Attachment 11 - 114-01 REPORTING ABNORMAL RADIOLOGY NUCLEAR MEDICINE EXAM RESULTS.pdf

POLICY MEMORANDUM

VA Medical Center 1030 Jefferson Avenue Memphis, TN 38104

Number: 114-01

Dated: August 17, 2018

Expires: August 16, 2021

Title: REPORTING ABNORMAL RADIOLOGY/NUCLEAR MEDICINE EXAM RESULTS

1. PURPOSE: To define the policy for reporting Radiology/Nuclear Medicine exam results to the ordering and treating practitioners at this facility.

2. POLICY:

a. Imaging test results will be communicated to the ordering practitioner within a timeframe that allows prompt attention and appropriate action.

b. All imaging studies performed at this facility will be ordered electronically. Orders should indicate the reason for the study (adequate history), the name of the ordering practitioner and primary care provider or resident and attending physician, location, phone number, and a pager number.

c. All ordering providers, including physician assistants and nurse practicitioners, must be equipped with an electronic paging device for use during their regular duty hours at the medical center.

d. All reports on imaging studies performed at this facility will be entered and verified in the electronic medical record.

3. RESPONSIBILITY:

a. Chief, Radiology Service is responsible for:

(1) Instructing staff regarding polices and procedures for communication of Radiology/Nuclear Medicine test results.

(2) Ensuring that an audit is performed of Code 5 View Alerts. This means an audit of the proper documentation when a code 5 is used. Any incident reports for failed code 5’s will be reviewed by the radiology QI committee. "View Alert" is a prompt in VISTA or CPRS, which directs the ordering practitioner to an abnormal x-ray report.

36C24920R0114 - Attachment 11

b. Radiologists are responsible for:

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

(2) Identifying and communicating emergent test results to the patient’s ordering practitioner or to the practitioner’s surrogate or supervisor as appropriate. Documenting the time and means of such communication, and the name of the practitioner contacted, in the medical record.

(3) Identifying and communicating abnormal test results that may be treated in non-urgent timeframe, using direct or electronic communication.

(4) Knowing which Diagnostic Codes trigger a mandatory View Alert.

c. Ordering Practitioners are responsible for:

(1) Placing the initial order with appropriate contact information for themselves and their preceptor if applicable.

(2) Taking responsibility for results of any orders that have been placed.

(3) Assigning a surrogate to receive abnormal test result notifications when the practitioner is not available to review results in a timely manner.

d. Radiology ADPAC is responsible for ensuring that parameters for Diagnostic Codes are appropriately set to issue mandatory View Alerts.

4. PROCEDURE:

a. Important findings that require emergent attention will be immediately and directly communicated to the patient's treating practitioner. A finding will be judged emergent by the radiologist if the finding has the potential to be life threatening or could cause serious harm, and requires a rapid intervention or change in patient management. Direct communication consists of a face-to-face conversation or telephone conversation for immediate life threatening findings. The time and means of such communication, and the name of the person contacted, will be entered into the dictated radiographic report. The radiologist will ascertain that the communication has been understood. If the ordering practitioner cannot be contacted, the report will be directly communicated to the practitioner’s surrogate or to other responsible provider, floor nurse, ICU nurse or supervisory nurse. The report should be given to the ER provider if no other provider or surrogate is available. Suitable surrogates include the practitioner’s supervisor or preceptor, or another practitioner who may take further, appropriate diagnostic or therapeutic action.

The radiologist will verify that each report includes the name of the provider notified, time notified, and the lengh of time following recognition of the critical result until notification of the responsible provider or surrogate (target 30 minutes). These findings will be coded with a Diagnostic code 5 View Alert. The following list provides examples of emergent life threatening medical conditions. This list is not all-inclusive and may be expanded as necessary by the reporting radiologist:

1. Intracranial hemorrhage

2. Acute aortic dissection

3. Leaking aortic aneurysm

4. Pleural or intraperitoneal air

5. Spinal cord compression

6. Acute spinal fracture

7. Definite pulmonary embolus

8. Ischemic bowel

9. Acute hemorrhage involving any organ or body cavity

10. Traumatic organ injury

11. Foreign body with potential for life threatening injury

12. Epiglottitis

13. Appendicitis

14. Brain tumor with mass effect

15. Any finding that may be life threatening or the potential for causing serious harm

b. Less urgent findings judged by the radiologist as important and requiring confirmed documented communication will be handled in the following manner:

(1) Diagnostic code 4 View Alert to ordering provider. The Code 4 View Alert informs the provider of an abnormality that needs attention, but is not immediately life threatening.

Examples include but are not limited to new suspicious pulmonary nodule(s), new lobar pneumonias or atelectasis, new solid organ nodules or masses, suspected GI tract or urinary bladder lesion that could be neoplastic and finally, findings that suggest treatment failure in known malignancies. The Code 4 View Alert also is used when an additional diagnostic exam or procedure is recommended by the radiologist. The Code 4 View Alert delivers notification to the ordering provider. The Code 4 View Alert is only removed after it is opened by the recipient.

(2) As a back-up to the electronic notification system, a “code 4 nurse” may be assigned to review and confirm practitioner acknowledgement.

(3) Diagnostic code 11 for Infectious Disease is sent as an alert to the provider. The hospital infectious disease nurse is also simultaneously notified with a Code 11.

(4) Diagnostic code 99 View Alerts for abnormal will no longer be used.

(5) Direct phone communication and e-mail may be used by the radiologist at his/her discretion to supplement notification for less urgent findings.

5. REPORTING REQUIREMENTS: None.

6. RESPONSIBLE OFFICE: Radiology Service (114)

7. REFERENCES: JCAHO Manual and ACR Guidelines for Communication of Diagnostic Imaging Finding (revised 2014)

8. RESCISSION: Medical Center Policy Memorandum 114-01, dated October 4, 2013

Medical Staff Concurrence: Date: August 17, 2018

/s/

Thomas C. Ferguson, MD Chief of Staff

/s/

David K. Dunning, MPA Medical Center Director