It has been our experience at the Penn State Hershey Medical Center (HMC) that patients seen for urgent symptoms in the Emergency Department (ED) who have “incidental” findings on imaging ,i.e., findings unrelated to the patient’s presenting complaint, do not always receive appropriate attention to these findings on follow-up. This can occur despite specific recommendations made by the Radiologist in the final Radiology report or even if a direct radiologist to ED or trauma surgeon clinician communication is made and documented.
At HMC, many adult patients seen in the ED undergo extensive imaging in order to evaluate specific acute findings; typically these Emergency physicians do not have the time or opportunity to concern themselves with the follow-up of incidental findings on imaging which are identified by Radiologists but are unrelated to the patient’s acute visit and acute symptoms. The expectation of the ED physicians is that patients will follow-up with their primary care provider. However, this assumption may not be valid for several reasons, including: (1) The primary provider is usually not notified of the patient’s ED visit or the results of their imaging, and generally will not be listed to receive a copy of the radiologist’s report in a timely fashion, if at all. (2) The patient does not have an ongoing relationship with a primary care physician (PCP), and (3) The patient may have a false sense of security since they have “seen a doctor” and undergone what seemed to them to be a thorough evaluation - they do not understand the limitations inherent in an ED situation as regards follow-up.
We in the Department of Radiology therefore recently implemented a new strategy (deemed “failsafe”) which was developed in cooperation with the Department of Emergency Medicine, The HMC Quality Department, and the Division of Family & Community Medicine to address this situation so that fewer patients”fall between the cracks” with regard to their follow-up. The approach involves the patient directly in the chain of communication between the Radiologist and the PCP.
Penn State faculty radiologists who interpret studies for adult patients in the ED are tasked to use our Primordial computerized tracking system to “flag” those ED patients who have incidental findings requiring specific follow-up which does not relate to their ED visit. Generally this would take the form of incidental (and indeterminate) mass lesions, although other types of incidental findings may be selected if, in the clinical judgment of the interpreting radiologist, specific imaging or other follow-up is needed on a non-emergent basis. As a rule of thumb, findings of sufficient urgency for the radiologist to communicate directly with the ED physician to ensure that they are appropriately and promptly addressed are generally excluded from “failsafe,” which is intended to focus on medium and long-term follow-up of findings which are not sufficiently clinically suspicious to warrant an immediate workup.
The cases identified by the interpreting Radiologist are reviewed on a weekly basis by a member of the Department’s seven-member “Failsafe Committee,” in order to verify the appropriateness of the patient selection and thus to ensure that uniform standards of patient selection are applied. Selected patients are then sent a standard letter to their mailing address of record (customized only with the patient’s name) advising them that there are findings on their ED imaging study (ies) requiring follow-up by their PCP, and instructing them as to how they can obtain the radiology report for their PCP if needed (primarily for physicians outside of our system) and also how they can readily obtain a physician referral from our Dept. of Family & Community Medicine should they not currently have an identified PCP. A copy of the patient letter is also sent via the electronic medical record to the inbox of the primary care physician, if there is one identified for the patient.
The “Failsafe letter” was vetted by the Departments of Risk and Quality in cooperation with legal counsel and emphasizes that the Department of Radiology cannot act in the place of a PCP in determining what follow-up is appropriate for a patient, but can only make recommendations to the PCP. Copies of the letters which are sent are archived on our Departmental servers.
We began the process on October 1, 2012, and have sent an average of 8 letters per week since that time. The Medical Staff at HMC was advised of this process by electronic memorandum sent though the HMC Medical Staff Office, and the project was enthusiastically received. We are considering adding pediatric ED patients after we have gained sufficient experience with adult patients and have streamlined the process.
We believe that this initiative, which encourages the active involvement of patients in their own care as a patient safety strategy, is a unique, novel approach; it is consistent with the Joint Commission’s National Patient Safety Goals. The plan has been enthusiastically received by our medical staff.
While receiving a “failsafe letter” may result in patient anxiety, we feel that the tradeoff of improved follow-up will result in an overall benefit to patients and will result in better patient outcomes for the population at risk.
Measurement of improved outcomes as a result of this method is difficult; it is impossible to know which patients in our system would not have received appropriate follow-up had the failsafe not been present. We are aware of only a handful of "index" cases where follow-up was missed, cases with severe consequences for the involved patients. We see this program as a means to prevent harm, and it is quite difficult to measure harms that were effectively prevented! We are tracking the number of letters sent, and plan to survey a sample of the patients who received the letters, in order to get a measure of the impacts (both positive and negative) of the program.
- Michael Bruno, Leader
- William Bird, Member
- James Birkholz, Member
- Gregory Caputo, Member
- Thomas Dykes, Member
- Kathleen Eggli, Member
- Glenn Geeting, Member
- Julie Mack, Member
- Jonelle Petscavage, Member
- Rafel Tappouni, Member