Standardised radiology alert system effective for incidental findings follow-up

30th June 2022

A standardised radiology alert system has enabled the follow-up of the majority of ED patients for whom incidental findings were detected

A standardised radiology notification system which identified and subsequently ensured the follow-up of emergency department patients for whom incidental findings were detected in scans, has proved to be highly successful.

This was the conclusion of a study by a team from the Department of Emergency Medicine and the Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, US.

The presence of incidental findings and which are unrelated to the initial indication for a radiological scan are not uncommon. For example, in a study of 1155 patients who had an emergency abdominal computed tomography scan, 700 had incidental findings detected, of which, 143 were deemed indeterminate requiring urgent investigations.

The presence of incidental findings are commonly detected in scans for trauma patients, with some that require urgent evaluation (type 1 findings) or at least should be communicated to patients (type 2 findings). Using this classification, in one study that retrospectively reviewed 3092 patients, type 1 findings were present in 32% of all scans and type 2 findings in 41.2% of scans.

Communication of findings to patients and appropriate follow-up is needed particularly where the findings indicate a potential malignancy.

For the present study, the US team developed a standardised radiology reporting system that created an electronic trigger to ensure that patients with incidental radiology findings were connected with an appropriate outpatient surveillance follow-up.

The team retrospectively examined the value of their standardised radiology reporting system by including all adult emergency department visits with a critical radiology alert for incidental findings. Operationally, if a radiologist identified important clinical or incidental findings, these were added to a critical alert messaging system which activated a ‘stop sign’ icon on the emergency department, indicating to clinicians that the alert needed to be reviewed and acknowledged.

The emergency department clinicians were then required to complete an appropriate follow-up request form which was sent to members of the department whose role was to liaise with patients and primary care physicians to arrange the recommended follow-up.

For the present study, the authors set the primary outcome measure as the proportion of emergency department (ED) patient visits with identified incidental findings that had documented communication with the patients and surveillance plans. For the secondary outcome, the team looked at the frequencies of post-ED surveillance clinic visits.

Standardised radiology alert system outcomes

During the period of analysis, there were 64,731 ED visits of which 932 (1.44%) patient visits had critical radiology alerts. This total included 53 visits with multiple findings so that the actual total was 982 incidental findings.

The primary outcome was met in 95.3% (95% CI 93.9% – 96.6%) of ED patient visits. For the secondary outcome, 99.1% of in-network referral to a primary care provider or specialist occurred.

The authors concluded that the successful implementation of a standardised radiology notification and referral system is an important patient safety intervention that provides the opportunity to detect undiagnosed malignancies.

Citation
Barrett TW 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

Incidental findings observed in almost a third of CT scans in emergency departments

27th June 2022

According to a systemic review, incidental findings seen on a CT scan in emergency departments are present in nearly a third of cases

The presence of incidental findings (IF) occurs in roughly a third of all computed tomography (CT) scans undertaken with emergency departments according to the findings of a systematic review by a group of US researchers.

The term ‘incidentaloma’ refer to an incidentally discovered mass or lesion, detected using imaging and which was performed for an unrelated reason. Such incidental findings are not uncommon, especially among scans for trauma patients with one study revealing how the findings were present in 15% of trauma CT scans.

Whilst the presence of IF do not affect or alter the emergency department clinician’s current diagnostic work-up, it is important that these observations are communicated to patients so as to ensure that where necessary, appropriate further tests and follow-up are instigated. However, in non-trauma patients, little is known about the level of incidental findings among CT scans undertaken within emergency departments.

For the present study, the US team sought to estimate the prevalence of radiologic IF among patients visiting an emergency department and who underwent a CT scan. A secondary aim was look at how hospitals managed and stratified the risks associated with abnormal findings.

Undertaking a comprehensive literature search, the authors looked for studies including terms such as ‘incidentaloma’ without a restriction on the type of study design and which included those that were retrospective, cross-sectional or prospective in nature. The primary outcome of the systematic review was the prevalence of IF on a CT scan.

Prevalence of incidental findings on CT scans

A total of 69 studies representing 147,763 emergency department encounters or radiology reports, with a median patient sample size of 882, were included in the analysis.

The majority of studies were cross-sectional in design (82.6%) with the remainder comprising cohort (7.2%) and those with a pre- and post-interventional design. Just over half of the studies (50.7%) were in trauma patients and 63.8% of studies included some form a risk stratification of IF.

The pooled prevalence of any incidental finding on CT scan was 31.3% (95% CI 24.4% – 39.1%) although there was marked evidence of heterogeneity in the studies. The highest prevalence of IF occurred in patients having a CT scan because of chest pain (36.6%), followed by trauma (34.7%).

In a total of five studies, all based in trauma centres, there were structural interventions designed to improve the recognition and notification or follow-up of patients identified with an IF on a CT scan. In one such study, for example, following implementation of the strategy to manage IF, patient notification increased from 17.7% to 32.4%.

The researchers also discovered that documentation of IF in the patient’s discharge notes was present in only 20.1% to 47.2% of cases.

In their conclusion, the authors identified the need to establish a comprehensive classification system and standard-based approach to help clinicians when faced with an IF. They also called for more flexible care co-ordination programs to ensure timely follow-up, clear documentation in medical records and which could easily be implemented within a busy emergency department.

Citation
Evans CS et al. Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis Ann Emerg Med 2022