Noting that computed tomography (CT) scans are obtained for more than 30 million emergency department (ED) patients annually and that 31.3 percent of ED CT scans reveal incidental findings, representatives from the American College of Radiology (ACR) and the American College of Emergency Physicians (ACEP) recently collaborated on best practice recommendations for addressing incidental imaging findings in EDs.
Radiologists and emergency physicians may agree that structured or templated formats should be utilized to report actionable incidental findings (AIFs) in emergency departments (EDs). However, two-thirds of those surveyed said structured reporting is sometimes used or “almost never used” for incidental findings on ED imaging.
That is one of the findings that emerged from a recently convened 15-member panel, including members of the American College of Radiology (ACR) and the American College of Emergency Physicians (ACEP), to address best practice recommendations for the management of incidental imaging findings in EDs.
The panel sought to address the reporting of AIFs in EDs, communication of AIFs with clinicians, communication of AIFs with patients and systems for tracking follow-up, according to the recently published findings of the panel in the Journal of the American College of Radiology. In order to achieve consensus, the panel members completed an anonymous survey, discussed the results, and proceeded with a second round of survey questions to address questions that did not have an initial consensus response.
Here are a few key takeaways.
1) The panel largely agreed that radiology reports involving AIFs should note the lesion size, location, and characteristics of the AIF; follow-up modality and time frame; any available evidence to support recommendations; documentation of notification or communication; and language geared toward patients. The panelists said the latter four elements should only be included in the summary section of the radiology report.
2) For the presence and recommended follow-up of an AIF, the panel unanimously agreed that written instructions should be given to the patient upon discharge from the facility and 93 percent of the panelists emphasized verbal communication between the emergency clinician and the patient as being “very important” regarding AIFs in the radiology report.
(Editor’s note: For related content, see “Managing Incidentalomas in Radiology: Embracing Challenges as Opportunities” and “Is CT Imaging Overutilized in the ER?”)
3) However, the panelists noted a wide variability with current communication of AIFs to patients. Fifty-three percent of the panelists said written communication happened “some of the time and 73 percent claimed that clinicals “almost always” provided verbal communication of AIFs to patients.
4) Over 80 percent of the panelists, including five radiologists, said direct communication from the radiologist to the patient regarding AIF(s) was unnecessary.
5) In regard to follow-up communication, only 27 percent of the panelists said this “almost always” occurs in cases involving AIFs. However, in the second round of the survey, 94 percent of the panelists said “communication … at a later time from the facility where the imaging was obtained” was important or very important.
6) When radiologists detect an AIF, the panelists unanimously agreed they should “activate an alert or tracking system” in addition to noting the finding in the radiology report.
7) The panelists unanimously agreed that tracking systems should be in place at hospitals in order to provide specific tracking of communication about AIFs and help monitor for appropriate follow-up.
“Perhaps the most important area in which agreement was strong was that the communication of incidental findings is ultimately a systems responsibility as opposed to the responsibility of individual clinicians,” wrote study co-author Lauren Parks Nicola, M.D., the chief executive officer of Triad Radiology Associates in Winston Salem, N.C., and colleagues. “ … Although either a radiologist or an (emergency physician) could potentially flag reports, approaches that allow automated flagging through structured reporting or natural language processing may provide the most reliable capture.”