Critical Radiology Alert Process

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Critical Radiology Alert Process

October 30, 2024

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Editor's Note: The content of the innovation summary is based on cited sources and information gathered in an interview the PSNet team conducted with the Innovation team.

Innovation Snapshot

When a patient presents to the emergency department (ED) and receives radiologic testing, the testing can identify unrelated abnormal findings¹ Unfortunately, this information is often not well communicated, which can lead to serious adverse health events.²

In response to these concerns, Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal of improving communication of radiologic abnormalities.³

The first 13 months of the innovation resulted in shared patient findings and care plans for 888 out of 932 (95%) targeted ED patient care episodes with abnormal radiologic findings.³

Description of Innovation

Incidental abnormal radiologic findings during an ED visit, unrelated to what a patient presents to the ED for, are an important patient safety issue.¹ In fact, up to 27% of these findings are related to the first diagnosis of malignancies.²The innovating organization found that 32% of their patients had unrelated incidental findings when they underwent computed tomography (CT) trauma evaluation.²

The innovators developed a critical radiologic alert process to improve the communication of abnormal incidental findings in their organization. When the radiologist identifies an incidental finding during interpretation of the study, they initiate a critical alert, which notifies the ED physician. The treating ED physician then completes an ED follow-up request form in the electronic health record (EHR) to start the process. The innovation consists of a four-step process: 1) informing the patient of the finding and documenting the discussion in the physician’s notes, 2) determining whether the patient is in or out of network with the innovating organization, 3) completing the ED follow-up request form, and 4) making a proper in- or out-of-network referral on the ED follow-up request form.³The process also places patients on a critical radiology alert weekly report, which is reviewed by ED nurse case managers and cancer center navigators to ensure all patients with critical alerts receive proper follow up.³

For out-of-network patients, ED nurse case managers contact the patient’s primary care provider (PCP) to fax necessary records about the finding and help arrange any necessary follow-up. If the patient doesn’t have a PCP, the nurse case managers work with a system of outpatient clinics to connect the patient with primary care. In-network patients are encouraged to discuss the findings with their PCP. If the PCP is within the innovator’s system, the PCP will automatically be notified about follow-up.

Exhibit 1 below demonstrates the incidental finding alert and associated follow-up request form that is completed by the healthcare providers.

Exhibit 1. This is an example of an incidental finding alert in the EHR system and ED follow-up request form, which the clinician completes to alert the case manager or cancer center navigator of the incidental finding and the need to schedule follow-up care.

Critical Radiology Alert screenshot

Published Results

Any adult who presented to the ED and was found to have an incidental radiology finding between May 3, 2020, and June 30, 2021, was included in analysis of the critical radiologic alert process.

The primary outcome was the proportion of ED patient visits with an identified incidental finding where there was communication from the innovation organization. In the first three months of the new process, 932 ED patient visits had critical radiology alerts, with 982 incidental findings (some patients had multiple findings, accounting for the increase in findings).³ Of these patients, 888 had documented communication after leaving the ED, with an associated follow-up plan developed.³ The team was unable to contact or confirm follow-up with 44 patients.³

This innovation has the benefit of being easily integrated into an organization’s EHR system. The results demonstrated this innovation could notify treating ED physicians quickly of incidental findings. The process allows for consistent and efficient follow-up with patients about these incidental findings, which may have been missed without this innovation. Additionally, the innovation allowed patients to be quickly connected with case managers and patient navigators to assist with necessary follow-up for the incidental findings at the innovation’s medical center and other healthcare facilities in the region.³

Planning and Development

The keys to success of any patient safety innovation or intervention include leadership and staff buy-in, staff involvement in planning and development, and establishing a data infrastructure to collect process and/or outcomes measures to track performance and drive improvement. Specific to this innovation, the following planning and development activities should occur prior to implementation:

Defining the problem and developing associated pathways for patient follow-up that consider a patient’s insurance type, which may impact the follow-up process (e.g., preauthorization, primary care provider referrals, etc.), are the first two steps that potential innovators should take when planning and developing the innovation.
Obtaining leader support and buy-in from the organization is necessary. In this case, the hospital, ED, and Cancer Center leadership teams enthusiastically supported the program and provided support for the ED nurse case managers, nurse navigator, and necessary modifications to the EHR.
The processes to activate the radiology critical alert and request the ED follow-up must be integrated into the radiologist’s interpretation and ED track board systems to reduce unnecessary burden on the practitioners. This requires the support of the innovating organization’s information technology developers.³
Buy-in is more easily obtained when the standardized process is simple and easy to follow. The innovation process is completed in a maximum of two minutes.
The month before launch, the innovating organization introduced the innovation to the ED clinicians at staff meetings, resident weekly conferences, and in weekly updates to communications about ED procedures³
New staff must be onboarded to the innovation.
- The innovators say that new staff are trained during orientation, with a specific EHR portion of the training focused on critical alerts.

Resources Used and Skills Needed

According to the innovators, the resources and skills used to support the implementation of this innovation are as follows:

A healthcare professional who assists patients with follow-up testing and practitioner referrals after an incidental finding is identified and communicated to the patient by the ED treatment team.
- This role is best served by someone with a healthcare background, like a nurse navigator or nurse case manager.
  - Patients often have questions in the face of these findings, so sensitivity and effective communication are important.
  - Medical expertise is also needed as there are frequent needs to review the radiologist’s interpretation for recommended follow-up testing and determine which specialist may be best to further evaluate the patient’s findings.
- Each system must determine the effort required for this role based on the volume of incidental findings needing follow-up in their patient population.
A dedicated cancer nurse navigator commits 25% to 50% of their time to ensure timely follow-up with patients identified with findings and to sustain the innovation. When building the innovation, the nurse navigator needs to commit additional time to adequately develop the appropriate workflows and processes. The dedicated time of the navigator can vary depending on the volume and nature of the communicated findings.
Building the innovation requires 50% of a full-time information technology analyst’s time. Once the innovation is up and running, the analyst only needs to dedicate 25% of their time.

Implementation Costs And External Funding Support

According to the innovators, the entire innovation was funded internally.

Sustaining the Innovation

It is beneficial to have the patient’s PCP involved in the process to review prior radiology records, schedule and monitor follow-up based on the incidental findings, and determine the optimal management plan based on their knowledge of the patient.³
The weekly report is reviewed by the ED case managers and cancer center navigator to ensure that every patient is contacted by one of the teams to ensure innovation sustainability.³
- According to the innovators, this report lists the critical radiology alerts for the last week. The ED case manager and cancer care navigator cross-check this report to ensure nothing is missed.
The innovator states that developing readily available training content is important. Even though staff may be trained on the innovation in the beginning, the innovator says that it is necessary to have training materials that team members can review to refresh their initial training. This can take the form of protocols and procedures, checklists, and online modules.
The innovators state that it is beneficial to conduct periodic data reviews to ensure the goals of the innovation are met.
The innovation has the potential to promote hospital growth by establishing new patients, and maintaining current patients, via the follow-up plans developed for the patients³

Use by Other Organizations

The innovators are not aware of other systems that have implemented this exact innovation. Some, however, have implemented other solutions to this important patient safety issue. The innovators have been asked to present their work nationally at the Association of Cancer Care Centers, including the National Oncology Conference and the Annual Meeting/Business Summit in 2021.

Evans CS, Dorris HD, Kane MT, et al. A natural language processing and machine learning approach to identification of incidental radiology findings in trauma patients discharged from the emergency department. Ann Emerg Med. 2023;81(3):262-269. [Available at]

Evans CS, Arthur R, Kane M, et al. Incidental radiology findings on computed tomography studies in emergency department patients: a systematic review and meta-analysis. Ann Emerg Med. 2022;80(3):243-256. [Available at]

References

https://pubmed.ncbi.nlm.nih.gov/25576049/
https://pubmed.ncbi.nlm.nih.gov/20335439/
https://www.annemergmed.com/article/S0196-0644(22)00275-X/fulltext
https://www.annemergmed.com/article/S0196-0644(13)00105-4/abstract
https://ajemjournal-test.com.marlin-prod.literatumonline.com/article/S0735-6757(08)00235-0/abstract

Summary

Vanderbilt University Medical Center developed an electronic trigger tool that alerts the care team of unrelated abnormal findings and provides a companion follow-up process, with the goal of improving communication of radiologic abnormalities. The first 13 months of the innovation resulted in shared patient findings and care plans for 888 out of 932 (95%) targeted ED patient care episodes with abnormal radiologic findings.

The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.