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Communication of imaging recommendations to ED patients: Pulmonary embolus CT
Communication of imaging recommendations to ED patients: Pulmonary Embolus CT Jonathan D. Sonis MD, Yadiel S´anchez, H. Benjamin Harvey MD, JD, Brian J. Yun MD, MBA, Ali S. Raja MD, MBA, MPH, Anand M. Prabhakar MD, MBA PII: DOI: Reference:
S0735-6757(16)30965-2 doi:10.1016/j.ajem.2016.12.062 YAJEM 56384
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
2 December 2016 23 December 2016 24 December 2016
Please cite this article as: Sonis Jonathan D., S´ anchez Yadiel, Benjamin Harvey H, Yun Brian J., Raja Ali S., Prabhakar Anand M., Communication of imaging recommendations to ED patients: Pulmonary Embolus CT, American Journal of Emergency Medicine (2016), doi:10.1016/j.ajem.2016.12.062
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Communication of imaging recommendations to ED patients: Pulmonary Embolus CT
PT
Jonathan D. Sonis MD1, Yadiel Sánchez2, H. Benjamin Harvey MD, JD2, Brian J. Yun MD, MBA1, Ali S.
Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston,
SC
1
RI
Raja MD, MBA, MPH1, Anand M. Prabhakar MD, MBA2,3,4*
NU
MA.
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, MA.
3
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of
MA
2
Emergency Imaging, Boston, MA.
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of
AC CE P
TE
Cardiovascular Imaging, Boston, MA.
D
4
*Corresponding author
For all correspondence, please contact: Anand M. Prabhakar, MD Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of Cardiovascular Imaging, 55 Fruit Street, Gray 2, Boston, MA 02114 E-mail: [email protected] Tel no: 617-726-8396, Fax no: 617-726-4891 All authors report no conflict of interest.
ACCEPTED MANUSCRIPT
The current gold standard for diagnosing pulmonary embolism (PE) is Computed Tomography (CT), which has a reported sensitivity greater than 98%.1 While its primary goal is to rule out thrombus in
PT
the pulmonary arteries, CTPE may also demonstrate unrelated incidental findings which then require non-
RI
emergent follow-up imaging. Prior work has demonstrated that patients often remain unaware of
SC
incidental findings and lack understanding of plans for clinical follow-up.2 Therefore, the purpose of our study was to quantify the frequency of incidental findings requiring recommendations for clinical follow-
NU
up in patients who underwent CTPE in the ED, and to determine the rate of inclusion of these recommendations in written patient discharge instructions.
MA
An IRB Approved study was performed at a 999-bed quaternary care academic center and Level 1 trauma center. Approximately 104,000 ED visits occur at the institution annually, and approximately
D
105,000 ED diagnostic imaging studies are performed and interpreted in the ED radiology department
TE
annually.
A retrospective search for adult (greater than age 18) ED patients who underwent CTPE for
AC CE P
evaluation of suspected PE from July 2015 to July 2016 was performed. Patients who underwent CTPE after leaving the ED were excluded, as were patients who died at any time after arrival in the ED. The electronic medical record (EMR) of these patients was reviewed for demographics and disposition. Finalized radiology reports in the EMR were then reviewed for the presence or absence of incidental findings in the “Impression” field which generated a recommendation for follow-up. Incidental findings were defined as imaging findings not related to the evaluation of PE that generated a recommendation, Studies with multiple recommendations was each analyzed separately. Inpatient or ED discharge summaries were reviewed for mention of recommendations in discharge instructions. There were 1754 CT-PE examinations during the study period. Of these, 638 (36.4%) had at least one recommendation included in the radiology report. 103 examinations were subsequently excluded because, although ordered as an ED study, the CTPE actually occurred after the patient had left the ED, due to subsequent patient death during inpatient admission, or because recommendations were unrelated
ACCEPTED MANUSCRIPT to an incidental radiographic finding. Thus, the total study population consisted of 535 CT-PE examinations. The average patient age of the study patients was 62 ± 16 years; 52.1% were women.
PT
The most common incidental findings were pulmonary nodules (43.1%), pulmonary infectious or inflammatory changes (32.8%), intraabdominal abnormalities (9.6%), and thyroid abnormalities (6.1%).
RI
A total of 500 examinations (93.5%) had only one incidental finding with recommended follow-up
SC
identified. Thirty-five examinations (6.5%) had two or more incidental findings with follow-up recommendations. The most common recommended follow-up imaging modalities included CT (75.6%),
NU
ultrasound (7.0%), and magnetic resonance imaging (MRI) (3.7%). Table 1 summarizes the CTPE results,
MA
types of incidental findings identified, and corresponding recommendations may by the interpreting radiologist.
Of the total recommendations, 329 (61.5%) examinations had at least one written
TE
D
recommendation in the discharge instructions, including 153 (60.5%) from the ED and 176 (62.4%) associated with patients admitted to the hospital and subsequently discharged. No written discharge
AC CE P
instructions were found for one patient discharged directly from the ED and four patients discharged after admission to the hospital. Table 2 summarizes the findings on discharge documentation. Only 62.4% of patients who were subsequently admitted to the hospital from the ED had recommendations communicated in their discharge summaries. Prior studies have demonstrated the potential for lost information during handoffs from the ED to inpatient services and from inpatient settings to outpatient providers at the time of hospital discharge.4,5 These findings highlight the importance of further improvement in handoff processes. While we did not characterize identified pulmonary nodules by type, the frequency of pulmonary nodules in our study population with an average age of 62 is of particular significance as prior work has demonstrated that in patients greater than 60 years of age, 65% of solitary pulmonary nodules represent malignancy.6 Our study has several limitations. First, while all discharge documentation was reviewed, there may have been cases in which providers gave verbal follow-up instructions to patients, or may have
ACCEPTED MANUSCRIPT contacted outpatient providers by postal or electronic mail to arrange these studies, which prior studies have demonstrated significantly increases rates of follow-up.7 Other limitations include limited
PT
generalizability to non-academic medical centers and also that this study is retrospective. Communication of clinically significant incidental findings identified in the ED to patients and
RI
their primary care physicians is essential. Further efforts should focus on the implementation of tools
SC
which alert providers to the presence of these findings at the time of patient discharge.
NU
References
van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179.
2.
Sullivan DR, Golden SE, Ganzini L, Hansen L, Slatore CG. 'I still don't know diddly': a longitudinal qualitative study of patients' knowledge and distress while undergoing evaluation of incidental pulmonary nodules. NPJ Prim Care Respir Med. 2015;25:15028.
3.
Holden WE, Lewinsohn DM, Osborne ML, et al. Use of a clinical pathway to manage unsuspected radiographic findings. Chest. 2004;125(5):1753-1760.
4.
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
5.
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012;60(2):152-159.
6.
Toomes H, Delphendahl A, Manke HG, Vogt-Moykopf I. The coin lesion of the lung. A review of 955 resected coin lesions. Cancer. 1983;51(3):534-537.
7.
Yeh DD, Imam AM, Truong SH, et al. Incidental findings in trauma patients: dedicated communication with the primary care physician ensures adequate follow-up. World J Surg. 2013;37(9):2081-2085.
AC CE P
TE
D
MA
1.
ACCEPTED MANUSCRIPT
Total number of studies with recommendations
535
31 502 2
5.8% 93.8% 0.4%
500 35
93.5% 6.5%
573 247 188 55 35 5 43
43.1% 32.8% 9.6% 6.1% 0.9% 7.5%
573 433 40 21 8 7 7 3 54
100.0% 75.6% 7.0% 3.7% 1.4% 1.2% 1.2% 0.5% 9.4%
SC
RI
Presence of Pulmonary Embolism (PE) Positive Negative Non-diagnostic
TE
D
MA
NU
Presence of Incidental Findings Studies with 1 incidental finding Studies with > 1 incidental finding Types of Incidental Findings Total incidental findings Pulmonary nodules Pulmonary infectious/inflammatory Abdominal Thyroid Bone Other Radiologist Recommendations Total recommended imaging studies CT Ultrasound MRI Subspecialty consultation PET-CT X-ray Mammography Other
AC CE P
PT
Table 1. CT-PE results, types of incidental findings identified, and recommended imaging modalities for follow-up.
ACCEPTED MANUSCRIPT Table 2. Recommendations and instructions on discharge summaries.
329
61.5%
No recommendations stated in discharge summary
201
37.6% 0.9% 100.0%
PT
One or more recommendation stated in discharge summary
RI
Recommendation Stated on Discharge Summary?
No recommendations stated in discharge summary
NU
SC
Discharge summary not available 5 Total 535 Discharge Summaries from Emergency Department (ED) Patients One or more recommendation stated in discharge 153 summary 99
D
MA
Discharge summary not available 1 Total 253 Discharge Summaries from Patients Admitted from the ED One or more recommendation stated in discharge 176 summary
60.5% 39.1% 0.4% 100.0%
62.4%
102
36.2%
Discharge summary not available Total
4 282
1.4% 100.0%
AC CE P
TE
No recommendations stated in discharge summary
S0735-6757(16)30965-2 doi:10.1016/j.ajem.2016.12.062 YAJEM 56384
To appear in:
American Journal of Emergency Medicine
Received date: Revised date: Accepted date:
2 December 2016 23 December 2016 24 December 2016
Please cite this article as: Sonis Jonathan D., S´ anchez Yadiel, Benjamin Harvey H, Yun Brian J., Raja Ali S., Prabhakar Anand M., Communication of imaging recommendations to ED patients: Pulmonary Embolus CT, American Journal of Emergency Medicine (2016), doi:10.1016/j.ajem.2016.12.062
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Communication of imaging recommendations to ED patients: Pulmonary Embolus CT
PT
Jonathan D. Sonis MD1, Yadiel Sánchez2, H. Benjamin Harvey MD, JD2, Brian J. Yun MD, MBA1, Ali S.
Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston,
SC
1
RI
Raja MD, MBA, MPH1, Anand M. Prabhakar MD, MBA2,3,4*
NU
MA.
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, MA.
3
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of
MA
2
Emergency Imaging, Boston, MA.
Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of
AC CE P
TE
Cardiovascular Imaging, Boston, MA.
D
4
*Corresponding author
For all correspondence, please contact: Anand M. Prabhakar, MD Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of Cardiovascular Imaging, 55 Fruit Street, Gray 2, Boston, MA 02114 E-mail: [email protected] Tel no: 617-726-8396, Fax no: 617-726-4891 All authors report no conflict of interest.
ACCEPTED MANUSCRIPT
The current gold standard for diagnosing pulmonary embolism (PE) is Computed Tomography (CT), which has a reported sensitivity greater than 98%.1 While its primary goal is to rule out thrombus in
PT
the pulmonary arteries, CTPE may also demonstrate unrelated incidental findings which then require non-
RI
emergent follow-up imaging. Prior work has demonstrated that patients often remain unaware of
SC
incidental findings and lack understanding of plans for clinical follow-up.2 Therefore, the purpose of our study was to quantify the frequency of incidental findings requiring recommendations for clinical follow-
NU
up in patients who underwent CTPE in the ED, and to determine the rate of inclusion of these recommendations in written patient discharge instructions.
MA
An IRB Approved study was performed at a 999-bed quaternary care academic center and Level 1 trauma center. Approximately 104,000 ED visits occur at the institution annually, and approximately
D
105,000 ED diagnostic imaging studies are performed and interpreted in the ED radiology department
TE
annually.
A retrospective search for adult (greater than age 18) ED patients who underwent CTPE for
AC CE P
evaluation of suspected PE from July 2015 to July 2016 was performed. Patients who underwent CTPE after leaving the ED were excluded, as were patients who died at any time after arrival in the ED. The electronic medical record (EMR) of these patients was reviewed for demographics and disposition. Finalized radiology reports in the EMR were then reviewed for the presence or absence of incidental findings in the “Impression” field which generated a recommendation for follow-up. Incidental findings were defined as imaging findings not related to the evaluation of PE that generated a recommendation, Studies with multiple recommendations was each analyzed separately. Inpatient or ED discharge summaries were reviewed for mention of recommendations in discharge instructions. There were 1754 CT-PE examinations during the study period. Of these, 638 (36.4%) had at least one recommendation included in the radiology report. 103 examinations were subsequently excluded because, although ordered as an ED study, the CTPE actually occurred after the patient had left the ED, due to subsequent patient death during inpatient admission, or because recommendations were unrelated
ACCEPTED MANUSCRIPT to an incidental radiographic finding. Thus, the total study population consisted of 535 CT-PE examinations. The average patient age of the study patients was 62 ± 16 years; 52.1% were women.
PT
The most common incidental findings were pulmonary nodules (43.1%), pulmonary infectious or inflammatory changes (32.8%), intraabdominal abnormalities (9.6%), and thyroid abnormalities (6.1%).
RI
A total of 500 examinations (93.5%) had only one incidental finding with recommended follow-up
SC
identified. Thirty-five examinations (6.5%) had two or more incidental findings with follow-up recommendations. The most common recommended follow-up imaging modalities included CT (75.6%),
NU
ultrasound (7.0%), and magnetic resonance imaging (MRI) (3.7%). Table 1 summarizes the CTPE results,
MA
types of incidental findings identified, and corresponding recommendations may by the interpreting radiologist.
Of the total recommendations, 329 (61.5%) examinations had at least one written
TE
D
recommendation in the discharge instructions, including 153 (60.5%) from the ED and 176 (62.4%) associated with patients admitted to the hospital and subsequently discharged. No written discharge
AC CE P
instructions were found for one patient discharged directly from the ED and four patients discharged after admission to the hospital. Table 2 summarizes the findings on discharge documentation. Only 62.4% of patients who were subsequently admitted to the hospital from the ED had recommendations communicated in their discharge summaries. Prior studies have demonstrated the potential for lost information during handoffs from the ED to inpatient services and from inpatient settings to outpatient providers at the time of hospital discharge.4,5 These findings highlight the importance of further improvement in handoff processes. While we did not characterize identified pulmonary nodules by type, the frequency of pulmonary nodules in our study population with an average age of 62 is of particular significance as prior work has demonstrated that in patients greater than 60 years of age, 65% of solitary pulmonary nodules represent malignancy.6 Our study has several limitations. First, while all discharge documentation was reviewed, there may have been cases in which providers gave verbal follow-up instructions to patients, or may have
ACCEPTED MANUSCRIPT contacted outpatient providers by postal or electronic mail to arrange these studies, which prior studies have demonstrated significantly increases rates of follow-up.7 Other limitations include limited
PT
generalizability to non-academic medical centers and also that this study is retrospective. Communication of clinically significant incidental findings identified in the ED to patients and
RI
their primary care physicians is essential. Further efforts should focus on the implementation of tools
SC
which alert providers to the presence of these findings at the time of patient discharge.
NU
References
van Belle A, Büller HR, Huisman MV, et al. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295(2):172-179.
2.
Sullivan DR, Golden SE, Ganzini L, Hansen L, Slatore CG. 'I still don't know diddly': a longitudinal qualitative study of patients' knowledge and distress while undergoing evaluation of incidental pulmonary nodules. NPJ Prim Care Respir Med. 2015;25:15028.
3.
Holden WE, Lewinsohn DM, Osborne ML, et al. Use of a clinical pathway to manage unsuspected radiographic findings. Chest. 2004;125(5):1753-1760.
4.
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651.
5.
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med. 2012;60(2):152-159.
6.
Toomes H, Delphendahl A, Manke HG, Vogt-Moykopf I. The coin lesion of the lung. A review of 955 resected coin lesions. Cancer. 1983;51(3):534-537.
7.
Yeh DD, Imam AM, Truong SH, et al. Incidental findings in trauma patients: dedicated communication with the primary care physician ensures adequate follow-up. World J Surg. 2013;37(9):2081-2085.
AC CE P
TE
D
MA
1.
ACCEPTED MANUSCRIPT
Total number of studies with recommendations
535
31 502 2
5.8% 93.8% 0.4%
500 35
93.5% 6.5%
573 247 188 55 35 5 43
43.1% 32.8% 9.6% 6.1% 0.9% 7.5%
573 433 40 21 8 7 7 3 54
100.0% 75.6% 7.0% 3.7% 1.4% 1.2% 1.2% 0.5% 9.4%
SC
RI
Presence of Pulmonary Embolism (PE) Positive Negative Non-diagnostic
TE
D
MA
NU
Presence of Incidental Findings Studies with 1 incidental finding Studies with > 1 incidental finding Types of Incidental Findings Total incidental findings Pulmonary nodules Pulmonary infectious/inflammatory Abdominal Thyroid Bone Other Radiologist Recommendations Total recommended imaging studies CT Ultrasound MRI Subspecialty consultation PET-CT X-ray Mammography Other
AC CE P
PT
Table 1. CT-PE results, types of incidental findings identified, and recommended imaging modalities for follow-up.
ACCEPTED MANUSCRIPT Table 2. Recommendations and instructions on discharge summaries.
329
61.5%
No recommendations stated in discharge summary
201
37.6% 0.9% 100.0%
PT
One or more recommendation stated in discharge summary
RI
Recommendation Stated on Discharge Summary?
No recommendations stated in discharge summary
NU
SC
Discharge summary not available 5 Total 535 Discharge Summaries from Emergency Department (ED) Patients One or more recommendation stated in discharge 153 summary 99
D
MA
Discharge summary not available 1 Total 253 Discharge Summaries from Patients Admitted from the ED One or more recommendation stated in discharge 176 summary
60.5% 39.1% 0.4% 100.0%
62.4%
102
36.2%
Discharge summary not available Total
4 282
1.4% 100.0%
AC CE P
TE
No recommendations stated in discharge summary