How Do You Handle Incidental Findings?

A CT scan of your abdominal pain patient is negative for appendicitis, but the radiologist finds a cystic lesion in the kidneys.

"It really has no bearing on my emergency care of this patient, but it needs to be followed up on," says Audie Liametz, MD, JD, assistant medical director of the ED and chairman of the ED Quality Improvement Committee at Mineola, NY-based Winthrop University Hospital. "The radiologist may be worried about getting sued and may tend to overcall things, so it could be nothing. But it might be something."

If the patient is still in the ED, you can inform them of the finding, then note in your discharge instructions that they were informed to follow up with their primary care physician. If they don' t have one, give them a referral. Then document these actions.

"The patient is now responsible for following your instructions. If they choose not to, you are afforded some protection under the concepts of contributory negligence and comparative negligence. In essence, this says that patients are responsible for following up on the care and instructions the practitioner provides them," says Liametz. "Failure to do say may negate or reduce any potential monetary award."

Regardless, the ED physician is put in a position of being "a quarterback to decide what followup is needed, based on an incidental finding," says Liametz. "And if the patient has a private doctor, should you be faxing the information to the private doctor? It gets really confusing and time consuming."

Another scenario involves a chest pain patient sent home from the ED because an x-ray didn't show pneumonia or pneumothorax, so you diagnose musculoskeletal chest pain or bronchitis. The next day, the official reading comes back and shows a calcification in the left upper lobe which may be tuberculosis and needs followup with a CT scan.

"Who is getting that report?" asks Liametz. "The ED doctor sent the patient home. It might come back to the ED as an x-ray recall, but somebody now needs to pull the record to see if the doctor made a notation about this, which they likely didn't do, and that it needs to be followed up on. Think about the resources that this takes from the institution."

Also, whoever is designated to make this effort-whether the director of the ED, a nurse who does quality control, or the physician's assistant working in the ED fast track, must do so while he or she is busy working with acutely ill patients in their care today.

"In some cases, maybe that incidental finding on a re-call won't ever be communicated and/or it gets lost," says Liametz. "Then two years later, the patient is diagnosed with lung cancer. The plaintiff's attorney goes back and looks at the ER record from two years ago, finds it, and asks, 'Who communicated this to the patient or doctor?'"

Another scenario involves missed fractures. The ED physician may read the film and say it's negative and later on, the radiologist says it's positive. The patient has already been discharged. "In the old days, the ED physician would make a reading and the radiologist would read it, and either concur or disagree," says Liametz.

"But now, when the radiologist is reading not in the ED but in a remote location, it may get lost in cyberworld and the concordance between the ED physician's and the radiologist's interpretations may not be there. So then, hopefully an x-ray recall will make its way down to the ED, and then somebody has to process and act on it."

Some EDs keep the x-ray recall forms in the department, but Liametz says that these should be sent to medical records to become part of the "official" medical record. "So if two years down the line, the plaintiff's attorney does subpoena the chart, they will see there was a missed fracture. But it will be noted in the record that there was action taken on it," he says. "It's documented that the patient was told to followup with an orthopedist."

Electronic medical records may make this process easier, since an addendum about a missed or incidental finding can be added with less effort. "In the paper world, if I work today and after I've documented my record and I'm gone for the day, and the x-ray recall comes back, somebody has to physically get that chart to add the addendum," Liametz explains.

The issue is making sure that it is documented that the information was communicated to the patient. "If it gets lost and the form is never made part of the official medical record, somebody could say you never did it," says Liametz. "But if you have it written somewhere and it's part of the medical record that it was communicated to the patient, that is a very good defense. You can say, 'Not only did we go out of our way to communicate incidental findings, we told you what to do about it.'"