D.38- IMAGING- REPORTING OF IMAGING TEST RESULTS MCP 11-141 JUNE 2021.pdf

IMAGING: REPORTING OF IMAGING TEST RESULTS

MCP 11-141

Syracuse VA Medical Center Syracuse, NY 13210

Signatory Authority:

Medical Center Director

Responsible Owner:

Imaging Manager

Rescinded Document:

MCPM 11-141, Imaging: reporting of Imaging Test Results, dated January

Effective Date:

June 2021

Recertification Date:

June 2026

1. POLICY

This medical center policy establishes guidelines to communicate all imaging test results, normal and abnormal, to the ordering healthcare provider (or clinical surrogate), within a specified timeframe to allow for prompt attention and appropriate clinical action to be taken. In addition, the ordering provider (or clinical surrogate) further communicates imaging test results in a timely and appropriate manner (per VHA Directive 1088) to patients or their personal representatives, so that they may participate in health care decisions. To verify the accuracy of verbally communicated critical results, a “read-back” confirmation of the essential elements of the result will be requested by the diagnostic provider (or designee) from the ordering provider (or clinical surrogate) and documented by the diagnostic provider (or designee) in the patient’s medical record, typically as part of the radiographic report.

2. JUSTIFICATION

In accordance with VHA Directive 2003-043, Ordering and Reporting Patient Test Results requires the facility to develop local policy.

3. RESPONSIBILITIES

a. Chief of Staff. The Chief of Staff is responsible for:

(1) To instruct the medical staff regarding policies and procedures for communication of Imaging test results.

(2) The Chief of Staff or his/her designee is responsible for ensuring that appropriate clinical action is initiated in a timely manner when the requesting physician is unavailable to follow up.

b. Ordering Health Care Provider. The Ordering Health Care Provider is responsible for:

Attachment D.38 RFP 36C24224R0049

May 2021 MCP 11-141

(1) Placing the initial order with appropriate contact information for communication and an alternate phone number for the surrogate if applicable.

(2) Maintaining computer access to view preliminary radiology.

(3) Assigning a surrogate or designee to receive critical result notifications when unavailable to review results.

(4) Following up critical value imaging reports that initiate a view alert, or from communication from a face to face or a phone conversation. The Clinical physician is responsible to properly hand off pertinent information regarding the finding of the imaging result to appropriate staff for prompt patient care.

c. Radiologist. The Radiologist is responsible for:

(1) Ensuring that verified test result reports are available in the electronic medical record within 24-48 hours.

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

(3) Identifying and communicating abnormal test results that may be treated in a non-urgent time frame, using direct or electronic communication, knowing which diagnostic codes trigger a mandatory View Alert.

d. Radiologic Technologist. The Radiologic Technologist is responsible for:

(1) Push or transmit images from Picture Archiving and Communication System (PACS) to the National Teleradiology Program (NTP) portal immediately after completion of the exam for (STAT) interpretation requests after-hours.

(2) Notify the Radiology resident for STAT Nuclear Medicine preliminary report requests for exams that NTP does not read after-hours.

4. OTHER PARAGRAPHS

a. Imaging Orders.

(1) All imaging studies shall be ordered electronically.

(2) Orders will not be accepted without a valid history for the study.

(3) The name of the ordering practitioner, contact information, including a pager or cell number must be entered to ensure communication follow-up.

(4) All Imaging reports require a diagnosis code to appropriately flag abnormal findings.

b. Exam Interpretation.

(1) The radiologist will interpret the exam and determine if it contains critical or other significant findings.

(2) Based on these findings the radiologist will assign an appropriate diagnostic code to the report.

(3) The acceptable length of time between interpretation and reporting of a critical imaging result to the ordering healthcare provider (or clinical surrogate) is defined as within 60 minutes.

(4) Findings require direct communication and immediate attention include, but are not limited to:

(a) Critical values reported from specific conditions for example: unsafe position of a medical device; pneumothorax; active hemorrhage. (See Appendix A) critical values).

(b) Any significant finding that could pose a public health risk including active Tuberculosis (TB), COVID 19, etc.

(c) Any abnormal findings: they generate an electronic” View Alert” in the patient’s electronic record. Levels and methods of communication vary in accordance to the urgency of the finding listed:

1. Code 1001: Significant Abnormality: Attention Needed; View Alert will be automatically generated to the requesting provider upon verification of the report.

2. Code 1002: Critical Abnormality: Results Called; The radiologist shall immediately notify the requesting physician of these findings, by phone or in person, and assure that the contacted person is aware of the critical nature of these results.

This communication shall occur within 1 hour of the time that the abnormal finding is discovered by a resident or attending radiologist. The date, time, and name of the contact shall be documented in Computerized Patient Record System (CPRS) in the radiology report.

(d) Critical results that present in the case when the radiologist is unable to contact the requesting provider or in instances where the CBOC clinic is closed; is to notify the ED attending. They are then tasked with tracking down the patient’s provider or intervene to ensure continuity of care.

(e) Radiologists are available in the department for consult and case review during the normal working hours. Staff members and house staff are encouraged to directly consult the department members.

(f) Radiologists are present in the department from 8:00 am to 4:30 pm Monday through Friday. It is the responsibility of the radiologist on-call to review all STAT and

Urgent studies up to 4:30 pm. STAT interpretations off-hours will be sent to NTP Teleradiology service.

(g) NTP provides turnaround times of 1 hour for STAT emergency interpretations, 30-minute critical test turnaround times for head Computerized Tomography (C.T.) to rule out stroke.

1. Operating Room (OR) STAT reading for retained surgical items will be given priority when sending to NTP Teleradiology Service during off-hours operations. This flagged priority should provide a turnaround time of 30 minutes or less from transmission to interpretation including the call to the OR physician. The Images will be uploaded to the priority Intra-operative portal by the technologist. The OR must provide the technologist the current phone number that the OR physician will be available for phone conversation with the NTP reading Radiologist. The on-call VA attending Radiologist (number in amion.com listing) is available to help mitigate any unforeseen problems that may impede results from the reading.

2. NTP Nuclear medicine reading after-hours have limited support at this time.

STAT Nuclear Medicine interpretation that are unsupported by NTP can be obtained by contacting the Radiology resident at State University of New York SUNY radiology department listed in the amion.com directory. The Radiology resident only provides preliminary results only. The on-call VA attending Radiologist (number in amion.com listing) is available to help mitigate any unforeseen problems that may impede results from the reading.

(h) The Radiology resident who provides a preliminary report will contact the ordering healthcare provider and documented the preliminary result as a permanent notation in the PACS system. The ordering healthcare provider is responsible for maintaining computer access to view preliminary reports, including PACS access. The on-call Veterans Administration (VA) attending Radiologist is available for any readings as needed. The Radiology resident’s preliminary report is followed up the next morning with the VA attending for final interpretation.

5. DEFINITIONS

a. Critical Result. are defined as critical abnormal findings listed in Appendix A that are potentially life-threatening time sensitive and require the immediate communication to requesting health care provider and, should not wait for or rely on normal means of reporting. The finding is communicated to the requesting health care provider through a face-to-face or telephone conversation with documentation of the time, date, and acknowledgement from the requester in the report when positive.

b. Ordering Healthcare Provider, An Ordering Healthcare Provider is a provider authorized to enter and sign orders for tests for patients. The ordering provider receives, acknowledges, and reviews subsequent imaging test results, and notifies patients in accordance with VHA Directive 1088.

NOTE: The ordering provider may delegate some of these actions to other qualified team members, as appropriate.

c. Diagnostic Provider. A diagnostic provider is a provider who performs or supervises the performance and interpretation of diagnostic tests either through privileges or by acting under a scope of practice.

d. Imaging Test Result. Imaging test results include findings from diagnostic imaging (Radiology and Nuclear Medicine) and Interventional Radiology procedures.

e. Significant Findings . Significant findings are defined as significant abnormal findings that require prompt reliable and documentable communication to the requesting provider, however, do not meet the same level of time sensitive urgency or potential for immediate morbidity/mortality as a critical finding. These include findings that are suspicious for new or previously undiagnosed neoplastic disease.

6. REFERENCES

a. VHA Directive 1088, Communicating Test Results to Providers and Patients, dated October 7, 2015. VHA Directive 1088 Communication Test Results to providers and patients . https://vaww.va.gov/vhapublications/index.cfm

b. Joint Commission, Closing the Loop on Test Results to Reduce Diagnostic Errors, dated January 9, 2020, https://www.jointcommission.org/closing-the-loop-on-test-results-to-reduce-diagnostic-errors .

7. RESCISSION

MCPM 11-141, Imaging: reporting of Imaging Test Results, dated January 2018, is rescinded.

8. REVIEW

At minimum at recertification and including when there are changes to the governing document (for example, national policy or a health care accreditation body mandate).

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of June 2026. This MCP will continue to serve as local policy until it is recertified or rescinded.

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

https://vaww.va.gov/vhapublications/index.cfm

10. SIGNATORY AUTHORITY

FRANK P. PEARSON, DPT, PA-C

CAPT, USN (Ret) U.S. Department of Veterans Affairs Director, Syracuse VA Medical Center Date Approved: June 30, 2021

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

DISTRIBUTION: MCPs are available at: Syracuse Medical Center Document Control SharePoint (DCS). https://dvagov.sharepoint.com/sites/VHASYR/svdc.

June 2021 MCP 11-141

APPENDIX A

1. CRITICAL VALUES RADIOLOGY

a. Physicians/ordering practitioners will be notified ASAP (as soon as possible) of the following radiology diagnostic test that are new, unexpected and/or life threatening. Example includes but not limited to:

(1) Acute appendicitis/peritonitis

(2) Acute brain infarction

(3) Acute DVT

(4) Acute PE

(5) Acute Pulmonary Edema

(6) Aneurysm- Leaking

(8) Bowel Obstruction

(9) Cord compression

(10) Foreign body in airway

(11) Fracture of major weight bearing bone

(12) Significant Hemorrhage/Bleed (includes brain and body)

(13) Significant Hydronephrosis

(14) Ischemic Bowel Disease

(15) Pneumomediastinum

(16) Pneumoperitoneum

(17) Pneumothorax (new and /or enlarging and/or tension)

(18) Significant misplacement of tubes or catheters

(19) Testicular Torsion

(20) Traumatic diaphragmatic herniation

(21) Unsafe position of a medical device