By Stacey Kusterbeck
Many tests ordered in the ED return with some type of “incidental” finding, something the provider was not looking for that was detected on imaging. Since it was not relevant to the reason for the visit, some of those findings are overlooked.
Christopher S. Evans, MD, MPH, and colleagues noticed incidental findings were common in their EDs, but there were challenges in identifying and managing those. “It became apparent there is a need for a dedicated systematic review focusing on the unique considerations in the emergency department environment,” says Evans, associate chief medical information officer at North Carolina-based ECU Health.
Evans and colleagues wanted to know more about the prevalence of incidental findings in the ED and reduce risk. They searched the literature, identifying 69 studies that reported the prevalence of incidental findings in CT scans of the head, neck, chest, or abdomen/pelvis.1 “The primary goal of this systematic review and meta-analysis was to help quantify the magnitude of incidental findings in the ED — and, secondarily, identify gaps in knowledge that may help inform interventions to improve appropriate patient follow-up,” explains Evans, an emergency physician (EP) at ECU Health Medical Center in Greenville, NC.
The 69 studies represented 147,763 ED visits. Overall, there was a prevalence of incidental findings of 31.3%. “This supports what many clinicians have already intuitively noticed in their clinical practice,” Evans says. Only a fraction of studies offered possible interventions to improve recognition and management of incidental findings in the ED.
“It highlights the need for continued work on how to most effectively identify and intervene on these findings in a way that works in the context of a busy ED workflow,” Evans offers.
The analysis included a summary of five studies that implemented interventions to help with the recognition of incidental findings. “Even with fairly resource-intensive protocols aimed at ensuring identification and patient notification, only moderate improvements in recognition were found,” Evans reports.
Six studies reported results related to successful follow-up. Less than half of incidental findings in those studies were followed up after ED discharge. “One of the most pressing knowledge gaps is the ability to classify which subset of incidental findings are the highest risk for patient harm or potential delays in diagnosis if not recognized,” Evans asserts.
One underlying issue is EHRs are built around a “problem list” instead of a “task list,” according to Michael S. Victoroff, MD, risk management consultant at COPIC, a Denver-based medical liability insurance provider. “While every EHR has alerts and reminders, none fully implement the principles of task-oriented medicine,” he says.
Following up on test results (including incidental findings) is an example of a function that many workflow systems do not handle well. “This has been a liability forever,” Victoroff laments. “But today’s volume of inbox messages imposes a nearly impossible burden on clinicians.”
For patients with incidental findings noted during an ED visit, it means risk of delayed recognition and intervention.
“Juries are often unsympathetic to ‘it was someone else’s job’ when multiple providers miss a critical problem,” Victoroff warns.
It is even more problematic if the incidental finding goes unnoticed during multiple subsequent healthcare encounters. Victoroff offers a typical scenario: A patient presents to an ED with symptoms of pneumonia. The EP orders an X-ray, and the patient is admitted. The radiology report notes: “Resolving pneumonia. Acute process may obscure a mass in right lower lobe. Recommend repeat in four to six weeks.”
The EP, the hospitalist, pulmonologist, and primary care physician all sign off on the normal result. All those providers might assume someone else is responsible for ensuring follow-up on the incidental findings. In this scenario, the EP would receive the report. However, since the EP will not see the patient again before discharge, he or she would have no reason to contact the patient. “That’s the liability exposure,” Victoroff says.
The plaintiff can ask the EP why he or she did not act on this. “Arguably, the ordering EP does have a responsibility to follow up on actionable findings in this case,” Victoroff offers.
The radiologist often will be excused if he or she followed American College of Radiology guidelines for reporting, and laboratories just need to follow their protocols for result notifications. “But this simply displaces liability onto the recipients, who always include the ordering provider,” Victoroff says.
Other potential gaps occur during shift changes, or when physician assistants or nurse practitioners order tests or sign off on results. When the patient returns in a year with cancer and sues, everyone involved might be named as defendants. Victoroff says managing future tasks is a critical missing link in clinical information systems. “As yet, there are no automated systems for reviewing inbox reports. Providers in every specialty depend on human vigilance,” Victoroff says.
One possible solution is to add a flag to the EHR to notify everyone receiving an imaging result that it requires follow-up, with alerts that escalate if action is not taken within specified timeframes. “EDs build safeguards around handoffs, which protect them from many missed tasks,” Victoroff notes.
However, information that is not essential for the immediate issue can be overlooked. All those incidental findings are a liability exposure everywhere test results are received. “When a delay of diagnosis explodes, a retrospective look at the causal pathway will often find ED providers in the chain,” Victoroff warns.
Heather A. Tereshko, JD, a principal in Post & Schell’s Philadelphia office, has defended EPs in multiple malpractice claims brought on behalf of patients who alleged they were not informed of incidental findings found on X-rays, CT scans, or lab results. There were some common fact patterns in those cases. Incidental findings were overlooked because the ED provider focused on the report’s final impression, and never reviewed the content of the radiology report. Someone called in the initial impression to the ED provider, but the report containing the incident findings was prepared later. The provider never reviewed that report.
It is critical for the ordering physician to read the entire report of any diagnostic studies ordered. That physician is the one charged with communicating all relevant and incidental findings to the patient, and ensuring the patient knows follow-up studies may be warranted.
In other cases, Tereshko says the ED provider is focused on a particular lab value, and an incidental abnormal value is simply overlooked or not communicated to the patient with advice to seek follow-up. Elsewhere, the radiologist sees something on a chest X-ray that appears abnormal or ill-defined, and recommends follow-up with a CT study. The EP gives the patient those instructions — but the patient never follows up. Years later, he or she is diagnosed with lung cancer. “In these types of cases, it typically comes to credibility of the ED provider and the credibility of the patient or patient’s family member,” Tereshko says.
In all these cases, good documentation of the conversation with the patient or family is critical. Ideally, the provider should document the specific abnormality that was communicated. “This is especially important if the patient is elderly or lacks the sophistication to appreciate the significance of the abnormality that is being communicated,” Tereshko says.
REFERENCE
1. 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;80:243-256.
The search continues for an effective technique to identify and intervene on these findings in a way that works in the context of a busy ED workflow.
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