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In our many columns on test results “slipping
through the cracks” there is one particular scenario
we always caution about. That pertains to the patient who is discharged from
the hospital or from the emergency department when the official result of one
or more tests is “pending”. Every hospital must have in place a mechanism to
ensure that the “clinician who needs to know” will follow up on that test
result and take appropriate action based upon that test result.
We’ve previously
discussed the emergency department as one area prone to failure to follow up,
particularly for radiology studies and lab tests. Callen et al. (Callen 2010)
noted that studies have reported rates of failure to follow-up laboratory tests
for ED patients range from 3% for microbiology tests to 75% for pregnancy tests
and that 6% of cervical spine injury might be missed.
The reason for the ED visit may also be
important. Trauma patients get lots of studies, particularly imaging studies,
that are likely to have incidental findings. Sich et
al. (Sich 2018) found that trauma
patients had a rate of incidental findings of 70%, of which 36% were clinically
relevant.
There are several factors that make “slipping
through the cracks” more likely in the emergency department. The clinician who
initially ordered the test may have already ended his/her shift, yet the
official report may be sent to that clinician. Worse yet, that clinician may
not be scheduled to be in the hospital again for some time (and maybe not even
at all). In some cases, the official report may come hours after the patient is
discharged or the following day. But sometimes several days may elapse.
Add to that another problem we often see: the
primary care physician is often never notified that his/her patient had an
emergency department visit and, thus, is unaware of any test results that are
pending. Hospital IT systems do not, in general, do a good job of ensuring that
the correct PCP is in the system. Patients may change PCP’s and the hospital IT
system may never be informed.
Responsibility to ensure closing the loop is
the responsibility of the ordering physician, the radiologist/imager (or lab
for lab test results), the physician primarily responsible for management of
the patient, and the patient him/herself.
A new study reported in the Annals of
Emergency Medicine (Mikhaeil 2020) addresses this issue as
it pertains to patients seen in the ED. It gives two examples of common
problematic occurrences:
The Mikhaeil study
was a systematic review of the literature on this topic. They found primarily four
types of processes used to address test results pending at discharge:
Nurses or clerical
staff contacting patients used a variety of methods. Phone contact,
followed up with a letter if phone contact was unsuccessful, was the most commonly used method. Some used certified letters. They
gave examples where these efforts resulted in an increased percentage of
patients with successful follow-up, from 8.1% before to 57% after the new
processes were implemented. The time to patient follow-up also decreased from
20.1 hours to 7.1 hours.
Physician-led
follow up included systems led by either emergency department physicians or
radiologists. We previously have recommended that the clinical director of the
emergency department, or his/her surrogate, could review cases the next day to
determine which patients needed follow up. Note that computer systems can help
identify such cases by using the timestamps on the reports and the timestamp
showing when the patient was discharged (these are helpful but not infallible).
The study by Callen et al. (Callen 2010) also suggested online “endorsement” of test results could be an
important intervention. If you had such a system in place, the physician
reviewing cases the following day could simply search for test results lacking
a physician “endorsement”.
Mikhaeil et al. describe the Callen study as the only
one where dedicated administrative shifts for
emergency physicians were used to follow up on test results pending at
discharge. The other studies involved radiologists doing the follow ups. We’ve done several columns highlighting the responsibility
of the radiologist to follow up on any report that has significant unexpected
findings. Systems must be in place to facilitate that. But we’ve
also pointed out the barriers and resulting frustrations for the radiologist
who is attempting to do that follow up. They would usually want to discuss the
findings first with a responsible clinician rather than calling a patient
blindly. But the clinician who ordered the study may no longer be available and
it may not be clear to the radiologist what clinician will be following the
patient after discharge from the ED.
Mikhaeil et al.
note that the process led by radiologists allowed 59% of patients to be
notified of their incidental findings and given appropriate follow-up
instructions, compared with the 7% before implementation.
Patient engagement.
We also always recommend that patient discharge instructions include comment
about any test results pending and encourage them to contact their physician if
they have not heard those results within a reasonable amount of time. We
emphasize “no news is not good news” and they should never assume the
test result was normal. The Mikhaeil
systematic review found some studies with unique ways in which patients were
engaged in the process. One of those studies was by Huppert et al. (Huppert 2012), who were studying a population of adolescents
and young adults seen in the ED with possible STI’s (sexually transmitted infections).
Those test results typically take several days to come back after ED discharge.
In those who test positive, follow up is important not only to ensure they
receive the correct treatment, but also to receive counselling on partner
treatment and safer sex practices.
First, they assigned a
single nurse practitioner (NP) to handle all STI follow-ups. Then they tried to
ensure they had a confidential phone number in the EMR for each patient by
issuing a prompt in the EMR for the clinician to update that phone number. Then,
they developed the “patient activation card”. Each business-sized
card read: “Our goal is to keep you healthy! You had tests performed on (date).
Your results should be back in about 3-4 days. Tell your doctor or nurse today
what number we should call to reach you. We will contact you in a few days if
your results are positive. You may also call Rachael at 513-xxx-xxxx to get
your test results. Please call between 9 AM and 5 PM”. The nurse practitioner
was also given a dedicated cell phone to receive these calls.
In the Mikhaeil study’s last category, the
“collaborative” methods were used to ensure the correct antibiotic was
being used in those patients for whom cultures were done and antibiotics prescribed.
Clinical pharmacists would review all microbiology results and confer with the
emergency physician about potential antimicrobial changes. After that discussion,
a nurse or a pharmacist would contact the patient with the recommendations.
We’ve always
recommended that hospital discharge summaries should always have a section for
“test results pending” and a phone conversation with the clinician assuming care
after discharge should specifically include discussion of test results pending.
Similarly, any ED summary intended to be sent to the PCP or other clinician
responsible for post-discharge care should also include a specific section for “test
results pending”.
The study by Sich
et al. (Sich 2018) was particularly enlightening,
and applied to trauma patients who were admitted or discharged from the
emergency department. Because of the high rate of failure to follow up on
incidental findings, they developed an intervention with 2 key changes. First,
radiologists were asked to report as a clinically relevant finding any incidental
finding with the potential for requiring follow-up or need for clinical
correlation. If a clinically relevant incidental finding (CRIF) was identified,
radiologists would provide high and low risk follow up modalities and time
intervals for each CRIF. Radiologists would report CRIF’s in the impression/summary
of their report for easy identification in addition to the body of the
dictation.
Secondly, the electronic trauma history and
physical examination was modified to include a required section for incidental findings.
Trauma providers were asked to report CRIF’s at the conclusion of the trauma
evaluation prior to admission or discharge from the emergency room and then
required to document it in a new section of the electronic H&P. When this
field was populated in the trauma H&P, it created a follow-up visit order automatically
with the PCP. This order was then pulled into the discharge instructions automatically
with other required follow-up visits.
In their systematic review, Mikhaeil et al. found 5 features in quality improvement
studies that improve the likelihood of successful follow-up for test results
pending at discharge:
Dedicating staff or giving clinicians “off”
time to carry out these processes, of course, costs money. But,
we’ll be the first to point out that a single malpractice case avoided by doing
this more than makes up for the additional expense incurred. We’ve
always favored assigning someone to check the day following ED visits for any
test results that came in after the patient left the ED (or have still not yet
come in). Using IT to help identify those tests that need follow up is also
important. Responsibility for closing the loop belongs to the hospital and its
ED, the ordering physician, the discharging physician, the radiologist/imager
(or lab for lab test results), the physician primarily responsible for
management of the patient, and the patient him/herself.
See
also our other columns on communicating significant results:
References:
Callen J, Georgiou A, Prgomet
M, et al. A qualitative analysis of emergency department physicians’ practices
and perceptions in relation to test result follow-up. Stud Health Technol
Inform 2010; 160(pt 2): 1241-1245
http://ebooks.iospress.nl/publication/13642
Sich N, Rogers A, Bertozzi D, et al. Filling the void: a low-cost, high-yield
approach to addressing incidental findings in trauma patients. Surgery 2018; 163:657-660
https://www.sciencedirect.com/science/article/abs/pii/S0039606017306918
Mikhaeil JS, Jalali H, Orchanian-Cheff A, Chartier LB. Quality Assurance Processes Ensuring
Appropriate Follow-up of Test Results Pending at Discharge in Emergency
Departments: A Systematic Review. Annals of Emergency Medicne
2020; Published online: August 25, 2020
https://www.annemergmed.com/article/S0196-0644(20)30590-4/fulltext
Huppert JS, Reed JL, Munafo
JK, et al. Improving notification of sexually transmitted infections: a quality
improvement project and planned experiment. Pediatrics 2012; 130(2): e415-e422
https://pediatrics.aappublications.org/content/130/2/e415
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