D.36 Communication of Abnormal Imaging Results.pdf

COMMUNICATION OF ABNORMAL IMAGING RESULTS

SOP 114-25

Oklahoma City VA Health Care System Oklahoma City, OK 73159

Signatory Authority:

Radiology Service Chief

Responsible Owner:

Radiology Service Chief

Service Line(s):

Radiology

Effective Date:

July 26, 2022

Recertification Date:

July 31, 2027

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on communication of critical results. This SOP replaces CM 114-8 Communication of Abnormal Imaging Results. This SOP must be followed by Radiologist who interpret imaging studies.

b. This SOP sets forth mandatory procedures and processes to ensure compliance with CM 11-138 Ordering and Reporting Test Results, March 25, 2016.

2. PROCEDURES

a. All radiology studies will be interpreted and reported in a timely manner.

The radiologist is responsible for interpreting imaging studies and reporting abnormal radiology findings. These abnormal findings will be assigned a diagnostic code that will alert the clinician electronically.

(1) Diagnostic codes are entered by the radiologist during the dictation phase, prior to electronically signing the dictated report.

(2) Automatic electronic view alert messages will be generated by the assignment of diagnostic codes. This will alert the requesting clinician of abnormal radiological findings.

(3) For codes that require verbal notification: Verbal communication of abnormal radiological findings will be made directly from the diagnostic practitioner to the ordering practitioner. If verbal communication to the ordering provider is not possible, the ordering provider’s surrogate/service chief shall be notified within the timeframes specified (for Teleradiology programs the Medical Officer of the Day or ER physician will be contacted). The interpreting radiologist will document this communication in his/her report. For verbal reporting of critical results to anyone other than the ordering physician, the complete imaging result will be verified by having the person receiving the information record, “read back” and confirm the complete test results. This read-back interaction must be documented in the imaging report. Contact person’s name, time abnormality discovered (Teleradiology is not required to enter discovery time this

July 26, 2022 SOP 114-25 per their policy) and time and date the communication occurred is required in the dictated report.

b. OKC VA Health Care System. This process is used when the interpreting physician is an employee of the OKC VA Health Care system

(1) The radiologist will verbally notify the requesting clinician to communicate all results indicating a 201-Critical Abnormality, 202-New Infectious Abnormality, and 1201- Abdominal Aortic Aneurysm Present They will call the Pulmonary Oncology for all results indicating a 232- Nodules/Masses greater than 2cm. or a 233- Ground Glass Opacities.

(2) Results will be alerted per the chart below

CODE

Oklahoma City VAMC

DIAGNOSTIC REPORTING

CODE DEFINITION

REQUIRES

VERBAL

NOTIFICATION

REQUIRES

ELECTRONI

NOTIFICATION

201 Critical Abnormality; Urgent Follow-Up Action Needed YES YES

202 New Reportable Infectious Abnormality-Active TB or Other Reportable Communicable Infectious Disease; Urgent Follow –Up Action Needed YES YES

203 Suspicious for New Malignancy;

Follow-Up Action Needed NO YES

Abnormality; Follow-Up Action Needed NO YES

212 Minor Abnormality or Abnormality Previously Identified NO YES

229 Pulmonary Embolism, Immediate Attention Needed (paired with 201) YES YES

1200 Abdominal Aortic Aneurysm Not Present: Maximum width of Infrarenal Aorta is less than 3cm NO YES

1201 Abdominal Aortic Aneurysm Present: Width of Infrarenal Aorta is at least 3cm NO YES

1202 Does not satisfy screen for AAA NO NO

230 Pulmonary Nodules less than 4mm NO YES

231 Pulmonary Nodules 4mm to less than 2cm NO YES

Nodules/Masses greater than 2cm; (paired with 203)

YES

(Pulmonary Oncology) YES

Ground Glass Opacities

(paired with 203)

YES

(Pulmonary Oncology) YES

1104 Bi-Rads Category 4 Mammo- Suspicious YES YES

1105 Bi-Rads Category 5 Mammo- Highly Suggestive of Malignancy YES YES

Bi-Rad Category 6 Mammo- Known Biopsy Proven Malignancy YES YES

c. National Teleradiology Service This is the process utilized by NTP when they are the interpreting physician. All NTP results are reported per NTP Quality Assurance Plan and Critical Results/Critical Test Policy February 2, 2022.

(1) Alerts are coded per the chart below

CODE

National Teleradiology Program

DIAGNOSTIC REPORTING

CODE DEFINITION

REQUIRES

VERBAL

NOTIFICATION

REQUIRES

ELECTRONIC

NOTIFICATION

Significant Abnormality Attention Needed NO YES

1002 Critical Abnormality YES YES

1003 Possible Malignancy NO YES

d. New Jersey Teleradiology New Jersey Teleradiology reports test results in accordance with VA New Jersey Health Care System MCP# PS-05 Communication of Test Results and Diagnostic Procedures Critical and Noncritical, dated October 1, 2021.

(1) Per the Memorandum of Understanding between New Jersey and the OKC VA Health Care System Part C:

“C. CRITICAL FINDINGS: Critical findings that require urgent provider attention will be immediately and directly communicated to the ordering provider or surrogate. This direct communication will occur within 60 minutes of the interpretation by the VA New Jersey HCS Radiologist of a critical finding. Direct communication consists of a telephone conversation with the provider followed by a memo in Agfa PACS. The time of such communication and the name of the person contacted will be entered in the study’s dictated report. If the ordering provider cannot be contacted, the report will be directly communicated to the provider’s surrogate and name dictated into the final report. Suitable surrogates include the provider’s supervisor or preceptor, or another provider who is privileged to take any necessary further appropriate diagnostic or therapeutic action. Findings that are considered critical and therefore require direct communication include, but are not limited to:

(1) Any finding that has the potential to be life threatening or could cause serious harm, and that requires an urgent intervention or change in patient management;

(2)Any finding that would result in the cancellation of on-going or imminent treatment;

Clinical examples of critical values could be: pneumothorax, tension pneumothorax, leaking or ruptured abdominal aortic aneurysm, ischemic small bowel on CT, acute extra-axial collection of blood (including acute subdural hematoma and epidural hematoma), unstable spinal fracture, pneumoperitoneum (not post op), significant misplacement of tubes or catheters and fractures.”

e. Follow-Up Evaluation

(1) Unacknowledged Critical results will be sent to clinical service chiefs and administrative officers to assure appropriate follow up action has been taken.

(2) Data on radiologist documentation and communication of results will be recorded on a spreadsheet and sent to the local Patient Safety Officer monthly.

3. ASSIGNMENT OF RESPONSIBILITIES

a. Radiology Service Chief. Ensure compliance with policy, reviews and recertifies policy.

b. Radiologist: Ensuring that verified test result reports are available in the electronic medical record in a timely manner. Ensure they are entering proper diagnostic code, and notification documentation in the dictated report.

c. PACS Administrator and/or ADPACS. Ensures that parameters for Diagnostic Codes are appropriately set to issue mandatory View Alerts/Notifications.

4. DEFINITIONS

a. Code 201: Critical Abnormality - Any new radiology finding that may be considered life threatening or could result in severe morbidity and require urgent or emergent clinical attention will be coded as 201. A verbal and electronic notification will be sent to the ordering provider within 1 hour of discovering the major abnormal result.

b. Code 202: New Reportable Infectious Abnormality – Any new abnormality considered suspicious of active tuberculosis or other reportable communicable infectious disease that is a significant public health risk will be assigned as 202. A verbal and electronic notification will be made to the ordering provider within 3 hours of the finding. The Infection Control Nurse will also be verbally notified of these findings.

c. Code 203: Suspicious for New Malignancy – Any abnormality that is suspicious or highly suggestive of new malignancy will be coded as 203. The ordering provider will be alerted electronically for appropriate follow-up action. Abnormalities of the chest region will be reported to the Pulmonary Oncology Service for follow-up with the Tumor Board.

d. Code 204: Abnormality – An abnormality that is not considered to be an urgent and immediate life threatening finding but needs attention and follow-up action as soon as possible will be coded 204. The ordering provider will be alerted electronically for appropriate follow-up action. (See Attachment 1)

e. Code 212: Minor Abnormality or Abnormality Previously Identified: The ordering provider will be alerted electronically for appropriate follow-up action.

f. Code 229: Pulmonary Embolism Immediate Attention Needed: This code is paired with a 201. A verbal and electronic notification will be made to the ordering provider within 1 hour of the finding.

g. Code 1200: Abdominal Aortic Aneurysm Not Present: Maximum width of Infrarenal Aorta is less than 3 cm. The ordering provider will be alerted electronically

h. Code 1201: Abdominal Aortic Aneurysm Present: Width of Infrarenal Aorta is at least 3 cm. The ordering provider will be alerted electronically for appropriate followup action.

i. Code 1202: Does not satisfy for AAA screening: No alert necessary

j. Code 230: Pulmonary Nodules less than 4mm: The ordering provider will be alerted electronically for appropriate follow-up action.

k. Code 234: Pulmonary Nodules less than 6mm: The ordering provider will be alerted electronically for appropriate follow-up action.

l. Code 231: Pulmonary Nodules 4mm to less than 2cm: The ordering provider will be alerted electronically for appropriate follow-up action.

m. Code 235: Pulmonary Nodules 6mm to less than 2cm: The ordering provider will be alerted electronically for appropriate follow-up action.

n. Code 232: Pulmonary Nodules/Masses greater than 2cm: Verbal notification will be made to Pulmonary Oncology and electronic notification will go out to the ordering provider.

o. Code 233: Ground Glass Opacities: Verbal notification will be made to Pulmonary Oncology and electronic notification will go out to the ordering provider.

p. Code 1104: Bi-Rads Category 4 Mammo-Suspicious Abnormality-Biopsy should be considered. Mammogram findings with suspicious abnormalities (with BiRads Category 4) will be coded 1104. All breast imagining is done through Non-VA Care and notification is provided by the outside facility to the ordering provider.

q. Code 1105: Bi-Rads Category 5 Mammo-Highly Suggestive of Malignancy Appropriate action should be taken. Mammogram findings highly suggestive of malignancy (Bi-Rads Category 5) will be coded 1105. All breast imagining is done through Non-VA Care and notification is provided by the outside facility to the ordering provider.

r. Code 1106: Bi-Rads Category 6 Mammo-Known Biopsy Proven MalignancyAppropriate action should be taken. Mammogram findings proven for malignancy (Bi-Rads Category 6) will be coded 1106. All breast imagining is done through NonVA care and notification is provided by the outside facility to the ordering provider.

s. Code 1201: Abdominal Aortic Aneurysm Present – The maximum width of the infrarenal aorta is greater than three centimeters. All breast imagining is done through Non-VA care and notification is provided by the outside facility to the ordering provider.

t. Code 1001: This code is selected if a finding requires follow up action, but not urgently. If the abnormality is already known to the ordering physician, then the radiologist need not set this code.

u. Code 1002: This code is used to indicate a finding that must be addressed immediately according to the TJC definition of a critical result. These findings are always called back.

v. Code 1003: This code should be used whenever a previously undiagnosed malignancy is discovered, or if the patient has a newly suspected recurrence. It should not be used if the patient has a known active malignancy. Common indications include a newly discovered pulmonary nodule, renal mass, or suspicious hepatic lesion.

5. REFERENCES

a. VHA Directive 1088 Communicating Test Results to Providers and Patients, Amended January 24,2022. VHA Publications (va.gov)

b. VHA Directive 1155(1) Treatment of Acute Ischemic Stroke, Amended November 13,2018. VHA Publications (va.gov)

c. NTP Quality Assurance Plan and Critical Results/Critical Test Policy, dated February 2, 2022, https://dvagov.sharepoint.com/sites/Vhatelerad/Shared Documents/Forms/AllItems.aspx?id=%2Fsites%2FVhatelerad%2FShared Documents%2FNTP Quality Assurance Plan with Critical Results and Tests Policy Feb 2022 signed%2Epdf&parent=%2Fsites%2FVhatelerad%2FShared Documents.

6. REVIEW

Required review at minimum at recertification and as needed.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of July 2027.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

Feroz Maqbool, MD Chief of Radiology Service Date Approved: July 26, 2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Emailed to the OKCRADIOLOGYSTAFF@VA.GOV distribution group. SOPs are available at: Radiology - Home (sharepoint.com) https://www.va.gov/vhapublications/publications.cfm?pub=1&order=asc&orderby=pub_Number https://www.va.gov/vhapublications/publications.cfm?pub=1&order=asc&orderby=pub_Number https://dvagov.sharepoint.com/sites/Vhatelerad/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVhatelerad%2FShared%20Documents%2FNTP%20Quality%20Assurance%20Plan%20with%20Critical%20Results%20and%20Tests%20Policy%20Feb%202022%20signed%2Epdf&parent=%2Fsites%2FVhatelerad%2FShared%20Documents https://dvagov.sharepoint.com/sites/Vhatelerad/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVhatelerad%2FShared%20Documents%2FNTP%20Quality%20Assurance%20Plan%20with%20Critical%20Results%20and%20Tests%20Policy%20Feb%202022%20signed%2Epdf&parent=%2Fsites%2FVhatelerad%2FShared%20Documents https://dvagov.sharepoint.com/sites/Vhatelerad/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVhatelerad%2FShared%20Documents%2FNTP%20Quality%20Assurance%20Plan%20with%20Critical%20Results%20and%20Tests%20Policy%20Feb%202022%20signed%2Epdf&parent=%2Fsites%2FVhatelerad%2FShared%20Documents https://dvagov.sharepoint.com/sites/Vhatelerad/Shared%20Documents/Forms/AllItems.aspx?id=%2Fsites%2FVhatelerad%2FShared%20Documents%2FNTP%20Quality%20Assurance%20Plan%20with%20Critical%20Results%20and%20Tests%20Policy%20Feb%202022%20signed%2Epdf&parent=%2Fsites%2FVhatelerad%2FShared%20Documents mailto:OKCRADIOLOGYSTAFF@VA.GOV https://dvagov.sharepoint.com/sites/VHAOKCHCS/Radiology/

Attachment 1

REPORTING RADIOLOGIC CRITICAL TEST RESULTS

1. The following are considered critical tests for immediate reporting to care provider.

a. For the Oklahoma City VAMC (All are to be entered as Code 201):

(1) Cerebral Hemorrhage/hematoma

(2) Acute stroke

(3) Unstable spinal fracture

(4) Pneumothorax (unsuspected or tension)

(5) Pneumoperitoneum (not post op)

(6) Aortic dissection

(7) Major pulmonary embolism

(8) Ruptured or leaking aneurysm

(9) Significant misplacement of tubes or catheters (i.e. enteric tube in lungs)

b. For the National Teleradiology Program (All are to be entered as Code 1001):

(1) Ectopic Pregnancy

(2) Testicular or Ovarian Torsion

(3) Pneumoperitoneum

(4) Acute Intracranial Hemorrhage

(5) Cervical Spine Fracture

(6) Thoracic or Lumbar Spine Fracture with cord compression

(7) Aortic Dissection

(8) Mediastinal or Retroperitoneal Hematoma

(9) Intracranial Mass with new Herniation

(10) Pulmonary Embolism or DVT

(11) Hemoperitoneum

(12) Acute Laceration of the Liver Spleen or Kidney

(13) Airway Compromise

(14) Appendicitis

(15) Abscess

(16) Pneumatosis of Bowel Wall

(17) Portal Venous Gas

(18) Acute Arterial Embolism/Occlusion

(19) Tension Pneumothorax

(20) And any other finding which is critical to the patient’s care

c. For New Jersey Teleradiology the following are considered critical results:

(1) Acute pneumonia

(2) Acute cholecystitis

(3) Acute renal obstruction / hydronephrosis

(4) New Malignancy

(5) Intracranial Hemorrhage

(6) New Brain Neoplasm

(7) New CVA or Hydrocephalus

(8) Spinal Cord Compression (Cervical and Thoracic Spine)

(9) Vertebral Compression Fracture – Any level, Any Etiology

(10) Any Major Vessel – Acute Dissection or Aneurysm and/or significant change or risk of rupture

(11) Pneumothorax

(12) Pulmonary Embolism

(13) Pneumoperitoneum – Etiology NOS Ex: recent surgery, PEG insertion, other

(14) Acute Appendicitis

(15) Acute Diverticulitis/Colitis

(16) Portal Venous Air/Pneumobilia

(17) Volvulus

(18) Mediastinal Emphysema

(19) Acute Intra-abdominal or Retroperitoneal Injury or Hemorrhage

(20) Osteomyelitis or New Infection /Abscess

(21) Ectopic Pregnancy

(22) Testicular or Ovarian Torsion

(23) Acute DVT (not chronic)

(24) Significant catheter or ETT/NGT malposition

(25) Any acute fracture or major large joint dislocation

(26) Intestinal Obstruction

(27) Retained Foreign Bodies

(28) Fetal Demise