“Failsafe” is the name for our new strategy to directly contact a selected population of the Penn State Hershey Medical Center patients via the U.S. mail, in order to facilitate these patients obtaining appropriate follow-up of incidental findings discovered on imaging.
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.
Failsafe was implemented in 2012 and has been in continuous operation since that time. Initially, Failsafe was limited to adult patients, but due to the widespread faculty enthusiasm for the program within the Penn State Children’s Hospital, Failsafe was soon expanded to include pediatric patients as well. We have continued to send approximately 6 - 8 letters per week, and the Failsafe letter has been translated into Spanish for patients whose primary language is listed as Spanish in the EHR. The work was also mentioned in a Wall Street Journal article.
An initial assessment of the Failsafe Program’s effectiveness was performed in which approximately 10% of the patients who had received Failsafe letters in the first year of the program were contacted by phone. In this initial survey performed in March-April of 2013 our patients’ reactions to receiving a “Failsafe” letter were almost universally positive. Of the patients contacted in the initial survey,80% remembered receiving the letter. Half (40% of the total sample) reported experiencing no psychological distress upon receiving the letter, while the other half stated that the letter upset them / made them feel somewhat anxious, although the majority of these stated that this was not a serious problem for them. Most described their reaction to the letter as making them feel “a little nervous.” Only one patient stated that receiving the letter made him “very upset,” but upon further questioning, it was clear that he was actually angry about the care he received from the E.D. physician, which did not meet his expectations, and the letter seemed to reinforce his impression that the E.D. physician had been inattentive to his needs.
Only one patient in our initial survey stated that she received, but chose to disregard, the letter; almost all stated that they had either already received or have arranged for the recommended follow-up through their PCP in the approximately six month interval between the letter and our follow-up phone survey. Another patient commented that she had been advised in the E.R. to obtain follow-up, but had not intended to do so until receiving our letter. She stated that it was the “Failsafe” program letter which motivated her to make the effort to obtain her recommended follow-up, which she otherwise would not have done. Six patients spontaneously expressed positive feelings about the “Failsafe” program when asked if they had “any other thoughts or suggestions for us.” Two patients were particularly enthusiastic about the “Failsafe” program, one saying, “HMC is really on the ball,” and the other saying “You people did a wonderful job.”
A subsequent phone survey, completed in November of 2014 by the same interviewer (MAB), conducted approximately 20 months after the first survey, was somewhat less encouraging. In this attempt, most of the Failsafe patients we phoned could not be successfully contacted and did not return calls despite multiple attempts and voicemail messages. Of more than 20 patients contacted in this second survey, only 3 were willing to speak to us about the program; all three had chosen to disregard the letter, for varying reasons. This experience has led us to believe that there may be issues involving patient engagement which are potentially limiting the effectiveness of Failsafe.
We are currently designing an extension to Failsafe to address the patient engagement issue. Under the auspices of the Chief Medical Officer and Chief Quality Officer, we are planning to establish a new position for a “Failsafe Nurse,” to routinely make phone contact with all patients receiving a Failsafe letter. We are hopeful that prompt, personal contact will make a difference for the sub-population who are resistant to the Failsafe message. Our efforts are ongoing. Dr. Michael Moore has joined our team, replacing Drs. Eggli and Tappouni.
- 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