Radiology studies receive a preliminary read in the ED. Later, the radiology overread might conflict with the original findings. If a radiologist is available overnight, any problems can be caught while the patient still is in the ED. “Benefits of in-house, overnight attending radiologists are disputed by some, stating that costs do not outweigh benefits,” says Ferco Berger, MD, EDER, FASER head of the emergency and trauma radiology division, department of medical imaging at Sunnybrook Health Sciences Centre in Toronto.
Berger and colleagues wanted to know how an overnight radiologist affected return callbacks for ED patients.1 They studied patients with imaging completed overnight in the two years before an overnight radiologist was added, and compared that information with the following year. In 2016 and 2017, the number of patients who underwent overnight imaging was 13,883 and 14,463, respectively. Fifty-four patients in 2016 and 61 patients in 2017 were called back regarding the imaging. After an overnight radiologist was added in 2018, 15,112 overnight imaging studies were performed in the next year. Of that group, only seven patients were called back. “This paper provides new evidence that there is benefit to having this service,” Berger says.
Not many patients are called back to the ED in relation to overnight imaging findings. However, the reduction in this number after introducing overnight attending radiologists “is significant, and does help reduce costs, overcrowding in the ED, and patient discomfort involved in having to return to the hospital,” Berger says. The sooner a patient receives appropriate treatment, the better. “We should do everything we can to improve patient safety and reduce the risk of error,” Berger stresses.
Berger and colleagues did not examine the specific diagnoses of patients involved in the study. Risks for individual ED patients range from nonexistent to significant, depending on the diagnosis. “Based on the results of our study, we see a benefit of having an attending radiologist cover overnight reporting in the emergency department setting whenever possible to reduce recall numbers as low as possible,” Berger says.
EPs are responsible for the results in any study they order. “If something is either missed on the EP’s read or noted on the formal read and not relayed to the patient, there is an opportunity for medical malpractice,” says Adam Hennessey, DO, medical director and chair of emergency medicine at Roxborough Memorial Hospital in Philadelphia and Lower Bucks Hospital in Bristol, PA.
A relatively common example is missed lung nodules that were lost to follow-up until someone identifies a large, advanced malignancy. Sometimes, this happens because the patient is admitted, and the ED providers assume inpatient providers will convey the findings. “It is not prudent to assume that an inpatient provider will notice a small discrepancy on a radiology read,” Hennessey cautions.
EDs need protocols for how to handle radiology discrepancies. Exactly how that happens will vary depending on the facility. Some make a point of verifying patients’ personal cellphone numbers or their preferred contact method. Others make a practice of contacting the patient’s primary care physician, either by phone or electronically. Still others use certified mail to inform patients of the need for follow up on abnormal findings.
If a patient files a malpractice lawsuit, the plaintiff attorney will explore whether the ED provider had the option for an official radiology read but went with a preliminary read instead.
“For example, if the ED physician makes a disposition or other clinical decision based on a technician’s read of an ultrasound rather than waiting for the official read, their actions could be considered negligent,” Hennessey explains.
For cases in which EPs are reading their own studies, Hennessey says it is a good idea to engage in a conversation with the patient to explain the process (and to document that conversation). EPs can explain their interpretation is a preliminary read, that a formal read will occur shortly afterward, and that any variances will be conveyed directly to the patient. Ideally, EDs maintain radiology coverage for all studies.
“It is reasonable to assume that an EP would assume less liability if they are operating within the structure established by their individual hospital,” Hennessey says.
From a medical/legal perspective, there are two reasons for a radiology overread, says Eric H. Weitz, JD, a Philadelphia-based medical malpractice attorney. One is to confirm or clarify the EP’s findings. “ED physicians’ standard of care requires a certain level of ability to interpret tests that they order. But when the findings become more nuanced or less common, a trained radiologist is needed,” Weitz says.
A second reason for the overread is to identify incidental findings that may not be within the EP’s scope of training. “The most common source of liability arises out of what happens, or does not happen, next,” Weitz says. “Failing to communicate a potentially lethal incidental finding is indefensible.”
ED staff need a consistent, clear, and simple way to communicate discrepancies to the patient and subsequent providers. Two crucial questions: What happens to the discrepancy report if the patient is no longer in the ED? Who is ultimately responsible to close the loop on reporting and acting on the discrepancy? “These are the real sources of considerable liability,” Weitz says.
Lack of good documentation makes it easy for plaintiff attorneys to assert that inadequate follow-up, or none at all, happened. “There was a purpose the test was ordered,” Weitz says. “Failing to close that loop is a very attractive trial story.”
- Mughli RA, Durrant E, Baia Medeiros DT, et al. Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90%. Emerg Radiol 2021; Jan 11. doi: 10.1007/s10140-020-01894-y. [Online ahead of print].