Your Shoulder Will Be Fine, But There’s Something in Your Lung

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The careful and intentional handling of incidental findings in the emergency department will improve overall patient care and lower your ED’s malpractice risk. Here’s how to do it.

Dear Director: We’re trying to establish a consistent way to talk to patients and document incidental findings on X-rays. Do you typically arrange follow-up testing for these patients?

While emergency physicians are clearly experts in all things urgent, many patients will require guidance as to potential health issues that could evolve down the road. I’ll never forget one phone call I received from an oncologist. He had just diagnosed a patient with metastatic lung cancer and on review of the EMR noticed that the patient had been seen in the emergency department years before. On that visit a lung nodule had been seen on chest X-ray, but there was no documentation of the doctor discussing the results with the patient.

The patient had been told to follow up with his primary care doctor if his symptoms didn’t improve, which they did. The man had no reason for a follow-up chest X-ray until years later, which led to the appointment with the oncologist. After having seen multiple cases like this over the years, I’ve become diligent about discussing incidental findings with patients and documenting what I need them to do, even when the situation isn’t urgent.

The Joint Commission mandates hospitals have a policy for dealing with incidental findings. The American College of Radiology and CMS have pushed radiologists to decide which incidental findings are important and to provide appropriate guidance to referring physicians. (Much of this emphasis revolves around increasing consistency between radiologists and providing evidence-based management.)

However, too often in the ED, it’s up to the individual bedside physician to determine how we communicate these findings to the patient and what we instruct them to do. And that’s assuming the patient is still in the ED.

REAL TIME FINDINGS

It’s estimated that across all imaging modalities, incidental findings occur in one in four tests. Pulmonary nodules are detected in 0.2% of chest radiographs and 8%–51% of CT scans in screening trials. Fortunately, most are benign and don’t usually require any immediate intervention by the emergency physician. However, because there is still a risk it could develop into something dangerous, we need to address it with the patient.

My standard process and documentation has become more robust and direct over the years. Not only do I discuss it with the patient and document the discussion in the chart, I also include specific details on the discharge instructions.

For instance: “Your chest X-ray is abnormal and you require a repeat X-ray in three months. Bring your X-ray report and these instructions to your doctor when you follow up this week.” It only takes one missed case and one lawsuit for your group to realize how big a deal this can be.

Lawsuits aside, there are practical reasons to go into greater detail about incidental findings. These days, patients are leaving the ED with copies of their results. If I don’t discuss that nodule now, they will call back in a day or two once they’ve read the report, wonder if they’re dying of cancer, and why I didn’t mention this to them.

I also think it’s important for the patient to have the information as they will typically be the most motivated to make sure they get the follow up they need.

AFTER THE PATIENT LEAVES

When a patient gets admitted from the emergency department it’s tempting – and common – to assume that incidental findings will be addressed by the inpatient team. But this hand-off is ripe for information loss. Consider the example of an abdominal CT scan ordered for appendicitis which shows acute appendicitis and a right renal mass.

One surgeon I respect a lot told me his practice is to review the CT to confirm the appendicitis before going to the OR and virtually ignore the incidental finding. While he may see the renal mass, he does not typically review the radiologists’ report and is only concerned about the acute issue—the appendicitis.

The patient in this example may never hear about the other finding. This situation is thankfully rare – even I expect an admitting physician to cover incidental findings with a patient – but we have to cover our bases. Is it our job? Should primary care docs be more responsible for this down the line? It doesn’t really matter; it’s reasonable to mention the incidental findings to the patient and document it in the chart.

What about when test results get revised after the fact? It’s estimated that 1% of “wet reads” are changed by the time they’re finalized. I used to work in an academic facility and at about 9 a.m. the radiology resident would bring over a list of patients where the attending disagreed with their interpretation.

Often this involved incidental findings noticed. The responsibility for contacting the patient typically fell to the ER team working that day. Although some hospitals may have the radiologist contact the patient, I long ago realized that the radiologists aren’t bedside clinicians and don’t have the patient-physician relationship that we have, so I’ve just accepted that all of these fall to us.

In these cases, someone in the ED would call the patient, let them know there was something seen on the test that required follow up, and then would document this conversation in the chart. If we didn’t reach the patient (no number, wrong number), then a letter would be sent.

I’ve worked in departments that used certified mail as well as regular first class mail. I like certified mail as I then have a documented receipt that the patient received it. It’s very reasonable to send a letter when you’re talking about an incidental finding as it will give the patient something concrete to bring to their doctor. A letter can also provide information about follow up if the patient doesn’t have a primary care doctor.

CONTACTING THE PMD

There’s a wide range of acceptable practice in my opinion when you have an incidental X-ray finding and contemplate contacting the primary care doctor. It may be determined by the culture of your hospital regarding communication, and the EMR that you use. At 9 a.m. or 2 a.m., I wouldn’t call the PMD for a lung nodule. However, contacting the PMD to close the loop on a patient you just diagnosed with metastatic cancer (certainly not an incidental finding) who needed close follow up but did not require admission would be appropriate by phone or email (if the culture and system allowed for that). There are some hospitals and systems where it’s possible and easy to send a note to the PMD about the patient.

I work in a hospital with a high Kaiser Permanente patient population. Although we don’t contact their PMDs directly, in certain cases the hospitalists rely on emailing the patient’s PMD to relay information and follow-up needs. Although our discharge instructions and patient summaries are sent to the PMDs who are in our system, I do not rely on this as a form of communicating with the PMD and passing on the responsibility of follow up to them. I also don’t believe that most PMDs have the time or capacity to routinely mine the EMR/portal for their patient’s ER visits.

In general, I don’t contact the PMD for incidental findings if the patient is reliable and I write clear discharge instructions for the patient.

GETTING THE WORK-UP ORDERED

While I will do all the appropriate testing while the patient is in the ED, you have to draw the appropriate line on when a handoff should occur. Patients are typically anxious when you talk about a mass seen on CT, so while it’s tempting to order an MRI for the patient with the liver mass, what then?

Without an office for follow up, it’s hard to give patients the care they need. Not to mention, we don’t always have the education about next steps. So I believe patients are better off following up with a primary care doctor who can follow up on the results. That said, there are always exceptions to the rule.

The neurologist or the neurosurgeon may want an MRI done before the patient sees them in the office that week. I’ve run into issues with insurance companies not covering outpatient tests ordered by emergency physicians but in principle, I’m not opposed to ordering an MRI before a patient follows up with a specialist and having the report sent to the specialist.

CONCLUSIONS

The ultimate goal of properly handling incidental findings in the ER is to improve the patient’s health in the long term and to reduce malpractice risk. Although most incidental findings are benign, we still need to deal with them. Taking the time to talk to the patient about the finding and the necessary follow up, as well as documenting this conversation in the chart and providing strict discharge instructions, can certainly help achieve these goals.

ABOUT THE AUTHOR

EXECUTIVE EDITOR
Dr. Silverman is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virgina Hospital Center. He authors the Director's Corner each month in EPM. Dr. Silverman’s practical wisdom is now available in an easy-to-use reference guide. Order today on Amazon.

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