Rapid Response: To Scan or Not to Scan? The Utility of Noncontrast CT Head for Altered Mental Status.

OBJECTIVES: The aims of the study were the following: (1) to determine how often computed tomography (CT) scans of the head are obtained on rapid responses called for altered mental status (AMS), (2) to determine whether CT imaging of the head is required during all rapid responses called for AMS, (3) to determine which patients would benefit from CT scans of the head in this setting, (4) to note whether an adequate neurologic exam was documented, (5) to determine the cost of CT scans that did not change management, and (6) to examine the role of medications leading to AMS. METHODS: The study was a retrospective chart review at Abington Jefferson Hospital. Data collected included the age, sex, time of rapid response, clinical condition of the patient, whether an arterial blood gas and blood glucose were done, and whether a neurological exam was documented in the resident's rapid response team note. The patien's medications were also reviewed. Computed tomography scan findings as well as changes made in a patient's care as a result of the scan were recorded. Any findings that did not lead to a change in management were considered a "negative" scan. RESULTS: Overall, 610 rapid responses were activated from January to August 2016. One hundred four (17.04%) of the total rapid responses were for AMS and 83 (79.8%) of these patients underwent noncontrast CT scan of the head. The mean (SD) age of the patients was 74.7 (13.6) years. A total of 56.6% were female. The most frequent clinical conditions documented at the time of rapid responses were noted as confused (33.7%, 28/83), either lethargic or unconscious (32.5%, 27/83), and concern for stroke (21.7%, 18/83). A total of 96.4% (80/83) of the CT scans done were negative for any acute changes. The three patients with positive scans (3/83) had a change in management as a result of the scans. If patients with symptoms concerning for stroke and unconscious patients are excluded, the total number of remaining patients is 56. Of these, zero patients had a positive scan. A total of 64.7% of the rapid response teams were activated either in the afternoon (31.3%) or at night (33.7%). A total of 33.7% had a complete neurological exam documented. A total of 66.2% were either incomplete (34.9%) or absent (31.3%). Sixty percent of the patients who had a CT head for AMS also had a blood sugar checked at bedside. Thirty-eight percent had an arterial blood gas. More than half the patients were taking one or more sedating medications (45/83, 57.8%). Most patients were not on anticoagulants (79.5%). CONCLUSIONS: The findings of this study suggest that CT scan of the head is useful in older patients, patients with symptoms concerning for stroke, or cases of sudden onset of impaired consciousness. Noncontrast CT scans of the head are not useful for other presentations of AMS.

Process improvement for follow-up radiology report recommendations of lung nodules.

In the modern healthcare system, there are still wide gaps of communication of imaging results to physician and patient stakeholders and tracking of whether follow-up has occurred. Patients are also unaware of the significance of findings in radiology reports. With the increase in use of cross-sectional imaging such as CT, patients are not only being diagnosed with primary urgent findings but also with incidental findings such as lung nodules; however, they are not being told of their imaging findings nor what actions to take to mitigate their risks. In addition, patients at high risk for developing lung cancer often obtain serial CT scans, but tracking these patients is challenging for the clinician. In order to advance quality improvement goals and improve patient outcomes, we developed a custom application and business process for radiology practitioners that mines available healthcare data, identifies patients with lung nodules in need of follow-up imaging, notifies the patient and the primary care physician via mail, and measures process efficacy via executed follow-up screenings and captured patient condition. This integrated analytics and communication process increased our average rate of patient follow-ups for lung nodules from 26.50 in 2015 to 59.72% in 2017. 17.18% of these patients had new lung nodules or worsening severity of lung findings detected at follow-up. This new process has added missing quality and care coordination to an at-risk patient population. Problem: Communication of imaging results and follow-up recommendations to patients and primary care providers (PCPs) is a challenge for healthcare systems. In addition, tracking whether a patient's follow-up has been completed is another significant gap in care coordination. Patients are often unaware of or cannot even understand the significance of radiology findings or follow-up recommendations reported after imaging procedures. In addition, patients may not have a primary physician listed at time of imaging if the first encounter is in the emergency room (ER) or if their primary care physician or specialist works in a different electronic health record platform. Communication of imaging results to different healthcare providers is challenging with the myriad of existing electronic health record systems that often lack interoperability with other clinical entities.Description of lung nodules in radiology reports can vary widely if a standardised lexicon is not used. Moreover, follow-up recommendations by radiologists can be varied for certain size lung nodules because an individual's risk factors to develop lung cancer may not be known at the time of dictation.Approximately 500 000 radiology imaging procedures are interpreted and performed annually by a single private group of 33 radiologists located at a 665-bed regional referral centre and at a 140-bed acute care community hospital, both located in the suburbs of a major metropolitan city. Management of this volume of patients in the health system can be overwhelming to nurse navigators, and there is usually no system in place for primary care physicians to follow-up lung nodules found unexpectedly on inpatient images. The goal of this project was to develop a better automated tracking method and communication tool to reduce the likelihood that needed follow-up studies are missed by patients and clinicians.

Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients.

BACKGROUND: Incidental findings are prevalent in imaging but often go unreported to patients. Such unreported findings may present the potential for harm as well as medico-legal ramifications. METHODS: A chart review of trauma patients was undertaken over a year. Systems-based changes were made utilizing our electronic medical record system and our staff protocols to improve the disclosure of clinically relevant incidental findings to patients. RESULTS: During the preintervention period, 674 charts were reviewed. Trauma patients had a rate of incidental findings of 70%, and 36% of patients had clinically relevant incidentals. Rates of follow-up recommendation and disclosure to patients were 22% and 27%, respectively. In the postintervention period, of the 648 charts were reviewed, the rates of a clinically relevant incidental finding were 35%, but the rates of follow-up recommendation and disclosure to patients were 68% and 85%, respectively. CONCLUSION: Incidental findings are more prevalent herein than previously reported. With simple changes and minimal resources, clinically relevant and important improvement in reporting incidental findings can be made to mitigate the harm and medico-legal impact of an incidental finding going unreported.