D.35 Reporting Critical Imaging Test Results.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 114-19-01 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 September 6, 2019

REPORTING CRITICAL IMAGING TEST RESULTS

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

2. DEFINITIONS

a. Critical Result. A result or finding that may be considered life threatening or that could result in severe morbidity, requiring urgent or emergent clinical attention.

b. Significant, Abnormal Test Result. Non-emergent, non-life-threatening results that need attention and follow-up action as soon as possible, but for which timing is not as crucial as a critical result.

3. POLICY: In accordance with STVHCS policy that critical imaging results be communicated to the ordering provider 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, critical, unsuspected findings that require urgent attention will be immediately and directly communicated to the requesting provider 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 provider cannot be contacted in a timely fashion, the report will be communicated to an appropriate surrogate. Suitable surrogates include the provider’s supervisor, preceptor, or another practitioner who may take further appropriate diagnostic/therapeutic action. If no suitable surrogate can be contacted, the clinic director or service chief will be contacted. Contacting the patient directly to instruct them to seek emergency care is a last option.

D.35 36C25721R0015

POLICY MEMORANDUM 114-19-01

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 significant morbidity without urgent intervention or change in management. NOTE: See attachment for a list of critical imaging findings.

f. Significant abnormal 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 Paragraph 3.c. 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. Additional communication options include closed loop communication via official e-mail with written acknowledgment by the ordering provider or Department of Veterans Affairs (VA) Skype with written acknowledgement/reply by the ordering provider. Examples of significant, abnormal but not critical 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.

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 provider, provider’s surrogate or supervisor, as appropriate, and ensuring that the ordering provider 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 Providers are responsible for:

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

(b) Providing enough relevant history and clinical justification 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 the provider is 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 if the ordering practitioner is not available to receive and act on critical imaging results in a timely manner;

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

(5) Imaging ADPACS are 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 promptly available 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:

a. Interim Guidance and ACR Standard for Communication: Diagnostic Radiology;

b. National Patient Safety Goal.02.01.01 “Report Critical Results of Tests and diagnostic procedures on a timely basis,” 2019, The Joint Commission.

4. RESPONSILILITY: Chief, Imaging Service (114)

5. RESCISSION: STVHCS Policy Memorandum 114-14-01 dated June 2, 2014.

6. RECERTIFICATION: September 2024

(Signed original on file)

CHRISTOPHER R. SANDLES, MBA, FACHE

Director

Attachment: (1)

DISTRIBUTION: A, B, & C

EEXAMPLES OF RADIOLOGY RESULTS WHICH

REQUIRE CRITICAL NOTIFCATION

Updated June 2, 2019

Brain & Spinal

Cord

Acute Stroke;

Acute Cord Compression;

Intracranial hemorrhage, if new or significantly worsened from prior;

Unstable Spine Fracture

Chest Pneumomediastinum, if unsuspected or new;

Pericardial effusion with evidence of tamponade;

New or tension pneumothorax;

Pulmonary embolism, if new;

Suspected active tuberculosis, if new;

Acute aortic dissection

Abdomen &

Pelvis

Ectopic pregnancy;

Free Air, unexpected;

GI bleeding site (positive localization by Nuclear Medicine test);

Leaking aortic aneurysm;

Necrotic bowel;

Ovarian or testicular torsion;

Ruptured hollow viscus

Vascular System Acute aortic dissection;

Deep vein thrombosis, if new

Nuclear Medicine Acute GI bleed;

Acute pneumothorax

General 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

Attachment