36C25718R0247-035.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 114-14-01 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 June 2, 1014

REPORTING CRITICAL IMAGING TEST RESULTS

1. PURPOSE: To establish a policy for reporting critical radiologic test results to ordering practitioners at the South Texas Veterans Health Care System (STVHCS).

2. POLICY: In accordance with STVHCS policy that critical imaging results be communicated to the ordering practitioner within a timeframe to permit prompt attention and appropriate action:

a. All Imaging studies performed at STVHCS will be ordered electronically. Orders must include a history which clearly demonstrates the appropriateness and urgency of the test requested. The consulting radiologist or nuclear medicine physician must be able to protocol the study and make appropriate triage decisions based on the clinical history. Orders must indicate the ordering practitioner’s name, urgency of the study, and accurate contact information.

b. All imaging studies performed at this facility will be entered and verified in the Computerized Patient Record System (CPRS) (electronic medical record).

c. Important, unsuspected findings that require urgent attention will be immediately and directly communicated to the requesting practitioner or appropriate surrogate within one hour of discovery. Direct communication consists of a face-to-face or telephone conversation. The time of communication, method of communication, and name of the person contacted will be entered in the study report: “Critical results communicated by phone or face to face to… at…time…date.” Diagnostic code 5 (Major Abnormality, Physician Aware) will be entered in the code field of the voice recognition report screen after communication of the abnormality.

d. If the ordering practitioner cannot be contacted in a timely fashion, the report will be communicated to an appropriate surrogate. Suitable surrogates include the practitioner’s supervisor, preceptor, or another practitioner who may take further appropriate diagnostic/therapeutic action. In the event that no suitable surrogate can be contacted, the clinic director or service chief will be contacted.

e. Direct, urgent communication is required for new, unsuspected or significantly progressed imaging findings that are life threatening could cause serious harm or could result in unnecessary discomfort without urgent intervention or change in management. See attachment for a list of critical imaging findings.

f. Important imaging findings that may require a change in patient management, but not necessarily within an urgent timeframe, will be communicated by direct, documented communication as per par 2.d. in a reasonable timeframe given the severity of the findings.

CPRS View Alerts may currently be used for non-critical findings, but cannot substitute for direct or telephonic conversation in setting of critical or important findings. Examples of important but not urgent findings include: new unsuspected malignancy, unsuspected aneurysm.

g. Every month, an audit will be performed of Critical Results notifications. A sample will be reviewed to determine the percentage of critical results relayed to the provider or surrogate within 1 hour of discovery. These results will be forwarded to Patient Safety.

h. The radiologist or nuclear medicine physician will also directly contact the requestor if the requestor specifically requests a “call back” and includes a reliable call back number in the history field. If the requestor is not available at the number provided and the results are not critical, this will be documented in the radiology report.

POLICY MEMORANDUM 114-14-01

i. Accountability:

(1) The Imaging Service Chief is responsible for:

(a) Instructing Imaging staff and ensuring compliance regarding policies and procedures for communication and documentation of critical test results;

(b) Ensuring that an audit is performed each month, and action taken if an adverse trend is discovered.

(2) The Interpreting Radiologist or Nuclear Medicine Physician is responsible for:

(a) Ensuring that verified test result reports are available in the medical record in a timely manner;

(b) Timely communicating critical test results to the ordering practitioner, practitioner’s surrogate or supervisor, as appropriate, and ensuring that the ordering practitioner understands the findings and recommendations (“read back”);

(c) Documenting, in the report, the provider contacted, the time and date of the communication, and the method of communication;

(d) Using diagnostic code 5 for all critical test results.

(3) Ordering Practitioners are responsible for:

(a) Completing the imaging request with appropriate contact information for themselves and their suitable surrogate if applicable;

(b) Providing sufficient history and clinical justification to meet relevant so that the consulting radiologist or nuclear medicine physician can better judge when a finding is critical or unanticipated;

(c) Taking responsibility for the results of any study ordered under their name;

(d) Assigning a reasonable surrogate to receive abnormal test result notifications when they are not available in a timely manner.

(4) Clinic Directors and Service Chiefs are responsible for:

(a) Instructing staff regarding policies and procedures for receiving critical test results;

(b) Ensuring a plan for adequate surrogate coverage in the event that the ordering practitioner is not available to take and act on critical imaging findings in a timely manner;

(c) Ultimately take responsibility for critical imaging findings if no other surrogate is available in a timely manner.

(5) Imaging ADPACS responsible for ensuring that parameters for Diagnostic Codes are appropriately set to issue mandatory View Alerts. ADPACs are also responsible for ensuring that images obtained by technologists have been transmitted and are available promptly to radiologists for interpretation.

(6) Imaging technologists are responsible for ensuring that images are transmitted promptly after each patient’s study is completed. After hours, Imaging Technologists are responsible to ensure that image transmission has been completed and are available to view in VistA Imaging and/or PACS and report any problems to the ADPAC, Supervisor and the AO as appropriate.

3. REFERENCE: Interim Guidance and ACR Standard for Communication: Diagnostic Radiology

4. RESPONSILILITY: Chief, Imaging Service (114)

5. RESCISIONS: STVHCS Policy Memorandum 114-10-01 dated June 25, 2010

6. RECERTIFICATION: June 2019

(Original signature on file)

MARIE L. WELDON, FACHE

Director

Attachment

DISTRIBUTION: A & C

EXAMPLES OF RADIOLOGY RESULTS WHICH

REQUIRE CRITICAL NOTIFCATION

Updated 5/6/14

Brain & Spinal Cord Acute Infarct;

Cord Compression;

Depressed Skull Fracture;

Hemorrhage (newly diagnosed);

Impending Herniation of Brain;

Chest Aspirated foreign bodies;

Mediastinal Emphysema (non-post-operative);

Pericardial Effusion (large);

Pneumothorax (new or enlarging);

Suspected Tuberculosis (new finding);

Wide mediastinum in appropriate clinical setting;

Abdomen & Pelvis Acute Appendicitis;

Acute Bowel Obstruction;

Acute Cholecystitis;

Anastomotic Leak;

Diverticulitis (acute and newly diagnosed);

Ectopic Pregnancy;

Free air (non-post-operative);

Gallbladder Emphysema;

GI Bleeding Site (positive localization by Nuclear Medicine test);

Leaking Aneurysm;

Necrotic Bowel;

Obstructing Urolithiasis (initial diagnosis);

Ovarian Torsion;

Over distended Urinary Bladder/Unsuspected Hydronephrosis;

Ruptured hollow discus;

Sub capsular hemorrhage;

Testicular Torsion;

Vascular System Acute DVT;

Dissection (acute or newly diagnosed or unsuspected);

Large reversible perfusion defect on radionuclide cardiac studies Leaking Aneurysm;

Pulmonary Thromboembolism;

Musculoskeletal System Acute dislocation (newly diagnosed or unsuspected);

Acute, significant fracture (newly diagnosed or unsuspected);

Nuclear Medicine New unsuspected malignancy new pneumonia;

Osteomyelitis or other infection high probability V-Q scan;

Unsafe position of medical device;

Large reversible defect on myocardial perfusion scan;

Acute fracture or concern for impending pathological fracture active hemorrhage;

Pneumothorax;

General Abscess (newly diagnosed);

Misplaced catheter, tubes and lines (In the appropriate clinical setting);

Any change to a wet read report which necessitates a change in diagnosis or treatment plan;

In addition to above, any other finding that has potential to be life-threatening or requires immediate intervention or cancellation of ongoing treatment;

Any unsuspected malignancy.

Attachment