his or her care. If a patient is uninsured or underinsured, the nurse will provide the medical records to a hospital social worker to connect the patient with a PCP who can arrange follow-up.
Another important step in the process involves verbally notifying the patient about an AIF and documenting that such a conversation took place. “We have advised clinicians to go in and talk to the patient and/or family member to let them know what this could mean,” Barrett says.
For example, the ED clinician might reassure the patient that these findings are common, but there is a chance it could be an early-stage cancer. The clinician will stress the importance of timely follow-up. Also, the clinician can indicate who will contact the patient about following up.
A more recent enhancement to the EMR-driven process ensures that when a provider clicks on the follow-up form in the EMR, all the information about the AIF and recommended follow-up automatically populates into the patient’s discharge paperwork. This is called the After Visit Summary. “Yet again, it is a reminder to the patient and/or their family member who may be with them,” Barrett says.
The EMR-driven process launched in May 2020. Researchers documented strong results for the first 13 months.3 Out of more than 64,000 patient visits to the ED, researchers reported there were 932 radiology alerts for incidental findings.
Of these, there was confirmed post-ED communication and a documented follow-up plan associated with 888 of the alerts. Researchers also reported the healthcare team could not contact or confirm follow-up plans with 44 patients, either by phone or through the health system’s electronic communications tools.
Further, while patient safety was the motivating force behind Vanderbilt’s efforts, Barrett notes the approach also has led to some revenue generation. “You are keeping [some of] these patients within your health system, and they are getting their recommended follow-ups and additional services that they need,” he says. “That offsets any health IT expenses or additional FTEs [full-time employees] as far as the additional case managers or navigator roles that are required.”
For other EDs interested in developing an EMR-driven follow-up process for AIFs, it is important to work closely with radiologists from the start. “This is very much a multidisciplinary process,” Barrett says. “Getting radiology buy-in is critically important.”
Other stakeholders include the hospital IT professionals who will be working with the EMR to implement the process, along with anyone assisting with follow-up. At Vanderbilt, ED nurse case managers and/or social workers handle much of this work, but other EDs may enlist different personnel.
When designing a system, consider the disposition of the patient from the ED. Some might incorrectly believe that if a patient is admitted to the hospital, that care team will handle the AIF. “However, if someone is hospitalized for seven days and the CT that was done while they were in the ED turned up something that was completely unrelated to what they were hospitalized for ... the [AIF] may fall through the cracks,” Barrett cautions.
Thus, it is important to develop a standardized process. “That is the way you will make sure that you don’t miss something and have one of those tragic events where someone comes back years later and has [a serious disease] that could have been prevented,” Barrett says.
A final safeguard built into the Vanderbilt process is a weekly review during which Barrett or a colleague analyzes a report detailing all the AIF-related critical alerts that were issued in the previous week. “We can look and make sure that all of those critical alerts were acknowledged and that follow-up plans were started,” Barrett explains. Such a review process is important, particularly when implementing a new process or for academic medical centers that may employ rotating clinicians who may be in the ED only for a month and may not be familiar with alert system. “Until this becomes a rote process for people, this is a really important safety step,” Barrett adds.
REFERENCES
1. Moore CL, Baskin A, Chang AM, et al. White paper: Best practices in the communication and management of actionable incidental findings in emergency department imaging. J Am Coll Radiol 2023;20:422-430.
2. Liao GJ, Liao JM, Lalevic D, et al. Location, location, location: The association between imaging setting and follow-up of findings of indeterminate malignant potential. J Am Coll Radiol 2019;16:781-787.
3. Barrett TW, Garland NM, Freeman CL, et al. Catching those who fall through the cracks: Integrating a follow-up process for emergency department patients with incidental radiologic findings. Ann Emerg Med 2022;80:235-242.
New recommendations help health systems implement processes that will preserve patient safety. These tips aim to make it easy for providers to do right by their patients when clinicians identify actionable incidental findings.
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