Patient Safety Tip
of the Week
April 17, 2018
More on Tests
Pending at Discharge
The problem of
significant abnormal test results “slipping through the cracks” is a serious
cause for preventable adverse patient outcomes and a leading cause of
malpractice settlements. A subset of this problem has to do with “tests pending
at discharge”. This refers to tests that were performed during an inpatient
hospitalization for which the formal interpretive report has not been completed
before the patient is discharged from the hospital. We’ve discussed this in our
Patient Safety Tips of the Week for March 1, 2011 “Tests
Pending at Discharge” and August 21, 2012 “More
on Missed Followup of Tests in Hospital” and the
list of other columns below.
In our March 1, 2011 Patient Safety Tip of the Week “Tests
Pending at Discharge” we
discussed a systematic review on the safety implications of missed test
results in hospitalized patients (Callen 2011). This is
an issue we have harped upon in many previous columns and the findings in the
new review are no less frightening. They found lack of followup
on test results ranged from 20-60% for inpatients and 1-75% for
emergency room patients. And the lack of followup
had clinical implications since some of the results were considered critical or
urgent or otherwise actionable.
A couple factors in
recent decades have contributed to this problem. One is the pressure to shorten
hospital lenghs of stay. The second has to do with
the widespread adoption of hospitalist programs. Don’t get us wrong. We love
hospitalists! But the nature of hospitalist scheduling often leads to reports
being sent to a hospitalist who will not be at the hospital for a considerable period of time or even never again. In our March 9,
2010 Patient Safety Tip of the Week “Communication
of Urgent or Unexpected Radiology Findings” we noted a study (Were
et al 2009) which showed that only 16% of tests with results pending actually
are documented in discharge summaries. They identified multiple changes in
attendings as an issue and difficulty identifying the physician who will
ultimately follow the patient after discharge. We also noted in our October 13,
2009 Patient Safety Tip of the Week “Slipping
Through the Cracks that studies have shown sending reports to two
physicians, rather than increasing the likelihood someone will follow up, actually doubles the risk that no one will
follow up (Singh
2009)!
Dalal and colleagues (Dalal 2018)
at Brigham and Women’s Hospital (Partners HealthCare) recently reported results
of a cluster-randomized controlled trial assessing the impact of automated
notification of tests pending at discharge (TPAD’s) on documented follow-up in
the EHR. (Note that we’ve described
some of the design and implementation of such systems by Dalal
and colleagues (Dalal 2011, Dalal 2012) in previous columns.)
Patients discharged from general medicine and cardiology
services with at least one TPAD between June 2011 and May 2012 were assigned to
intervention or usual care groups based upon the randomization status of their
discharging attending and PCP. They adapted an established algorithm to
identify actionable TPAD’s. All
normal, near-normal, and benign results were excluded. 7.5% of all TPAD’s
sampled were determined to be actionable and underwent subsequent chart review.
Examples of actionable TPAD’s include malignant cells in pericardial fluid
cytology, low vitamin D level, HIV genotype, positive urine culture, low
protein C level, gastric biopsy positive for H. pylori, and positive hepatitis
C antibody. Most commonly documented actions included establishing, changing,
or confirming a diagnosis and communicating results with the patient.
Most TPAD’s were generated on patients discharged from
general medicine services. The most frequent test type was
chemistry/hematology. Most discharging attendings were male and had
5 years or less of experience. 66%
of patients had non-network PCP’s. The proportion of actionable TPAD’s
listed as pending in the discharge summary was 50.7% and 49.5% in the
intervention and control groups, respectively.
The proportion of actionable TPAD’s with documented action
was not statistically different for the intervention arm compared to usual care
(60.7 vs. 56.3%). But almost all (97.4%) instances in the intervention arm who
had action had evidence of documented action on the same day.
The proportion of actionable TPADs with documented action
was significantly higher for pathology compared to other test types (77.2 vs.
48.5%). There was a non-significant trend towards increased proportion of
actionable TPADs with documented action for patients discharged by hospitalists
compared to non-hospitalists (62.3 vs. 54.4%). There was a significantly
greater impact of the intervention on documented follow-up of actionable TPAD’s
among patients with network PCPs (70 vs. 50%). There was no evidence of effect
modification of the intervention by clinical service, provider type or
experience, test type, or number of actionable TPAD’s per patient.
Even with the automated notification system there were still
approximately 40 percent of patients who
had no evidence of documented follow-up for actionable TPAD’s, including
several patients with biopsy specimens that revealed malignancies.
The proportion of actionable TPAD’s lacking documented
follow-up was 39.9% for acknowledgment, and 41.1% for action. Types of
actionable TPADs without documented follow-up included abnormal vitamin levels
(n = 25), pathology specimens (n = 15,
including 6 malignancies); abnormal rheumatology titers (n = 9,
including an extremely elevated anti-DS DNA titer); abnormal endocrine results
(n = 8); abnormal viral tests (n = 8,
including an elevated HCV viral load); positive microbiology cultures (4); and
miscellaneous (32)
Notably their healthcare system also had separate
notification systems running in parallel for pathology and radiology. The
authors suspect that may account for the higher proportion of pathology follow
up action documented and for the very low number of radiology TPAD’s identified
(most significant radiology TPAD’s were identified prior to discharge).
Note that this study only included patients who were
inpatients. It did not address the issue of patients seen in the ED and discharged before official reports of
all tests were done. The ED is particularly vulnerable because the individual
ED physician may not be returning to the hospital soon (or never in some circumstances).
So the ED medical director or his/her designee must be
assigned the task of going over the previous day’s tests to ensure no test
results are “pending” and have not been acknowledged by the original ED
physician. Similarly, particularly for radiology studies, each facility must
have a system in place a system where the ED
physician’s interpretation of an imaging study is reconciled with the official
radiology report and any discrepancies get back to a party in position to take
appropriate follow up action.
The other issue it does not address is the amended report. We discussed that in our Patient Safety Tips of
the Week for October 2, 2012 “Test
Results: Everyone’s Worst Nightmare” and March 12, 2013 “More
on Communicating Test Results”. Each facility must have in place a system in
which any report that is amended gets conveyed to a party responsible for the
patient.
Although the study did not show significant improvement in
the proportion of actionable TPAD’s with documented follow-up, they did observe
significant improvement in time to documented follow-up favoring the
intervention.
The study does demonstrate that the system designed at the
Brigham resulted in significant improvement in documented follow-up for
patients of network PCP’s and shortened the time to follow up action. One other
positive aspect of the study is that Partners HealthCare clearly has a good
algorithm for identification of potentially actionable TPAD’s (tests pending at
discharge). In our Patient Safety Tip of the Week August 21, 2012 “More
on Missed Followup of Tests in Hospital” we
discussed some of the barriers to identifying all those pending test results
and in being able to attribute responsibility for followup
to the correct party.
Also, since the
Brigham is a tertiary referral center and a very high percentage of inpatients
were non-network patients (66% of their patients had non-network PCP’s), it
might be anticipated that a system like theirs might be more effective in
hospitals that have a higher proportion of in-network patients and PCP’s, such
as community hospitals.
It's also
encouraging that the systems for communicating significant results for radiology
and pathology seem to be working well at the Brigham.
And it's encouraging
that the percentage of discharge summaries identifying tests pending at
discharge has improved since our original columns (the proportion of actionable
TPAD’s listed as pending in the discharge summary was 50.7 and 49.5% in their intervention
and control groups, respectively). But that’s still short of the 100% target we
have.
But the Brigham study
found that about 40% of actionable TPAD’s did not have follow-up documented
in the EHR, including a few high-risk results such as malignancies. The study shows that we still have a big gap in
“closing the loop” on test results when patients are discharged prior to
official test result reports being available.
To address this gap, Dalal and team
envision integration of newer digital health tools with the hospital's
electronic health record that not only notifies discharging attending
physicians and primary care physicians, but that empowers patients to make sure
their test results are followed-up in a timely manner. They note that most
major EHR vendors can extend existing functionality to externally notify
clinicians of actionable TPAD’s via institutional email, secure messaging, or
mobile app “push” notifications. They can also flag importance in subject
headings or notification banners, facilitate knowledge transfer between key
inpatient and ambulatory clinicians; and request acknowledgment electronically.
See also our other
columns on communicating significant results:
- Patient
Safety Tip of the Week May 1, 2007 “The
Missed Cancer”
- Patient
Safety Tip of the Week February 12, 2008 “More
on Tracking Test Results”
- Patient
Safety Tip of the Week October 13, 2009 “Slipping
Through the Cracks”
- What’s
New in the Patient Safety World July 2009 “Failure
to Inform Patients of Clinically Significant Outpatient Test Results”
- Patient
Safety Tip of the Week March 9, 2010 “Communication
of Urgent or Unexpected Radiology Findings”
- Patient
Safety Tip of the Week March 1,
2011 “Tests
Pending at Discharge”
- Patient
Safety Tip of the Week August 21,
2012 “More
on Missed Followup of Tests in Hospital”
- Patient
Safety Tip of the Week for October 2, 2012 “Test
Results: Everyone’s Worst Nightmare”
- Patient
Safety Tip of the Week for March 12, 2013 “More
on Communicating Test Results”
- What’s
New in the Patient Safety World
October 2013 “New
AHRQ Toolkit: Improving Your Office Testing Process”
- What’s
New in the Patient Safety World
January 2014 “Email
Alerts for Pending Test Results”
- What’s
New in the Patient Safety World
July 2015 “Technology
to Avoid Delays in Follow-up of Significant Results”
- Patient Safety Tip of the Week November
17, 2015 “Patient
Perspectives on Communication of Test Results”
- Patient Safety Tip of the Week December
20, 2016 “End-of-Rotation
Transitions and Mortality”
References:
Callen J, Georgiou A, Li J, Westbrook JI. The safety
implications of missed test results for hospitalised
patients: a systematic review. BMJ Qual Saf 2011; 20: 194-199 Published Online First: 7
February 2011
http://qualitysafety.bmj.com/content/20/2/194.full.pdf
Were MC, Li X, Kesterson J, et al.
Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending
Results and Outpatient Follow-up Providers. Journal of General Internal
Medicine 2009; 24(9): 1002-1006
http://springerlink.com/content/57u6374273282457/?p=8d1facb4fd6c402a9b895f3a46a59022&pi=1
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of
Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern
Med. 2009; 169(17): 1578-1586.
http://archinte.ama-assn.org/cgi/content/short/169/17/1578?home
Dalal AK, Schaffer A, Gershanik EF, et al. The Impact of Automated Notification
on Follow-up of Actionable Tests Pending at Discharge: a
Cluster-Randomized Controlled Trial, Journal of General Internal Medicine 2018;
Published online 12 March 2018
https://link.springer.com/article/10.1007%2Fs11606-018-4393-y
Dalal AK, Schnipper JL,
Poon EG, et al. Design and implementation of an automated email notification
system for results of tests pending at discharge. J Am Med Inform Assoc 2012; 19(4):
523-528
http://jamia.bmj.com/content/19/4/523.abstract?sid=e567bfae-e816-4f48-8080-36ee4119062d
Dalal AK, Schnipper JL,
Poon EG, et al. Design and implementation of an automated email notification
system for results of tests pending at discharge. J Am Med Inform Assoc 2012; 19(4):
523-528
http://jamia.bmj.com/content/19/4/523.abstract?sid=e567bfae-e816-4f48-8080-36ee4119062d
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