S02 - SOLICITATION ATTACHMENT - D.25 IMAGING - REPORT OF IMAGING TEST RESULTS.pdf

DEPARTMENT OF VETERANS AFFAIRS

VA HEALTHCARE NETWORK

UPSTATE NEW YORK AT SYRACUSE

Medical Center Professional Memorandum January 2018

Imaging 11-141________

IMAGING: REPORTING OF IMAGING TEST RESULTS

I. PURPOSE:

The purpose of this policy is to establish policies and procedures for defining, reporting, and monitoring critical and other significant findings.

II. POLICY:

The policy of the Syracuse VAMC imaging department for critical and other significant findings to be communicated to the requesting health care provider within a timeframe that allows for prompt and appropriate action. The communication of imaging test results will be through verbal and/or electronic means.

III. Definitions:

A. Critical Values: are defined as critical abnormal findings listed in Attachment A that are potentially life-threatening time sensitive, and require the immediate communication 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. Critical Tests: ( Attachment A) are exams that, due to the nature of the exam or circumstances under which it is performed, for which the results must be communicated immediately whether positive or negative.

C. Significant Findings: are defined as significant abnormal findings that require prompt reliable and documentable communication to the requesting provider but 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.

D.25 MCPM 11-141

Medical Center Professional Memorandum January 2018

Imaging 11-141 ____ Page 2

A significant finding is communicated to the requesting health care provider through a View Alert in the patient electronic chart for immediate attention.

III. PROCEDURES:

A. All imaging studies shall be ordered electronically. Orders will not be accepted without a valid history for the study. The name of the ordering practitioner, contact information, including a pager number must be entered to ensure communication follow-up. All Imaging reports require a diagnosis code to appropriately flag abnormal findings.

B. The radiologist will interpret the exam and determine if it contains critical or other significant findings. Based on these findings the radiologist will assign an appropriate diagnostic code to the report. Findings that may require direct communication and immediate attention include, but are not limited to:

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

Attachment (A) critical values).

• Any significant finding that could pose a public health risk including active TB.

C. Abnormal findings 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:

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

• Code 1002: Critical Abnormality: 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 CPRS in the radiology report.

• Code 1003: Possible Malignancy: View Alert will be automatically generated to the requesting provider upon verification of the report.

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• Code 55: Critical Test: 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 30 minutes after completion of the test. The finding whether positive or negative will be generated in the report with the date, time, and name of the contact who acknowledges the results given. The information is located in the patient’s electronic record (CPRS)

• Code 919: TB suspected: View Alert will be automatically generate to the requesting provider upon verification of the report.

D. 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. Off- Hour studies:

1. 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.

2. NTP provides turnaround times of 1 hour for STAT emergency interpretations, 30 minute critical test turnaround times for head CT’s to rule out stroke.

3. OR STAT readings for retained surgical items will be given priority when sending to NTP Teleradiology Service. 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 O.R. must provide the technologist the current phone number that the O.R. physician will be available for phone conversation with the NTP reading Radiologist. The on-call Radiologist (number in amion.com listing) is available to help mitigate any unforeseen problems that may impede results from the reading.

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4. NTP Nuclear medicine interpretations after-hours are not supported at this time. STAT Nuclear Medicine interpretation can be obtained by contacting the Radiology resident at SUNY University radiology department listed in the amion.com directory. The Radiology resident provides preliminary results only.

5. Preliminary interpretations provided by the Radiology resident is documented as a permanent notation in the PACS system, and made available thereby to the provider. Providers are responsible for maintaining computer access to view preliminary reports, including PACS access. The VA attending Radiologist on-call is available for any readings as needed. The Radiology resident’s preliminary report is followed up the next morning with the VA attending.

IV. RESPONSIBILITIES:

A. Chief of Staff is responsible:

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. Clinical Physician is responsible:

1. To follow up all imaging results that initiate a view alert or through direct communication from the Imaging physician. 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. Imaging Physician is responsible for:

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

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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.

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

D. Ordering Health Care Provider is responsible for:

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

3. Maintaining computer access to view preliminary radiology reports (non-critical results) stored as a permanent note in the PACS system.

4. Assigning a surrogate or designee to receive critical result notifications when unavailable to review results.

5. Following up critical value imaging reports whether communicated from a face to face or a phone conversation.

E. Radiology Resident On-call. is responsible to

1. Provide preliminary readings of general radiology studies or Nuclear

Medicine exams designated as STAT within 1hr of notification.

F. Radiologic Technologist is responsible to

1. Push or transmit images from PACS to NTP portal immediately after completion of exam for STAT interpretation requests after-hours.

2. Notify the Radiology resident for STAT Nuclear Medicine preliminary report requests for exams after-hours.

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G. Imaging ADPAC/ PACS manger is responsible for:

1. Ensuring that parameters for Diagnostic Codes are appropriately set to issue mandatory View Alerts.

V. REFERENCES:

Joint Commission Accreditation Standards

VHA DIRECTIVE 2003-043-Ordering and Reporting Patient Test Results http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=270

10N2-112-10 Network 2-Information Management Policy

VI. RESCISSION:

Medical Center Professional Memorandum 11-141 Reporting of Imaging Results dated

November 2014.

VII. REVIEW DATE:

January 2020

VIII. FOLLOW-UP RESPONSIBILITIES:

Manager, Imaging, 114

S ASIF ALI, MD

Chief of Staff

Attachment A http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=270

Attachment A

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. Aneurysm- Leaking

6 Bowel Obstruction

7. Cord compression

8. Foreign body in airway

9. Fracture of major weight bearing bone

10. Significant Hemorrhage/Bleed (includes brain and body)

11. Ischemic Bowel Disease

12. Pneumomediastinum

13. Pneumoperitoneum

14. Pneumothorax (new and/or enlarging and/or tension)

15. Significant misplacement of tubes or catheters

16. Testicular Torsion

B. Critical Values are defined as critical abnormal findings that are potentially life-threatening and require the immediate attention of the requesting health care provider and, due to their urgency or potential for patient morbidity/mortality, 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.

CRITICAL TEST RADIOLOGY

All Head CT scans ordered or authorized by the Emergency Department/ Stroke team to rule out hemorrhage in a pre- TPA candidate have been determined by the Chief Radiologist as a critical test. These tests are treated as top priority to be examined and reported ASAP (within 30 minutes) to the Emergency Department physician or designated appointee. Critical tests require the

Radiologist to report their finding whether positive or negative.

Generate abnormal alert

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: